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A    MANUAL   OF    SURGERY 
jfor  StuDcnts  ant)  fcractitionets 


MANUAL  OF  SURGERY 


jfor  Stufccnts  anfc  practitioners 


BY 


WILLIAM   ROSE,  M.B.,  B.S.,  Lond.,  F.R.C.S., 

Professor   of  Clinical  Surgery  in  King's  Collf.ge,  London,  and  Senior  Surgeon 
to  King's  College  Hospital,  etc. 


ALBERT  CARLESS,  M.S.  Lond.,  F.R.C.S., 

Surgeon  to  King's  College  Hospital,  and  Teacher  of  Operative  Surgery 
in   King's  College,  London;    Examiner  in   Surgery  to  Glasgow  University,  etc. 


FIFTH     EDITION 


NEW     YORK 

WILLIAM     WOOD     &     COMPANY 

MDCCCCH, 


TO 

LORD   LISTER,   ll.d.,  f.r.s., 

President  of  the  Royal  Society, 

THE     FATHER     OF     ANTISEPTIC     SURGERY, 

THIS   WORK    IS,    WITH    PERMISSION, 

gefoicatei)  bn  the  Jluthors, 

IN    GRATEFUL    ACKNOWLEDGMENT    OF    THE    MANY    ADVANTAGES 

THEY    HAVE   DERIVED 

WHILST   ASSOCIATED    WITH    HIM    IN    HIS   WORK 

AT    KING'S   COLLEGE    HOSPITAL. 


PREFACE  TO  FIFTH   EDITION. 


In  issuing  a  fifth  edition  of  this  work  within  twelve  months  of  the 
fourth  we  would  note  that  considerable  modifications  have  been 
made  in  order  to  bring  it  up  to  date  and  to  fit  it  more  satisfac- 
torily to  modern  requirements.  It  seemed  undesirable  to  per- 
petuate any  longer  the  idea  that  the  first  and  most  important 
element  in  surgical  practice  is  a  knowledge  of  inflammation  and 
its  treatment,  and  hence  this  subject  has  been  removed  from  its 
original  position  and  has  been  located  to  one  secondary  to  that 
occupied  by  Bacteriology  and  the  principles  of  Antiseptic  and 
Aseptic  Surgery.  Sundry  other  changes  will  be  found  which  will 
lead  to  a  more  harmonious  pathological  and  clinical  picture  than 
was  previously  presented. 

In  conclusion  we  must  acknowledge  our  indebtedness  to  many 
friends  who  have  made  valuable  and  useful  suggestions ;  to 
Professor  R.  T.  Hewlett,  who  has  run  over  the  sheets  of  the  first 
chapter  and  indicated  various  modifications  to  us  which  make  it 
more  authoritative  ;  and  to  Mr.  T.  P.  Legg,  our  Surgical  Registrar 
at  King's  College  Hospital,  who  has  undertaken  at  very  short 
notice  the  arduous  task  of  revising  the  Index. 

August,  1902. 


PREFACE  TO  FIRST  EDITION. 


In  preparing  this  Manual  of  Surgery  for  the  profession,  we 
have  endeavoured  to  meet  what  we  think  is  at  the  present  time 
a  genuine  need.  The  many  large  and  valuable  text-books  and 
works  of  reference  already  in  existence  are  almost  more  than  the 
ordinary  student  can  master  during  the  time  at  his  disposal.  It 
has  therefore  been  our  aim  to  present  the  facts  of  surgical  science 
in  a  concise  and  succinct  form,  so  as  to  satisfy  the  needs  of  the 
student,  even  of  those  who  are  preparing  for  the  higher  examina- 
tions. At  the  same  time,  the  requirements  of  the  general  prac- 
titioner have  not  been  overlooked,  for  we  have  taken  care  to 
discuss  in  detail  those  conditions  which  are  most  likely  to  be  met 
with  in  ordinary  practice.  The  main  difficulty  has  been  to  com- 
press into  a  small  space  the  ever-increasing  amount  of  material 
available,  so  that  we  have  only  been  able  to  sketch  in  out- 
line much  that  could  have  been  elaborately  described  did  the 
size  of  the  book  permit.  For  the  same  reason,  historical  and 
bibliographical  references  have  to  a  large  extent  been  omitted, 
whilst  diseases  of  special  regions — such  as  the  eye,  ear,  and  female 
genital  organs — are  also  practically  excluded,  except  in  so  far  as 
they  encroach  on  the  domains  of  general  surgery.  The  progress 
of  bacteriology  and  the  influence  of  antisepsis  have  so  transformed 
the  characters  and  extended  the  scope  of  surgical  work  that  many 
of  the  traditions  and  theories  of  the  past  have  had  to  be  discarded, 


PREFACE  TO  FIRST  EDITION 


although  at  the  same  time  we  have  endeavoured  to  preserve  and 
respect  that  which  has  been  shown  to  be  good  and  useful  in  the 
laborious  researches  and  accumulated  experiences  of  bygone 
generations. 

In  conclusion,  our  best  thanks  are  due  to  Dr.  St.  Clair  Thom- 
son, who  has  kindly  looked  through  the  proofs  of  the  sections 
devoted  to  the  nose  and  ear ;  to  Dr.  Silk,  who  has  fulfilled  a 
similar  office  in  reference  to  the  chapter  on  anaesthetics  ;  to  Mr. 
William  Turner  for  preparing  the  index  ;  and  to  Dr.  Arthur 
Griffiths,  late  of  the  Bristol  General  Hospital,  who  has  drawn 
several  of  the  pictures,  and  given  other  valuable  assistance. 

Many  of  the  illustrations  have  been  specially  prepared  for  this 
work,  but  we  have  also  to  acknowledge  the  loan  of  blocks  from 
Messrs.  Veit  and  Co.,  of  Leipzig  ;  from  Messrs.  Cassell  and  Co., 
J.  and  A.  Churchill,  Longmans  and  Co.  ;  and  from  the  editors  of  the 
Lancet  for  the  loan  of  Fig.  287  [296].  The  various  sources  from 
which  these  are  derived  are  acknowledged  throughout  the  book. 
Illustrations  of  instruments  are  mainly  derived  from  Messrs. 
Down  Brothers,  who  have  kindly  placed  them  at  our  disposal. 

W.  ROSE, 

17,  Harley  Street,  W. 

A.  CARLESS, 

10,  Welbeck  Street,  W. 
London, 

May  1,  1898. 


CONTENTS 


CHAPTER  PAGE 

I.    SURGICAL     BACTERIOLOGY SEPSIS      AND     INFECTION 

ANTISEPSIS    AND    ASEPSIS       -                   -                   -                   -  I 

II.    INFLAMMATION                     -                   -                   -                   -                   '  23 

III.  SUPPURATION    AND    ABSCESS       -                   -                   -                   "  41 

IV.  ULCERATION        -                   -                   -                   -                   -  58 
V.    GANGRENE            -                   -                   -                   -                   -  67 

VI.    INFECTIVE    DISEASES      -                                      -                   -                   -  90 

VII.    TUMOURS    AND    CYSTS     -                                       -  150 

VIII.    WOUNDS                 ...---  igo 

IX.    HEMORRHAGE    -                   -                   -                   -                   -...."  222 

X.    INJURIES     AND     DISEASES     OF     ARTERIES ANEURISM 

LIGATURE    OF    ARTERIES          ...                   -  246 

XI.    SURGERY    OF    THE    VEINS                ....  298 

XII.    DISEASES    OF    THE    LYMPHATICS                   -                                      -  312 

XIII.  AFFECTIONS    OF    NERVES                  ....  326 

XIV.  SURGICAL      DISEASES      OF       THE      SKIN       AND      OF       THE 

CUTANEOUS    APPENDAGES       -                   -                   -                   "  351 

XV.    AFFECTIONS    OF    MUSCLES,    TENDONS,    AND    BURSE            -  363 

XVI.    DEFORMITIES      ------  378 

XVII.    INJURIES    OF    BONES FRACTURES              -                   -                   -  417 

XVIII.    DISEASES    OF    BONE          -----  495 

XIX.    INJURIES    OF    JOINTS DISLOCATIONS      -                   -                   -  539 

XX.    DISEASES    OF    JOINTS       -----  573 

XXI.    INJURIES    OF    THE    SPINE                 ...                   -  628 


CONTENTS 


CHAPTER 


XXII.    DISEASES    OF    THE    SPINE         -  646 

XXIII.    HEAD    INJURIES              .....  667 

XXIV.    DISEASES     OF     THE     SCALP,    CRANIUM,     AND     CRANIAL 

CONTENTS                    .....  705 

XXV.    AFFECTIONS    OF    THE    LIPS    AND    JAWS                  -                   -  723 
XXVI,    AFFECTIONS    OF    THE    NOSE    AND    NASO-PHARYNX            -  753 
XXVII.    AFFECTIONS     OF     THE     MOUTH,     THROAT,    AND     OESO- 
PHAGUS     --..-.  772 
XXVIII.    AFFECTIONS    OF    THE    EAR        ....  813 

XXIX.    SURGERY    OF    THE    NECK            ....  822 

XXX.    SURGERY   OF    THE    AIR-PASSAGES,  LUNGS,  AND  CHEST  838 

XXXI.    DISEASES    OF    THE    BREAST     -                   -                   -                   -  866 

XXXII.    ABDOMINAL    SURGERY                   ....  89I 

XXXIII.    HERNIA               ......  970 

XXXIV.    INTESTINAL    OBSTRUCTION      -                   -                   -                   -  IOOg 

XXXV.    AFFECTIONS    OF    THE    RECTUM    AND    ANUS         -             *     -  IO25 

XXXVI.    SURGICAL    AFFECTIONS    OF    THE    KIDNEYS          -                   -  IO5O 

XXXVII.    SURGERY    OF    THE    BLADDER    AND    PROSTATE                     -  IO72 

XXXVIII.    AFFECTIONS    OF    THE    URETHRA    AND    PENIS    -                   -  III7 

XXXIX.    AFFECTIONS     OF    THE    TESTIS,    CORD,    SCROTUM,    AND 

SEMINAL    VESICLES                 -                                                          -  II43 

XL.    AMPUTATIONS                   -                                                          -                   -  II65 

XLI.    ANAESTHESIA                     -                   -                                                          -  I184 

INDEX                  -                                                                                                 -  I  192 


LIST  OF  PLATES. 


PLATE  PAGE 

I.  Various  Types  of  Bacteria          -                                      -  To  face  i 

II.  Fig.   i. — Early  Stage  of  Abscess  Formation  -  44 

Fig.  2. — Section  of  Abscess  Wall  Eight  Days  Old         ,,  44 

III.  Fig.   1.  —  Military     Tubercle     with    Giant    Cell     (Highly 

Magnified)  -  -  To  face     142 

Fig.  2. — Tuberculous    Abscess    from    a    Suppurating    Lym- 
phatic Gland  (Low  Power)      -  -  -  To  face     142 

IV.  Exostosis  of  the  Radius  -  -  -        ,,         165 
V.   Fig.   1. — Hard    Glandular   Carcinoma,  with    abundance    of 

firm  Fibro-Cicatricial  Stroma  (Scirrhous  Mamm.e)    To  face     180 
Fig.  2.  —  Granulation  Tissue  from  a  Healing  Wound      ,,         180 
VI.  Skiagram   of   Hand,  with  Needle   embedded   in   the   Palm, 

close  to  the  Carpus  -  -  -  -  To  face    200 

VII.  Splinter   of    Glass    in    Hand,  close   to  Metacarpal  Bone, 
of  the  Index  Finger     -  -        To  follow  Plate  VI. 

VIII.  Fig.   1. — Section   of    a  Wound   Healed   by  First  Intention 

Ten  Days  after  its  Infliction  -  -  To  face    214 

Fig.  2. — Scar  from  a  Recently  Healed  Superficial  Wound 

(Low  Power)        -  -  To  face    214 

IX.  Skiagram  of  Double  Coxa  Vara  -  -  -  394 

X.  Oblique   Fracture    of    Tibia,    showing   the    Ends    of    the 

Fragments  shaped  en  bee  de  flute  -  To  face     420 

XL  Impacted  Fracture  of  Anatomical  Neck  of  Humerus         ,,         450 
XII.  Fracture  of  Surgical  Neck  of  Humerus    To  follow  Plate  XI. 

XIII.  Separation  of  the  Lower  Epiphysis  of  the  Humerus,  with 

Displacement   Outwards,  in    a   Young    Person,  a   little 
over  the  Age  of  Puberty       -  -  To  face    458 

XIV.  Fracture  of  Olecranon  before  Operation      -  ,,         460 
XV.  Fracture  of  Olecranon  Two  Weeks  after  Operation 

To  follow  Plate  XIV. 


LIST  OF  PLATES 


PLATE  I'AGE 

XVI.  Fracture  of  Olecranon  Six  Weeks  after  Operation 

To  follow  Plate  XV. 
XVII.  Fracture   of    Shaft    of    the    Radius — Antero-posterior 

View     -  -  To  face    462 

XVIII.  The  same  Fracture  seen  from  the  Side 

To  follow  Plate  XVII. 
XIX.  Colles's     Fracture  :     a     Simple    Case,    without     much 

Lateral  Displacement  of  Hand   -  -  To  face    462 

XX.  Colles's  Fracture  :  a  Bad  Case,  with  the  Styloid 
Process  of  the  Ulna  torn  off'  and  much  Outward 
Displacement  of  Hand        -  -     To  follow  Plate  XIX. 

XXI.  Fracture   of    both    Bones    of    the    Forearm,  with    Dis- 
placement Outwards  -  To  face    466 
XXII.  Fracture    of    both    Bones    of    the    Leg,    seen    from    in 

Front  -  -  -  -To face    488 

XXIII.  The  same  Fracture  as   in  Plate  XXII.,   seen  from    the 

Inner  Side       -  -  To  follow  Plate  XXII. 

XXIV.  Bad  Pott's  Fracture,   with    well-marked  Displacement 

Outwards  of  the  Foot,  as  well  as  of  the  Lower 
Fragment  of  the  Fibula  and  the  Internal  Malleolus. 
(Skiagram  taken  from  in  Front)  -  -  To  face    490 

XXV.  Tuberculous  Disease  of  Radius        -  -        ,,         514 

XXVI.  Double  Congenital  Dislocation  of  the  Hip         -        ,,        542 
XXVII.  Dislocation     of     Radius    Forwards,    and    Fracture     of 

Upper  Third  of  Ulna  -  -  To  face    558 

XXVIII.  Tuberculous  Disease    of    Knee-joint,  showing   Invasion 

of  Patella      -  -  -  -  To  face     588 

XXIX.  Skiagram   of    Pelvis,  showing  Tuberculous    Disease   of 

Right  Hip-joint         -  -  To  face    616 

N.B. — All  the  X-ray  pictures  in  this  work  have  been  taken  by  Messrs.  Allen  and 
Hanbury,  48,  Wigmore  Street,  W.,  who  have  kindly  placed  the  negatives  at  our 
disposal. 


ERRATUM. 
On  page  160,  line  7,  for  '  p.  145,'  read  '  p.  181. 


PLATE  I. 


.,  ^    t««, -*• 


Fig.    i. 


Fig.  2. 


Fig.  3. 


Fig.  4. 


Jo  face  ./.  1.  ] 


Fig.   5. 


Fig.  6. 


A    MANUAL    OF    SURGERY. 


CHAPTER  I. 


SURGICAL    BACTERIOLOGY  — SEPSIS    AND    INFECTION  — 
ANTISEPSIS  AND  ASEPSIS. 

Bacteriology,  or  the  science  devoted  to  the  study  of  bacteria, 
must  necessarily  be  the  basis  of  all  scientific  surgery,  which  apart 
from  such  knowledge  degenerates  into  little  more  than  a  technical 
art.  It  is  the  surgeon's  duty  to  understand  the  life-history  and 
methods  of  activity  of  bacteria,  so  that  he  may  be  able  to  prevent 
their  access  to  wounds,  or,  if  they  have  gained  a  foothold  in  the 
system,  be  able  to  combat  them.  To  this  latter  end  he  must  call 
to  his  aid  all  the  powers  of  resistance  latent  in  the  economy,  and 
should  be  able  to  add  to  these  by  the  introduction  of  suitable 
protective  substances  developed  artificially.  Of  course,  it  is  not 
altogether  desirable  that  an  active  operating  surgeon  should  be 
constantly  working  in  the  laboratory  with  virulent  germs,  but 
he  must  have  acquired  a  sound  knowledge  of  bacteriological 
technique,  and  be  fully  capable  of  appreciating  the  researches  and 
investigations  made  by  others. 

Bacteria,  or  schizomycetes,  form  a  very  important  and  numerous 
class  of  minute  vegetable  organisms,  which  are  in  the  present  day 
looked  upon  as  the  essential  cause  of  putrefaction  and  of  most  of 
the  inflammatory  diseases.  They  consist  of  minute  masses  of 
protoplasm  enclosed  in  a  cell  wall,  and  with  sometimes  a  gelatinous 
capsule  or  envelope,  which  may  suffice  to  hold  together  two  or 
four  elements  or  even  larger  colonies. 

They  vary  in  shape,  size,  and  arrangement,  and  from  a  mor- 
phological standpoint  have  been  classified  under  the  following 
headings : 

i.  Micrococci,  or  Cocci,  are  roundish  or  oval  cells,  multiplying 
rapidly  by  a  process  of  fission  (i.e.,  division  into  equal  parts). 
They  may  remain  isolated,  but,  as  a  rule,  are  collected  into 
certain  definite  formations,  and  in  consequence  are  termed  staphy- 

i 


A   MANUAL  OF  SURGERY 


lococci,  or  cluster-cocci  (Fig.  3),  when  they  are  grouped  like  a 
bunch  of  grapes,  usually  occurring  thus  in  localized  inflamma- 
tions;  streptococci,  or  chain-cocci  (Plate  I.,  Fig.  1),  when  they 
develop  in  chains  or  strings,  the  characteristic  of  spreading 
inflammations  ;  diplococci,  when  they  occur  in  pairs — e.g.,  the 
gonococcus  or  pneumococcus,  met  with  in  gonorrhoea  and  pneu- 
monia respectively.  When  they  are  grouped  into  packets  of  four 
or  eight  individuals,  they  are  usually  termed  sarcina  (Plate  I., 
Fig.  2).  Occasionally  any  of  the  above  may  occur  in  masses  or 
colonies,  slimy  or  gelatinous  in  character  (zooglcea). 

2.  Bacilli,  or  rod-shaped  bacteria,  are  found  in  the  form  either 
of  long  or  short  filaments,  made  up  of  an  aggregation  of  individual 
rods  united  end  to  end;  or  they  may  become  curved,  and  so  form 
spiral  rods,  which  may  break  up  into  the  so-called  comma-shaped 
bacilli  ;  or  they  may  persist  in  the  body  of  their  host  as  isolated 
rods,  free  in  the  blood  or  lymph,  or  within  the  substance  of  the 
cells  invaded.  They  multiply  by  fission,  or  by  the  formation  of 
spores  in  their  interior.  These  latter  are  much  more  resistant 
and  less  easily  destroyed  than  the  parent  rods.  The  spore  may 
develop  in  the  centre  of  the  bacillus,  as  in  Bac.  anthracis,  or  at 
one  end,  as  in  the  so-called  drumstick-shaped  Bac.  tctani. 

3.  Spirilla  (Plate  I.,  Fig.  4)  form  corkscrew  -  like  threads, 
possessing  active  power  of  movement.  They  are  of  no  surgical 
interest,  and  in  human  pathology  only  occur  in  a  few  conditions, 
such  as  remittent  fever. 

It  will  here  only  be  possible  to  sketch  in  outline  a  few  general 
facts  as  to  the  life-history  and  mode  of  activity  of  these  organisms. 

Methods  of  Examination. — These  are  in  the  main  threefold  : 

1.  Microscopic  Examination. —  High  powers  of  the  microscope  (e.g.,  -,V  in-  oil 
immersion)  are  needed  for  this  work,  and  even  with  them  it  is  often  difficult  to 
determine  the  characters  of  any  particular  form  of  microbe  under  examination. 
Minute  differences  in  the  size  and  shape  may  assist,  and  the  relative  arrange- 
ment in  chains,  clusters,  etc.  ;  whilst  the  effect  of  different  staining  reagents  is 
also  important.  Into  the  various  methods  of  demonstrating  and  staining 
bacteria  it  is  impossible  to  enter. 

2.  Cultivation  in  or  on  various  nutrient  media  is  of  the  greatest  assistance  in 
determining  the  exact  nature  of  any  special  organism  under  examination.  For 
this  purpose  the  cut  surface  of  a  raw  potato  after  sterilization  of  the  exterior 
suits  excellently  in  many  cases.  Fluids,  such  as  meat  infusion,  milk,  or  fresh 
blood  serum,  are  not  very  satisfactory,  but  similar  materials,  solidified  by  the 
addition  of  gelatine  or  agar-agar,  and  either  placed  in  test-tubes  or  on  plates, 
or  meat  infusion  mixed  with  peptone,  are  the  most  suitable  nutrient  bases.  In 
testing  the  life-history  of  any  microbe,  it  is  important  to  note  whether  or  not 
it  will  develop  in  contact  with  the  air.  This  may  be  accomplished  by  the  use 
of  nutrient  gelatine  poured  into  test-tubes,  some  of  which  are  allowed  to  cool 
in  the  vertical  position,  and  others  on  the  slant.  The  former  are  inoculated 
by  puncturing  the  horizontal  surface  with  an  infected  platinum  wire  (stab 
culture),  the  latter  by  streaking  it  along  the  oblique  surface  (streak  culture). 

3.  Inoculation  experiments  are  really  the  most  reliable  means  of  examining 
into  the  relations  of  micro-organisms  to  any  particular  affection  ;  but  it  must 
be  clearly  recognised  that  animals  are  not  necessarily  affected  in  the  same  way 


SURGICAL  BACTERIOLOGY 


as  man.     Koch  has  insisted  that  the  four  following  essentials  must  be  fulfilled 
in  order  to  prove  the  infective  character  of  any  particular  disease  : 

(i.)  The  organism  must  be  present  in  every  case,  either  in  the  tissues  or  in 

the  blood, 
(ii.)  It  must  be  possible  to  cultivate  it  for  many  generations  apart  from  the 

body, 
(iii.)  Its  inoculation  into  a  suitable  animal  must  be  followed  by  the  appear- 
ance of  the  specific  disease  ;  and 
(iv.)  The  organism  must  be  found  in  the  tissues  or  blood  of  the  animal 
infected  in  this  manner. 

Habitat. — Bacteria  are  almost  universal  in  their  distribution. 
Earth,  air,  and  water  are  full  of  them,  and  especially  so  in 
populous  neighbourhoods.  The  greater  the  number  of  the 
inhabitants,  the  larger  the  number  of  organisms  in  the  air.  In 
isolated,  and  especially  mountainous,  districts  there  are  com- 
paratively few,  whilst  in  the  air  of  a  crowded  hospital  ward 
swarms  of  them  are  present,  and  these  often  of  a  most  dangerous 
type.  Food-stuffs  and  fluids,  such  as  water  and  milk,  are  fre-. 
quently  contaminated,  and  by  these  means  disease  is  often  intro- 
duced into  the  system.  The  surface  of  the  body  is  impregnated 
with  bacteria,  which  extend  to  a  depth  greater  than  can  be 
affected  by  mere  domestic  cleanliness,  whilst  the  intestinal  tract 
teems  with  them  from  mouth  to  anus.  It  appears  that  whilst  the 
external  auditory  meatus  and  inferior  meatus  of  the  nose  are 
occupied  by  bacteria,  the  upper  meati  of  the  nose  are  sterile,  as 
also  the  upper  part  of  the  virgin  vagina  and  the  deeper  portion 
of  the  (uncontaminated)  male  urethra.  The  gall-bladder,  as  well 
as  the  biliary  and  pancreatic  ducts,  is  also  normally  free  from 
germs,  whilst  in  a  healthy  individual  the  solid  organs,  the  blood, 
and  lymph  are  also  practically  sterile.  Any  condition  of  general 
weakness  facilitates  the  entrance  of  germs  into  the  system,  or, 
perhaps  one  should  say,  diminishes  the  resistance  of  the  body  to 
their  presence  and  activity,  and  hence  lays  the  individual  open  to 
the  occurrence  of  diverse  infective  diseases. 

Mobility. — The  cocci  are  as  a  group  incapable  of  active  locomo- 
tion, although  they  manifest,  in  common  with  all  minute  non- 
living particles,  '  Brownian '  movements.  Most  bacilli  and 
spirilla  have  in  addition  the  power  of  moving  from  place  to  place, 
accomplished  by  means  of  flagella,  which  develop  at  one  or  both 
ends  as  single  filaments  or  in  bunches  all  over  the  organism. 
These  can  be  readily  demonstrated  in  the  Bac.  typhosus  (Plate  I., 

Fig-  3). 

Multiplication. — The  power  of  multiplying  possessed  by  bacteria 
is  enormous,  though  not  unlimited.  Two  methods  have  been 
mentioned  above — viz.,  fission  and  the  formation  of  endospores. 
Spore  formation  is  not  known  to  occur  in  the.  cocci  or  sarcinae, 
and,  although  common  among  the  bacilli,  is  not  invariable  ;  thus 
the  Bac.  typhosus  and  the  Bac.  diphtheria  are  asporogenous.  Only 
one   spore   forms   in   each   bacillus,   and,  as  already  stated,  its 

i — 2 


A  MANUAL  OF  SURGERY 


position  varies  in  different  species.  The  conditions  favourable 
to  the  development  of  spores  have  not  yet  been  fully  ascertained, 
but  in  most  varieties  a  free  supply  of  oxygen  is  required  ;  it  is 
also  a  fact  that  spores  rarely  form  amongst  the  living  tissues  of 
the  body. 

Conditions  of  Growth. — The  activity  and  development  of  bacteria 
are  physiological  phenomena,  carried  out  in  accordance  with  the 
general  laws  governing  animal  and  vegetable  life,  and  requiring 
certain  definite  conditions  to  be  present.  The  pabulum,  or  food- 
stuff, differs  somewhat  with  the  particular  species,  but  they  all 
require  water,  oxygen,  hydrogen,  nitrogen,  carbon,  and  certain 
inorganic  salts  ;  they  usually  grow  better  on  highly  complicated 
substances  than  on  more  simple  materials.  Desiccation  arrests 
bacterial  growth,  although  the  organisms  are  not  killed  thereby. 
Temperature  has  also  considerable  influence  upon  their  develop- 
ment. Few  germs  grow  well  under  200  C,  and  pathogenic 
organisms  develop  best  at  about  370  to  380  C.  Cold  checks  all 
growth,  but  does  not  kill  the  germs.  Any  degree  of  heat  above 
570  C,  if  allowed  to  act  long  enough,  will  suffice  to  kill  most 
bacteria,  but  spores  require  a  much  higher  temperature  for  their 
destruction.  Light,  especially  direct  sunlight,  has  a  retarding 
influence  on  the  development  of  most  micro-organisms. 

The  necessity  or  not  for  atmospheric  air  in  their  development 
constitutes  the  basis  of  the  division  of  microbes  into  aerobic  and 
anaerobic.  When  they  can  grow  in,  and,  indeed,  require  for  their 
development,  the  actual  presence  of  free  air,  they  are  termed 
obligate  aerobes.  If,  however,  they  have  the  power  of  acquiring 
the  oxygen  they  need  from  the  tissues  surrounding  them,  they  are 
then  known  as  facultative  anaerobes ;  their  development  is  then 
rather  less  rapid  than  when  aerobic  conditions  are  present. 
Obligate  anaerobic  organisms  are  those  which  require  an  atmosphere 
around  them,  from  which  oxygen  is  rigidly  excluded,  and  these 
usually  flourish  best  in  nitrogen  or  hydrogen — e.g.,  the  bacillus  of 
tetanus.  It  must  be  remembered,  however,  that  although  their 
power  of  development  is  arrested  by  the  presence  of  oxygen,  it  is 
not  destroyed  ;  the  restoration  of  anaerobic  conditions  will  at  once 
restore  their  vital  activities. 

Results  of  Growth. — Many  different  substances  result  from 
bacterial  growth,  both  in  culture  media  and  in  the  body,  and  upon 
the  characters  of  these  depend  to  a  large  extent  the  symptoms  of 
the  special  diseases.  Chief  amongst  them  are  the  Toxins,  which 
are  perhaps  more  intensely  poisonous  than  anything  else  known. 
Many  of  them  are  albuminous  bodies  (possibly  albumoses) ;  most 
of  them  have  a  ferment-like  action  ;  and  not  a  few  are  capable  of 
liquefying  gelatine  or  peptonizing  proteids.  The  toxins  formed 
by  putrefactive  organisms  {the  ptomaines)  are  more  or  less  peculiar 
in  that  they  are  alkaloidal  in  nature — i.e.,  built  up  in  the  like- 
ness of  ammonium   hydrate   (NH4HO) — they   unite  with  acids, 


SURGICAL  BACTERIOLOGY— SEPSIS 


and  can  be  crystallized.  The  development  of  toxins  in  the  body 
is  the  all-important  cause  of  the  symptoms  of  disease ;  locally, 
they  give  rise  to  various  inflammatory  phenomena,  and  by  their 
general  absorption  produce  either  pyrexia  alone,  or  peculiar  and 
characteristic  manifestations,  as  in  tetanus  and  diphtheria. 

Other  results  of  bacterial  activity  are  less  important,  though 
some  are  very  obvious,  i.  Acid  substances  may  be  formed  ;  e.g., 
the  Bac.  acidi  lactici  is  the  constant  cause  of  the  souring  of  milk. 
2.  Alkaline  products  may  develop;  e.g.,  the  Diplococcus  urea  trans- 
forms the  urea  of  urine  into  carbonate  of  ammonia.  3.  Gases, 
often  of  a  very  penetrating  odour,  may  be  produced  by  others ; 
e.g.,  Bac.  coli  communis,  or  Bac.  cedematis  maligni.  4.  Various 
colouring  bodies  are  generated,  but  this  property  is  mainly  limited 
to  the  non-pathogenic  group.  5.  Phosphorescence  is  also  caused 
by  certain  bacteria. 

From  their  environment  in  pathological  conditions,  bacteria 
are  divided  into  two  great  classes,  according  to  whether  or  not 
they  can  develop  in  the  living  tissues.  The  pathogenic  or  parasitic 
bacteria  can  do  so,  producing  what  are  known  as  infective 
diseases ;  but  when  an  organism  can  only  develop  in  dead  tissues, 
such  as  masses  of  slough,  or  in  exudations  of  blood,  serum,  or 
pus,  or  in  some  non-living  nutrient  material,  it  is  called  a  non- 
pathogenic; saprophytic,  or  carrion  microbe,  and  any  inflammatory 
reaction,  local  or  general,  thereby  induced  is  due  to  the  irritating 
effect  of  the  toxic  bodies  produced  in  this  way,  and  not  directly 
to  the  action  of  the  bacteria.  Some  of  the  pathogenic  organisms 
are  capable  of  continuing  their  development  in  dead  tissues  as 
facultative  saprophytes,  and  this  property  is  one  of  great  danger,  in 
that  it  permits  of  extensive  diffusion  of  the  virus  ;  the  tetanus, 
anthrax,  and  malignant  oedema  bacilli,  as  also  the  pyogenic  cocci, 
are  characterized  by  this  property. 

It  is  now  possible  to  define  the  terms  '  sepsis '  and  '  infection  ' 
as  employed  in  surgical  practice. 

Sepsis. 

Sepsis  is  a  term,  somewhat  loosely  applied,  to  indicate  that  a 
wound  or  sore  has  become  infected  w7ith  micro-organisms  in  such 
a  way  as  to  interfere  with  healthy  reparative  action.  When  it 
involves  an  operation  wound,  it  is  due  to  contamination  from  a 
dirty  state  of  the  skin,  impure  instruments,  ligatures  or  sutures, 
unsterilized  hands  of  the  surgeon  or  assistant,  a  faulty  dressing, 
etc.  Sepsis  may  also  develop  in  connection  with  any  unprotected 
sore  or  abrasion,  and  the  offensive  odour  which  accompanies 
neglected  syphilitic  or  cancerous  sores  is  simply  due  to  this,  and 
is  no  essential  part  of  the  causative  affection. 

The  organisms  present  in  septic  affections  vary  considerably, 
but  are  of  two  main  types  :  (a)  Various  non-pathogenic  microbes, 


A  MANUAL  OF  SURGERY 


especially  the  Proteus  vulgaris,  P.  Hausevi,  sundry  forms  of  Sarcince, 
and,  under  certain  circumstances,  the  Bac.  coli  communis,  and 
(b)  the  ordinary  pyogenic  bacteria,  especially  the  staphylococci 
and  streptococci,  which  are,  of  course,  pathogenic. 

The  method  of  action  of  these  organisms  is  somewhat  diverse. 
(a)  The  former,  or  non-pathogenic  group,  can  only  develop  in 
dead  tissues  or  fluids,  or  in  passive  material  such  as  blood-clot, 
pus,  or  serum ;  they  may  occasionally  gain  an  entrance  to  the 
general  circulation,  but  are  rapidly  destroyed,  and  do  no  harm. 
It  is  obvious,  therefore,  that  a  dry  wound  is  less  likely  to  become 
septic  than  one  in  which  there  is  much  exudation  of  blood  or 
serum,  so  that  absolute  haemostasis  and  good  drainage  are  two 
most  important  preventive  measures. 

When  once  admitted  to  the  part,  the  organisms  rapidly 
multiply,  causing  putrefaction  or  other  changes  in  any  suitable 
pabulum  present,  and  thus  produce  irritating  or  poisonous 
chemical  substances,  upon  the  action  of  which  the  symptoms  of 
sepsis,  whether  local  or  general,  depend.  If  a  large  quantity  of 
putrescible  material  is  present,  the  wound  or  part  may  become 
very  offensive,  and  a  sloughing  process  may  ensue  as  a  result  of 
the  irritating  local  action  of  the  toxins,  whilst  at  the  same  time 
general  toxic  symptoms  are  manifested,  varying  in  severity  with 
the  dose  absorbed. 

(b)  The  latter  group  of  true  pyogenic  bacteria  are  capable  of 
growth  in  a  similar  manner,  but  in  addition  are  able  to  invade 
and  develop  in  the  tissues  of  the  body  (infection),  and  so  may  give 
rise  to  spreading  inflammation,  such  as  erysipelas  or  cellulitis, 
and  to  general  infective  diseases,  such  as  pyaemia  or  septicaemia. 

Into  the  question  of  local  appearances  and  treatment  it  is 
unnecessary  to  enter  here,' but  it  is  desirable  to  add  a  few  words  as 
to  the  general  conditions  which  are  associated  with  a  septic  wound. 
They  are  entirely  due  to  the  absorption  of  the  toxins  produced 
in  the  inflammatory  focus,  and  hence  vary  considerably  in  severity 
with  the  dose.     Thus  three  varieties  have  been  described  : 

i.  When  the  dose  is  small,  but  if  it  is  absorbed  regularly  and 
for  a  long  time,  a  definite  diurnal  range  of  temperature  follows, 
known  as  hectic  fever  (p.  52).  It  is  always  associated  with  per- 
sistent and  prolonged  suppuration. 

2.  Septic  Traumatic  Fever  is  due  to  the  absorption  of  a  some- 
what larger  amount  of  the  poison  after  an  operation  or  injury, 
which  is  followed  by  septic  inflammation.  A  burn  or  compound 
fracture  which  is  not  rendered  aseptic  is  always  accompanied  by 
fever,  ranging  from  1020  to  io4°F.  for  some  days,  until  the  wound 
is  securely  sealed  off  by  the  development  of  granulation  tissue. 
When  once  this  has  occurred,  the  fever  usually  disappears,  unless 
septic  material  is  retained  under  pressure.  The  actual  phenomena 
connected  with  such  an  attack  are  in  no  way  peculiar. 

3.  Acute    Saprsemia,   or   Septic  Intoxication,   results   from   the 


SEPSIS  AND  INFECTION 


absorption  of  a  large  dose  of  toxic  material.  This  condition  was 
for  long  confounded  with  true  infective  septicaemia,  and  even 
now,  though  clearly  distinguished  pathologically,  a  clinical  dis- 
tinction between  the  two  is  not  always  possible,  except  by  await- 
ing the  result.  Sapraemia  is  essentially  a  toxaemia,  or  condition 
due  to  chemical  poisoning ;  the  blood  is  not  infective,  and  the 
symptoms  are  directly  proportionate  to  the  dose.  Any  condition 
in  which  there  is  a  large  mass  of  putrefying  tissue  or  fluid  from 
which  absorption  can  occur  may  lead  to  sapraemia — e.g.,  a  portion 
of  decomposing  placenta  in  the  puerperal  uterus,  the  existence  of 
septic  pus  under  pressure  in  the  peritoneal  cavity,  a  joint,  or  else- 
where ;  or  a  mass  of  putrefying  blood-clot,  say,  in  the  pleural 
cavity  after  a  penetrating  wound. 

The  Symptoms  usually  commence,  two  or  three  days  after  the 
cause  has  come  into  operation,  with  a  severe  rigor,  followed  by  a 
maintained  high  temperature,  although  sometimes  it  is  subnormal 
in  the  more  serious  cases.  This  is  associated  with  loss  of 
appetite,  a  dry  tongue,  a  quick  pulse,  rapidly  becoming  weak, 
severe  headache,  and  nocturnal  delirium  of  some  intensity.  The 
patient  is  at  first  constipated,  but  vomiting  and  diarrhoea  may 
ensue  from  gastro-intestinal  irritation,  followed  by  fatal  exhaus- 
tion and  collapse,  or  he  may  become  comatose  and  unconscious 
for  some  time  before  death,  according  to  whether  the  toxins  act 
chiefly  upon  the  alimentary  system  or  upon  the  cerebral  centres. 
Dyspnoea,  from  pulmonary  congestion,  and  albuminuria,  also 
occur.  Should,  however,  the  putrefying  mass  be  removed  in 
time,  the  fever  will  cease  as  by  magic,  the  tongue  cleans,  the 
appetite  returns,  the  headache  vanishes,  and  in  twenty-four  hours 
the  patient  feels  a  different  individual. 

Post-mortem  Appearances.  —  Decomposition  is  early,  rigor 
mortis  feeble,  and  cadaveric  lividity  well  marked,  especially  along 
the  lines  of  the  superficial  veins  and  posteriorly.  The  blood 
coagulates  imperfectly,  and  is  dark  and  tarry  in  colour  ;  if  allowed 
to  stand,  the  serum  which  separates  from  the  corpuscles  is  much 
stained  from  the  breaking  up  of  the  red  blood-cells  which  occurs 
in  all  septic  and  infective  cases.  This  condition  explains  the 
amount  of  cadaveric  lividity,  and  also  the  post-mortem  staining 
of  the  endocardium  and  tunica  intima  of  the  larger  vessels,  which 
is  such  a  marked  feature  in  these  cases,  and  which  was  formerly 
supposed  to  result  from  a  diffuse  arteritis.  Most  of  the  serous 
cavities  contain  a  certain  amount  of  blood-stained  fluid,  and 
under  almost  all  the  serous  membranes  are  well-marked  petechia?, 
especially  under  the  pericardium  and  pleura.  The  lungs  are 
deeply  congested,  particularly  at  the  back,  and  very  cedematous ; 
the  liver,  spleen,  and  kidneys  are  enlarged,  pulpy,  soft,  and 
congested,  notably  the  spleen.  The  epithelium  of  most  of  the 
secreting  glands,  if  examined  microscopically,  gives  evidence  of 
cloudy  swelling. 


A  MANUAL  OF  SURGERY 


The  Treatment  of  acute  sapraemia  must  be  chiefly  directed  to 
the  local  cause,  which  is  dealt  with  by  suitable  surgical  means. 
General  treatment  is  merely  symptomatic.  Possibly  a  good  purge 
may  be  advisable  in  the  early  stages,  but  in  the  later  a  supporting 
and  stimulating  plan  of  treatment  must  be  adopted.  Recently  it 
has  been  proposed  to  deal  with  the  acute  toxaemia  of  peritonitis 
and  similar  conditions  by  the  repeated  injection  into  the  veins  of 
large  quantities  of  saline  solution  (7)i.  ad  Oi.),  and  excellent  results 
have  been  obtained  by  this  means,  the  injections  being  followed 
by  diuresis  and  diarrhoea,  which  presumably  assist  in  the  elimina- 
tion of  the  poison.     (See  also  on  Septicaemia,  p.  102.) 


Infection. 

An  infective  process  is  one  due  to  the  activity  of  micro- 
organisms, which  are  capable  of  developing  in  living  tissues — 
the  true  pathogenic  bacteria  or  parasites.  Such  find  an  entrance 
into  the  body  in  many  ways,  as  through  the  healthy  skin,  or  by 
the  mucous  membranes  of  the  alimentary  canal,  respiratory  tract, 
or  genito-urinary  apparatus,  or  through  wounds  and  abrasions  ; 
and  very  often  the  manifestations  of  disease  differ  widely  with 
the  channel  of  entrance.  Occasionally  they  are  absorbed  into 
the  blood  through  some  comparatively  insignificant  local  lesion, 
and  although  insufficient  in  numbers  to  produce  general  symp- 
toms, yet  they  may  find  elsewhere  some  suitable  spot  for  their 
development,  and  there  settle,  giving  rise  to  an  acute  outbreak  of 
mischief,  which  may  attain  grave  proportions.  Such  a  condition 
is  said  to  be  due  to  auto-infection.  (See  Acute  Osteomyelitis, 
Chapter  XVIII.) 

It  must  not  be  imagined  that  mere  exposure  to  infection 
inevitably  results  in  an  outbreak  of  disease.  Nature  has  pro- 
vided us  with  very  efficient  protective  agents,  and  many  factors 
enter  into  the  question  as  to  whether  or  not  bacteria  are  able  to 
develop  in  the  body. 

1.  The  dose  of  the  organisms  is  an  all-important  element, 
especially  in  connection  with  the  pyogenic  bacteria,  which  are 
those  most  commonly  met  with,  and  against  the  activity  of  which 
we  are  fairly  well  protected.  Much  experimental  work  has  been 
undertaken  to  establish  this  point,  and  it  is  now  well-known  that 
usually  an  enormous  number  of  cocci  have  to  be  injected  into  the 
blood-stream  in  order  to  establish  general  infection  ;  a  smaller 
number  has  but  little,  or,  at  any  rate,  a  very  temporary  effect. 

2.  The  vivulcnce  of  the  organisms  varies  very  considerably  under 
different  circumstances,  and  bacteria  which  under  one  set  of 
conditions  are  comparatively  harmless  may  under  others  become 
intensely  noxious.  It  is  only  necessary  to  mention  the  frightful 
severity   of   some    diffuse   inflammatory  attacks   after,    say,    the 


SEPSIS  AND  INFECTION 


prick  of  an  infected  pin  to  emphasize  the  potentialities  for  mischief 
latent  in  some  germs. 

3.  The  resistance  of  the  tissues  is  another  factor  in  the  case,  the 
nature  of  which  we  shall  allude  to  anon.  Here  we  would  only 
call  attention  to  the  fact  that  anything  that  diminishes  this  resist- 
ing power  favours  the  chances  of  infection.  Thus  exposure  to 
wet  and  cold,  especially  if  prolonged,  unquestionably  leads  to  a 
decided,  if  temporary,  lowering  of  the  vitality  of  the  tissues, 
which  may  then  more  easily  fall  a  prey  to  the  organisms  which 
are  so  constantly  present  and  ever  ready  to  take  advantage  of 
any  weak  spot  in  our  defensive  armour.  The  effect  of  such 
exposure  varies  with  the  individual,  but  in  most  cases  his  own 
particular  '  weak  spot  '  will  be  found  out.  In  one  a  mere  cold 
in  the  head — i.e.,  a  congestion  of  and  hypersecretion  from  the 
Schneiderian  mucous  membrane  —  will  result ;  in  another  the 
mischief  will  extend  more  deeply,  leading  to  pleurisy  or  pneu- 
monia ;  in  a  third  some  weak  organ,  such  as  the  stomach  or 
bladder,  may  be  involved  ;  whilst  in  another  an  attack  of 
rheumatism  may  be  induced.  A  localized  injury  to  the  tissues, 
whether  in  the  nature  of  a  burn,  bruise,  or  crush,  etc.,  will  render 
them  more  liable  to  microbic  invasion ;  whilst  general  con- 
ditions of  the  blood,  such  as  occur  in  chronic  alcoholism,  Bright's 
disease,  diabetes,  etc.,  are  always  associated  with  a  diminished 
power  of  resistance.  Want  of  fresh  air,  living  in  unsanitary 
surroundings,  overloading  of  the  system  with  rich  food,  especially 
if  the  excretory  apparatus  of  the  body  is  not  effective — all  such 
conditions  favour  the  activity  of  organisms,  and  render  the  subject 
more  prone  to  be  attacked. 

4.  The  amount  of  suitable  and  available  pabulum  has  a  distinct 
influence,  particularly  in  the  case  of  the  pyogenic  organisms, 
which  are  facultative  saprophytes,  and  so  may  readily  develop 
in  non-living  material,  such  as  blood-clot,  etc.,  allowed  to  collect 
in  or  on  a  wound.  This  is  followed  by  a  local  development  of 
toxins,  which,  acting  on  the  immediately  contiguous  living  tissues, 
cause  them  to  become  inflamed ;  local  diminution  of  resistance 
follows,  and  may  lead  to  actual  infection,  which  otherwise  the 
patient  could  easily  have  resisted.  Hence  the  importance  of 
draining  all  wounds  where  effective  haemostasis  has  not  been 
attained,  and  of  giving  an  exit  to  all  collections  of  blood,  etc., 
which  might  become  septic.  In  the  healthy  individual  a  wound 
will  often  heal  perfectly,  in  spite  of  the  presence  of  organisms, 
granting  that  it  is  dry  and  free  from  bruising.  The  existence  of 
blood-clot  or  exudation  in  which  the  cocci  can  develop  would  be 
likely  to  favour  suppuration. 

A  good  deal  of  confusion  has  existed  between  the  terms  '  contagion  '  and 
'  infection ';  and  it  is  well  to  explain  that  by  '  contagious  '  is  meant  a  disease 
which  can  only  be  transmitted  to  a  healthy  person  by  direct  contact  with  the 
infected   individual,  or  by  the  direct  transmission  of   the  virus  through  an 


A   MANUAL  OF  SURGERY 


intermediate  individual  or  object,  provided  that  the  organism  has  not  multiplied 
outside  the  body.  Syphilis  is  eminently  contagious,  either  directly,  from  one 
person  to  another,  or  indirectly,  as  by  smoking  an  infected  pipe.  Thus,  con- 
tagion is  merely  a  limited  type  of  infection.  On  the  other  hand,  many  infective 
diseases  are  due  to  organisms  which  can  readily  develop  outside  the  body, 
i.e.,  to  the  facultative  saprophytes,  but  to  these  the  term  '  contagious  '  should 
not  be  applied. 

Local  Infective  Processes  are  those  caused  at  the  spot  of  inocula- 
tion by  the  growth  and  development  of  the  microbes.  After  a 
period  of  incubation — which  varies  with  different  organisms,  and 
during  which  we  may  imagine  that  they  are  struggling  with  the 
germicidal  action  of  the  tissues,  and  establishing  their  foothold  in 
the  body — the  bacteria  begin  to  grow  and  multiply,  and  by  the 
deleterious  products  of  their  activity  cause  irritation  of  the  tissues 
and  various  degrees  of  inflammation. 

These  inflammatory  foci  may  remain  limited,  or  diffusion  may 
occur  by  the  bacteria  spreading  with  more  or  less  rapidity  by 
continuity  of  tissue  or  along  lymph  channels  ;  or  the  organisms 
may  be  widely  disseminated  through  the  body  by  the  blood- 
vessels in  the  shape  of  emboli.  A  certain  amount  of  constitutional 
disturbance  may  accompany  these  manifestations,  due  to  the 
absorption  of  the  toxins  produced  locally,  whilst  in  some  diseases 
the  general  toxic  symptoms  (or  toxaemia)  associated  with  some 
local  mischief  may  be  extremely  severe,  as  in  tetanus  and 
diphtheria.  Hence  local  infective  processes  may  be  classified 
in  two  divisions  :  (a)  those  in  which  there  is  but  little  or  no 
general  toxaemia,  such  as  a  soft  chancre,  a  tuberculous  abscess, 
or  a  mild  attack  of  gonorrhoea ;  and  (b)  those  in  which  the 
toxsemic  condition  is  well  marked,  as  in  erysipelas,  tetanus,  diph- 
theria, etc.,  the  character  of  the  symptoms  varying  necessarily 
with  the  different  toxins. 

Many  of  the  organisms  which  are  the  causes  of  local  infection 
may  also  develop  generally  in  the  system,  and  produce  grave 
constitutional  affections. 

General  Infective  Processes  are  those  in  which  the  organisms 
develop  and  multiply  in  the  blood-stream,  so  that  inoculation  of 
a  sound  person  with  the  blood  would  almost  certainly  transmit 
the  disease  if  a  sufficient  dose  were  introduced.  Many  of  the 
bacteria  producing  local  infection  give  rise  to  these  general 
diseases,  and,  indeed,  in  surgery  we  rarely  see  the  latter  without 
some  local  condition  being  present  to  explain  its  origin.  Septi- 
caemia, pyaemia,  acute  tuberculosis,  the  second  stage  of  syphilis, 
anthracaemia,  and  probably  the  exanthemata,  are  illustrations  of 
general  infection  (see  Chapter  VI.). 

Resisting  or  Antiseptic  Power  of  the  Tissues — Immunity. — If 
we  are  surrounded  with,  and  if  even  our  bodies  are  invaded  by,  so 
great  a  swarm  of  enemies,  many  of  which  could  under  suitable 
circumstances  produce  grave  diseases,  there  must  necessarily  be 


SEPSIS  AND  INFECTION 


present  within  us  some  potent  natural  means  of  resisting  their 
activity  and  development.  If  bacteriologists  can  only  determine 
how  organisms  are  naturally  kept  at  bay,  we  may  hope  to  elaborate 
along  the  same  lines  defensive  measures  which  will  be  available 
when  the  enemy  has  broken  through  the  first  line  of  defence,  and 
is  actively  attacking  the  body. 

That  a  Natural  Immunity  to  certain  diseases  is  present  in 
various  individuals  is  only  hi  accord  with  the  observation  that 
various  animals  are  capable  of  resisting  the  action  of  microbes 
which  can  develop  in  others  ;  thus,  rats  are  unharmed  by  anthrax 
bacilli,  whilst  the  dog,  the  goat,  and  the  ass  are  practically 
immune  to  tubercle.  Again,  negroes  are  relatively  insusceptible 
to  yellow  fever,  whereas  white  people  are  extremely  susceptible. 
That  this  natural  immunity  is  not  absolute  is  also  a  fact,  since 
organisms  which  will  have  no  effect  on  a  healthy  animal  will 
sometimes  attack  one  which  has  been  brought  into  an  asthenic 
condition. 

It  is  also  a  well-known  fact  that  immunity  to  certain  diseases 
may  be  acquired  in  various  ways  :  (i)  Thus,  one  attack  of  many 
specific  diseases  frees  the  individual  from  the  risk  of  contracting 
it  again — e.g.,  the  exanthemata  and  syphilis — but  this  freedom  is 
not  absolute,  and  second  attacks,  even  of  such  an  affection  as 
syphilis,  are  not  unknown.  In  some  infective  diseases — e.g., 
erysipelas — it  seems  probable  that  any  immunity  which  develops 
subsequently  is  of  extremely  short  duration  and  quickly  passes 
away,  leaving  the  patient,  if  anything,  more  prone  to  infection 
than  formerly.  (2)  Inoculation  with  the  actual  virus  of  an 
infective  disease  has  been  utilized  in  the  case  of  small-pox, 
choosing  such  a  time  as  suits  the  individual,  and  when  he  is  in 
good  health.  This  practice  has  ceased  since  the  introduction  of 
vaccination,  but  the  method  is  still  utilized  in  the  case  of  certain 
animals.  Thus,  an  animal  can  be  immunized  by  inoculating  it 
with  minute  doses  of  a  specific  organism,  which  are  gradually 
increased,  until  no  more  effect  is  produced,  whatever  the  dose 
given.  (3)  After  Pasteur  had  made  his  brilliant  and  most  valuable 
discovery  that  the  virulence  of  germs  could  be  easily  mitigated, 
and  that  exposure  to  heat  for  a  short  time  sufficed  to  attenuate 
the  virus  in  the  majority  of  cases,  much  experimental  work  on 
animals  became  possible,  and  considerable  success  has  attended 
the  use  of  an  attenuated  virus  in  order  to  protect  cattle  from 
anthrax.  (4)  Going  one  step  further,  it  has  been  found  that  one 
need  not  use  the  living  organism  at  all,  but  that  inoculation  with 
the  sterilized  products  of  bacterial  activity  (i.e.,  the  dead  bacteria, 
together  with  their  toxins)  is  in  many  diseases  quite  sufficient  to 
determine  immunization.  A  minute  dose  is  at  first  administered, 
but  as  the  degree  of  immunity  increases  the  dose  is  gradually 
augmented,  until  finally  the  animal  can  receive  with  impunity  an 
injection   of  many   hundred  times    the    dose  which  would    have 


A   MANUAL  OF  SURGERY 


killed  it  at  first.  The  typhoid  and  plague  vaccines  are  of  this 
nature.  (5)  Lastly,  it  is  now  known  that  the  blood  serum  of  an 
immunized  animal  has  considerable  protective  powers,  and  what 
has  been  termed  passive  immunity  may  be  developed  in  this  way. 
Most  of  the  serotherapy  of  the  present  day  depends  on  this 
property,  and  the  serums  known  as  antitetanic,  antidiphtheritic, 
and  antistreptococcic  are  all  of  this  najture.  The  immunity 
conferred  by  this  means  is  rapidly  acquired,  but  does  not  generally 
last  long. 

Much  discussion  has  arisen  as  to  the  way  in  which  the  invasion 
of  infective  organisms  is  repelled  in  the  body,  and  two  chief 
schools  of  thought  have  arisen  :  (1)  The  French  school,  led  by 
Metchnikoff,  maintains  that  the  leucocytes,  and  also  the  larger 
round  cells  derived  from  the  connective-tissue  corpuscles,  described 
elsewhere  as  '  fibroblasts,'  have  the  power  of  taking  into  their 
substance  the  microbes,  and  destroying  them  by  a  process  of 
digestion.  This  idea  of  Phagocytosis  is  based  on  the  results  of 
microscopic  examination,  it  being  tolerably  easy  to  demonstrate 
the  presence  of  bacteria  within  the    living    leucocyte   (Fig.   1), 


Fig.   1. — Phagocytosis.     (Tillmanns.) 

In  the  first  figure  the  rod-shaped  organism  is  being  absorbed  or  swallowed  by 
the  phagocyte  ;  in  the  second  it  is  incorporated  in  its  body ;  and  in  the 
third  it  is  being  disintegrated. 


although  opponents  to  this  theory  suggest  that  it  is  only  dead  or 
dying  organisms  which  are  dealt  with  in  this  way  ;  whilst  it  is 
also  a  well-known  fact  that  the  presence  of  organisms  within  cells 
is  no  absolute  evidence  of  phagocytosis,  since  the  latter  may  be 
invaded  and  finally  destroyed  by  the  bacteria,  as  in  leprosy  and 
gonorrhoea.  As  an  important  outcome  of  this  doctrine  has  arisen 
the  idea  of  Chemiotaxis,  a  term  introduced  to  indicate  an  attractive 
or  repulsive  power  exercised  upon  the  leucocytes  by  foreign  bodies 
or  various  chemical  substances,  particularly  those  dependent  on 
bacterial  activity.  By  positive  chemiotaxis  is  meant  the  attrac- 
tion whereby  leucocytes  are  gathered  towards  any  tissues  in  which 
bacteria  have  commenced  to  develop  ;  the  organisms  or  their 
products  seem  to  have  a  power  of  causing  active  diapedesis  and 
exudation  of  plasma,  as  a  result  of  which  the  spread  of  the 
microbic  invasion  is  more  likely  to  be  limited,  and  the  inflamma- 
tion thus  caused  is  protective  rather  than  destructive.     Positive 


SEPSIS  AND  INFECTION  13 

chemiotaxis  is  to  be  looked  on,  then,  as  one  of  Nature's  defences 
against  an  active  and  vigorous  microbic  attack.  That  it  occurs 
cannot  be  questioned,  though  no  explanation  as  to  its  origin  or 
nature  is  at  present  forthcoming.  It  must  be  noted,  however, 
that  its  existence  is  no  absolute  evidence  in  favour  of  Metchnikoff's 
theory,  since  where  leucocytes  are  collected,  there  is  also  certain 
to  be  an  increased  effusion  of  plasma  or  serum.  Negative  chemio- 
taxis, on  the  other  hand,  is  the  term  applied  to  a  condition  in 
which  the  leucocytes  are  apparently  repelled  by  the  organisms, 
probably  on  account  of  their  virulent  nature,  though  it  is  impossible 
to  prove  that  any  active  repulsion  exists.  Both  phenomena  can 
be  seen  very  well  by  inoculating  the  cornea  of  an  animal  with  the 
Aspergillus  nigev,  as  was  done  by  Leber  ;  the  spot  of  inoculation 
looks  opaque  and  dull,  owing  to  the  development  therein  of  the 
mycelium  of  the  fungus,  and  the  necrosis  caused  thereby  ;  around 
this  is  an  area  of  clear  corneal  tissue  which  is  necrotic,  but  free 
from  leucocytes  owing  to  negative  chemiotaxis.  Outside  this, 
again,  is  a  circle  of  infiltrated  tissue,  at  first  of  a  whitish-yellow 
colour,  and  finally  breaking  down  into  pus,  the  result  of  positive 
chemiotaxis.  (2)  More  recently  the  theory  of  phagocytosis  has 
been  very  vigorously  attacked  by  the  German  school  of  patho- 
logists, and  it  has  been  maintained  that  the  chief  germicidal 
powers  of  the  body  reside  in  the  blood  serum  and  its  constituents. 
This  idea  is  certainly  supported  by  the  well-known  fact  that  fresh 
blood  serum  is  a  bad  medium  for  the  cultivation  of  bacteria.  Its 
inhibitory  or  germicidal  properties  can,  however,  be  removed  by 
keeping  it,  or  by  exposing  it  to  a  process  of  dialysis,  or  by  heating 
it  for  about  half  an  hour  to  a  temperature  of  550  C.  Moreover, 
as  mentioned  above,  the  blood  serum  of  immunized  animals 
evidently  contains  certain  substances  of  an  antibacterial  or  pro- 
tective nature,  and  may  be  used  as  a  curative  agent.  Certain 
special  albuminous  substances,  more  or  less  of  the  nature  of 
ferments,  have  been  isolated,  to  which  the  name  of  Protective 
Albumens  or  Alexines  has  been  given.  Probably  there  is  truth 
in  both  these  theories,  the  two  different  powers  being  called  into 
play  under  varying  circumstances  and  in  different  stages  of  the 
disease,  the  phagocytes  only  coming  in  to  complete  the  work 
which  has  been  already  mainly  effected  by  the  blood  plasma  ;  or 
possibly  the  protective  albumens  are  developed  by  the  leucocytes 
and  set  free  into  the  serum. 

The  inflammatory  phenomena  which  supervene  upon  a  localized 
infection  are  to  be  looked  on  as  Nature's  means  of  repelling  the 
bacterial  invasion.  The  irritation  induced  by  the  toxins  calls 
forth  an  increased  supply  of  blood  (hyperaemia),  and  that  involves 
an  increased  flow  of  blood  serum,  whilst  leucocytes  are  gathered 
together  from  all  parts  by  a  process  of  chemiotaxis  ;  indeed,  so 
marked  is  this  latter  detail  that  sometimes  leucocytosis  is  induced, 
and  a  blood  count  will  often  indicate  whether  or  not  an  infective 


14 


A   MANUAL  OF  SURGERY 


process  is  being  satisfactorily  resisted  (p.  47).  Even  should  an 
abscess  form,  that  is  merely  to  be  looked  on  as  one  of  the  means 
of  eliminating  bacteria  from  the  system.  Occasionally,  however, 
the  virulence  of  the  organisms  may  be  so  great,  or  the  protective 
powers  of  the  individual  so  slight,  that  all  opposition  is  borne 
down,  and  the  bacteria  invade  the  system  generally,  perhaps 
causing  the  patient's  death. 

An  important  outcome  of  modern  ideas  as  to  infection  and 
immunity  is  the  development  of  means  of  treating  infective 
diseases  or  of  securing  protection  against  them  by  artificial  sera, 
containing  suitable  antitoxins  (serotherapy).  It  may  be  antici- 
pated that  in  the  near  future  a  considerable  advance  will  be  made 
in  this  direction,  but  at  present  the  chief  sera  in  use  are  those 
directed  against  diphtheria,  tetanus,  and  streptococcal  affections 
(as  preventive  and  curative  agents).  In  the  production  of  these 
sera  some  suitable  animal  (frequently  a  horse)  is  gradually 
immunized  by  increasing  doses  of  the  virus,  and  then  the  blood 
serum,  which  presumably  contains  the  antitoxin,  is  withdrawn 
and  utilized,  after  the  addition  of  a  small  quantity  of  thymol  as 
a  preservative.  Sometimes  the  blood  serum  is  dried,  and  needs 
to  be  dissolved  in  sterilized  water  before  use.  The  antitoxins  act, 
as  already  indicated,  in  one  of  two  ways — either  by  preventing 
the  further  development  of  organisms  in  the  body — i.e.,  by  im- 
munizing the  individual  (inhibitory  action) — or  by  counteracting 
the  effect  of  the  toxins  already  produced  (antitoxic  action).  Suit- 
able reference  as  to  the  use  of  these  agents  will  be  found  in  the 
sections  on  Tetanus,  Erysipelas,  etc. 

Having  now  indicated  in  outline  how  Nature  repels  from  within 
a  bacterial  invasion  of  the  body,  and  what  assistance  may  be 
given  to  her  by  means  of  serotherapy,  it  only  remains  in  this 
chapter  to  point  out  the  methods  adopted  by  surgeons  in  protect- 
ing their  operation  wounds  from  external  contamination  with 
micro-organisms.  In  this  connection  the  name  of  Lord  Lister 
will  ever  stand  pre-eminent  as  that  of  the  man  who  applied  to 
surgery  the  principles  which  were  being  taught  by  Pasteur  as  to 
the  microbic  origin  of  disease.  It  is  no  exaggeration  to  say  that 
Lister  by  the  introduction  of  antiseptic  surgery  completed  the 
revolution  of  surgery  which  had  already  commenced  twenty  or 
thirty  years  earlier  owing  to  the  discovery  of  anaesthesia. 

Antisepsis  and  Asepsis. 

The  Antiseptic  plan  of  treating  wounds,  originally  introduced 
by  Lord  Lister,  is  an  outcome  of  the  germ  theory  of  putrefaction. 
It  has  for  its  object  the  prevention  of  bacterial  development  in 
the  wound  by  the  use  of  chemical  agents,  some  of  which  are  true 
germicides,  capable  of  destroying  the  bacteria,  whilst  others  merely 
prevent  or  inhibit  their  growth.     Innumerable  methods  of  apply- 


ANTISEPSIS  AND  ASEPSIS  15 


ing  this  treatment  have  been  adopted,  and  multifarious  antiseptic 
agents  have  been  used,  promiment  among  them  being  carbolic 
acid,  corrosive  sublimate,  iodine,  iodoform,  salicylic  acid,  boric 
acid,  etc. 

Carbolic  Acid,  the  first  antiseptic  introduced  by  Lister,  has  a  direct  germi- 
cidal action  in  strong  solutions,  and  an  inhibitory  effect  in  weaker  ones.  The 
crystals,  when  heated  with  10  per  cent,  of  water,  constitute  an  oily  fluid  known 
as  pure  or  liquefied  carbolic  acid,  which  is  a  powerful  though  superficial 
caustic,  and  may  be  employed  without  much  fear  to  infected  lesions,  in  order, 
if  possible,  to  sterilize  them.  Thus,  it  is  always  well  to  treat  tuberculous 
wounds  with  this  fluid  after  scraping  them,  in  order  to  destroy  any  portions 
of  tuberculous  material  which  may  have  escaped  the  spoon.  The  liquid 
carbolic  dissolves  in  water  on  the  application  of  a  little  warmth,  and  the 
1  in  20-  and  1  in  40  solutions  are  those  mainly  employed  ;  the  former  is  an 
efficient  and  potent  antiseptic,  but  must  be  used  carefully  on  delicate  skins. 
Carbolic  acid  is  frequently  somewhat  crude  and  impure,  and  many  of  the 
irritative  and  toxic  phenomena  are  due  to  cresylic  acid  and  other  substances 
which  should  not  be  present.  General  absorption  of  this  reagent  leads  to 
darkening  of  the  urine,  which  may  become  olive-green  or  even  black  in  colour, 
and  this  carboluria  is  often  associated  with  a  rise  in  temperature  and  some 
intestinal  irritation,  whilst  diseased  kidneys  may  be  seriously  affected.  It  is 
more  likely  to  occur  when  weaker  solutions  are  employed  than  when  the 
liquefied  or  pure  acid  is  applied.     The  latter  is  seldom  absorbed. 

Corrosive  Sublimate  is  a  valuable  though  very  poisonous  remedy,  which 
is  usually  employed  in  solutions  of  1  in  2,000,  1  in  1,000,  or  1  in  500.  Occa- 
sionally the  last  of  these  three  solutions  has  5  per  cent,  of  carbolic  acid 
added  to  it,  constituting  what  is  known  as  Lister's  strong  mixture.  Sublimate 
solutions  are  inhibitory  in  action  rather  than  germicidal,  but  are  potent  and 
reliable.  They  have  less  power  of  penetration  than  carbolic  acid,  but  have 
no  hardening  or  roughening  influence  on  the  skin.  If,  however,  a  dressing 
soaked  in  a  sublimate  solution  (1  in  2,000)  is  kept  for  long  in  contact  with  the 
skin,  it  acts  as. a  direct  irritant,  and  may  lead  to  an  abundant  formation  of 
pustules,  owing  to  the  activity  of  the  germs  in  the  deeper  parts  of  the  cutis 
which  have  not  been  destroyed  by  the  antiseptic.  Instruments  should  not  be 
placed  in  sublimate  solutions,  as,  even  if  plated,  they  soon  lose  their  bright 
appearance.  It  must  be  remembered  that  individuals  very  sensitive  to  the 
action  of  mercury  may  be  salivated  by  this  agent. 

Biniodide  of  Mercury  is  a  potent  antiseptic,  which  has  been  chiefly  employed 
in  the  form  of  a  1  in  500  solution  in  70  per  cent,  methylated  spirit  for  the  puri- 
fication of  the  hands  or  of  the  skin  of  the  patient.  It  is,  of  course,  extremely 
toxic. 

Boric  or  Boracic  Acid  is  a  mild  and  weak  antiseptic,  which  may  be  utilized 
when  stronger  remedies  might  prove  harmful — e.g.,  in  plastic  operations  and 
for  infants.  It  is  also  useful  when  antiseptic  fomentations  are  required  in 
treating  inflammatory  phenomena. 

Iodoform  is  a  yellow  powder  of  characteristic  and  unpleasant  odour,  which 
probably  acts  by  being  decomposed  in  the  tissues  and  slowly  giving  off  iodine. 
Commercial  iodoform  is  usually  contaminated  with  a  variety  of  germs,  as  may 
be  shown  by  dusting  it  over  a  film  of  nutrient  gelatine  and  allowing  them  to 
develop.  It  is  therefore  wise  to  wash  the  iodoform  before  use  in  1  in  20 
carbolic  lotion  or  some  such  antiseptic.  Its  chief  value  is  in  septic  or  tuber- 
culous wounds,  and,  indeed,  it  seems  to  have  a  specific  inhibitory  action  upon 
the  development  of  the  Bat.  tuberculosis.  It  may  be  suspended  in  glycerine 
(10  per  cent.),  and  after  sterilization  by  heat  injected  into  tuberculous  tissues, 
joints,  or  abscesses;  or  if  open  wounds  exist,  gauze  soaked  in  this  emulsion, 
as  it  is  incorrectly  termed,  may  be  packed  into  them  with  advantage.  Toxic 
effects  of  very  variable  type  may  follow  from  undue  absorption  of  the  drug. 
Gastro-intestinal   disturbances,  vomiting,   diarrhoea,  colic,  etc.,  may  be  the 


16  A  MANUAL  OF  SURGERY 

chief  symptoms,  but  delirium  and  collapse  often  supervene.  There  is  always 
an  abundance  of  iodine  in  the  urine.  Various  substitutes  have  been  proposed 
in  order  to  avoid  the  unpleasant  smell — e.g.,  aristol,  orthoform,  etc. — but  they 
are  of  doubtful  value.  Perhaps  the  best  means  of  obviating  the  odour  is  to 
mix  it  with  Jj  part  of  Coumarin,  the  active  principle  of  the  Tonquin  bean, 
which  has  a  powerful  aroma. 

Chinosol  is  a  yellow  substance,  harmless  and  free  from  toxic  qualities  ;  it  is 
freely  soluble  in  water,  and  possesses  powerful  antiseptic  properties. 

Lysol  is  another  useful  antiseptic  derivative  of  coal-tar.  It  is  freely  soluble 
in  water,  and  as  a  2  per  cent,  solution  may  be  used  in  syringing  out  cavities, 
such  as  the  vagina,  external  ear,  etc.  One  of  its  great  advantages  is  that  the 
solution  is  somewhat  sticky,  and  tends  to  cling  to  the  tissues  and  prolong  its 
action. 

Permanganate  of  Potash,  Sanitas,  and  Peroxide  of  Hydrogen  all  act  in  the 
same  way  as  oxidizing  agents ;  they  are  necessarily  unstable  and  cannot  be 
utilized  for  dressings,  and  are  therefore  chiefly  employed  in  the  disinfection 
of  cavities  or  wounds  already  contaminated.  The  most  potent  of  these  is 
peroxide  of  hydrogen,  which  is  sold  as  a  fluid  capable  of  setting  free  10  or  20 
times  its  volume  of  nascent  oxygen.  It  is  quite  unirritating,  and  may  be  poured 
directly  into  a  septic  wound,  or  even  into  the  peritoneal  cavity ;  forthwith 
it  commences  to  effervesce,  liberating  its  oxygen,  and  forming  a  frothy  foam, 
which  is  likely  to  bring  to  the  surface  any  loose  foreign  bodies.  Its  use  is 
particularly  indicated  in  the  treatment  of  septic  ulcers,  carbuncles,  sloughy 
abscess  cavities,  and  the  like.  Sanitas  and  permanganate  of  potash  are  used 
in  solutions  of  varying  strength,  and  act  more  slowly  ;  the  latter  has  the  dis- 
advantage of  staining  the  tissues  with  which  it  is  brought  in  contact. 

Whilst  the  practice  differs  in  various  surgical  schools  as  to  the 
antiseptics  employed  and  the  details  of  their  application,  yet  the 
principle  in  some  form  or  other  is  now  generally  adopted.  We 
shall  here  merely  sketch  out  the  routine  usually  practised  in 
undertaking  an  operation  or  in  the  treatment  of  a  wound. 

1.  The  hands  of  the  surgeon  are  rendered  pure  by  scrubbing 
them  thoroughly  with  soap  and  hot  water  (preferably  sterilized) ; 
the  nails  are  cut,  if  need  be,  and  cleansed,  special  attention 
being  directed  to  the  semi-lunar  folds  of  skin  at  the  base,  where 
septic  material  is  so  apt  to  collect.  For  this  purpose  a  purified 
nail-brush  is  employed  with  advantage.  The  hands  are  then 
immersed  in  an  efficient  antiseptic  lotion,  such  as  1  in  40  carbolic, 
or  1  in  2,000  sublimate  solution,  preceded,  perhaps,  for  a  few 
moments  by  a  1  in  500  solution  of  biniodide  of  mercury  in  70  per 
cent,  methylated  spirit.  The  hands,  once  purified,  should  not  be 
dried  except  on  a  sterilized  towel ;  but,  indeed,  it  is  better  to  keep 
them  moist  and  redip  them  from  time  to  time  during  the  operation 
either  in  the  1  in  40  carbolic  or  1  in  2,000  sublimate  solution, 
or  in  intraperitoneal  work  in  sterilized  salt  solution  (~)\.  to  1  pint). 
Another  plan  which  has  been  used  successfully  and  gives  good 
results  consists  in  immersing  the  hands  and  forearms  in  a  saturated 
solution  of  permanganate  of  potash,  after  thorough  washing  with 
soft  soap  and  water  until  they  become  a  deep  mahogany-red 
colour.  They  are  then  placed  in  a  warm  saturated  solution  of 
oxalic  acid  until  completely  decolorized,  and  are  finally  washed 
over  with    sublimate   solution.      This    method  causes  a   certain 


ANTISEPSIS  AND  ASEPSIS  17 

amount  of  irritation  of  the  skin  of  the  forearms.  It  is  possible 
that  in  many  instances  complete  sterilization  of  the  hands  is  not 
effected,  but  the  surgeon  must  always  keep  complete  asepsis  of 
his  hands  before  him  as  an  ideal  to  be  attained.  On  several 
occasions  when  our  hands  and  those  of  our  assistants  were  tested 
bacteriologically  after  the  use  of  the  biniodide  of  mercury  and 
sublimate  solutions  they  were  found  to  be  sterile,  even  scrapings 
from  beneath  the  nails  giving  no  reaction.  Some  authorities  have 
been  so  concerned  at  the  imperfection  of  their  results  that  they 
are  in  the  habit  of  operating  in  sterilized  gloves ;  it  has,  however, 
been  demonstrated  that  such  is  no  real  protection.  Careful 
attention  to  the  skin  after  operations— e.g.,  the  application  of 
glycerine  at  night,  so  as  to  prevent  it  becoming  rough  and  harsh 
— is  a  most  important  element  in  success. 

2.  All  instruments  are  sterilized  in  a  bath  of  carbolic  lotion 
(1  in  20),  which,  it  must  be  remembered,  takes  an  appreciable 
time  to  destroy  microbes,  and  therefore  if  during  an  operation  a 
fresh  instrument  is  suddenly  called  for,  which  has  not  been 
previously  purified,  it  is  not  enough  just  to  momentarily  immerse  it 
in  the  solution,  but  it  is  first  placed  in  liquefied  carbolic  acid  for  a 
few  seconds,  and  then  rinsed  through  the  1  in  20  solution.  Special 
care  is  directed  towards  the  forceps,  to  see  that  the  teeth  and 
serrations  are  free  from  dried  blood-clot  and  other  dirt.  Should 
an  instrument  fall  on  the  floor  during  an  operation  it  is,  of  course, 
not  used  again  until  thoroughly  repurified.  Boiling  the  in- 
struments either  in  carbolic  lotion  or,  better,  in  a  weak  solution 
of  bicarbonate  of  soda  (1  per  cent.)  for  five  or  ten  minutes,  is 
even  a  more  certain  means  of  rendering  them  aseptic,  and 
although  the  surgeon  may  ordinarily  trust  to  immersion  in 
carbolic  lotion,  he  should  always  boil  his  instruments  after  using 
them  for  a  septic  case.  The  water  should  be  boiling  before  they 
are  immersed,  and  thus  discoloration  will  be  avoided. 

3.  Sponges,  unless  very  carefully  treated,  are  a  fertile  source  of 
mischief.  They  should  be  thoroughly  purified  in  1  in  20  carbolic 
lotion  before  use,  and  wrung  out  of  a  1  in  40  solution  or  a  1  in 
2,000  solution  of  sublimate  during  the  operation.  Unless  the 
surgeon  can  be  absolutely  certain  of  the  nurse  it  is  better  to  use 
only  a  limited  number  of  sponges — say  two — and  for  the  assistant 
to  cleanse  them  in  a  bowl  of  lotion  placed  in  a  suitable  position. 
Portions  of  wool,  Gamgee  tissue  or  gauze,  soaked  in  a  carbolic  or 
sublimate  lotion,  or  thoroughly  sterilized,  are  often  advantageously 
employed  instead  of  sponges.  It  is  never  advisable  to  use  sponges 
for  tubercular  disease  or  rectal  operations,  or  for  any  conditions 
where  pus  is  present. 

In  cleansing  sponges  after  an  operation  the  following  procedure 
is  adopted  :  They  are  first  thoroughly  wrung  out  of  cold  water, 
and  then  placed  to  soak  for  an  hour  or  so  in  a  fairly  strong 
solution  of  washing  soda.     They  are  then  again  well  rinsed  in 

2 


A   MANUAL  OF  SURGERY 


cold  or  hot  water,  so  as  to  remove  all  the  soda,  and  finally 
immersed  in  a  solution  of  carbolic  acid  (i  in  20),  in  which  they 
are  kept  till  required. 

4.  The  ligatures  and  sutures  of  catgut  or  silk  are  soaked  for 
some  hours  in  1  in  20  carbolic  lotion  before  use.  Silk  requires 
very  thorough  purification  ;  in  order  to  prevent  stitch  suppuration, 
it  is  advisable  to  boil  it  thoroughly  for  at  least  half  an  hour  before 
placing  it  in  carbolic  lotion  ;  it  should  be  in  loose  coils,  and  not 
wound  on  a  reel,  as  then  only  the  outside  strands  are  sterilized. 
Catgut,  on  the  other  hand,  must  not  be  boiled  or  immersed  in 
carbolic  lotion  for  too  long,  as  it  is  apt  to  become  rotten  and 
break  when  used.  It  may,  however,  be  boiled  in  cumol  at  a 
temperature  of  1650  C.  for  an  hour  without  harming  it ;  it  is  then 
dried  at  a  temperature  of  ioo°  C.  in  a  hot-air  oven  for  two  hours, 
and  is  transferred  to  sterilized  test-tubes.  Mayo  Robson  has 
advised  the  sterilization  of  catgut  in  xylol,  which  is  kept  at  the 
temperature  of  boiling  water  for  half  an  hour.  A  special  metal 
cylinder  with  a  screw  top  is  required.  The  catgut  is  loosely 
wound  on  a  reel  or  slide,  and  sufficient  xylol  is  placed  in  the 
cylinder  to  cover  the  catgut  ;  the  top  is  then  screwed  down, 
and  the  cylinder  is  placed  in  a  saucepan  of  cold  water,  which 
is  gradually  brought  to  the  boil,  and  allowed  to  remain  boiling  for 
half  an  hour.  The  catgut  is  then  removed,  and  kept  in  a  5  per  cent, 
carbolic  solution  in  alcohol.  Another  simple  and  effective  method 
is  to  place  the  catgut  wound  loosely  on  a  glass  reel  in  a  5  per  cent, 
solution  of  formalin  for  twenty-four  hours  ;  it  is  then  immersed  in 
boiling  water  for  five. minutes,  and  subsequently  kept  in  a  solution 
of  corrosive  sublimate,  1  part,  glycerine,  250  parts,  and  methy- 
lated spirit,  1,000  parts. 

5.  The  skin  of  the  patient  is  shaved  prior  to  operation  if  the 
part  is  hairy,  and  then  thoroughly  washed  with  soap  and  water, 
and  covered  with  an  antiseptic  compress  for  some  hours.  When 
the  patient  is  on  the  table  and  anesthetized,  a  final  cleansing  is 
undertaken.  The  part  is  first  well  rubbed  with  turpentine  or 
ether,  to  remove  all  fat  and  grease,  and  then  with  soft  soap  ; 
finally,  it  is  flushed  over  with  strong  carbolic  lotion,  or  even 
scrubbed,  but  not  too  energetically,  with  a  nail-brush.  Corrosive 
sublimate  (1  in  1,000)  or  biniodide  of  mercury  in  rectified  spirit 
(1  in  500)  is  sometimes  used  instead  of  carbolic  acid.  It  must 
not  be  forgotten  that  a  very  vigorous  use  of  carbolic  acid  will  be 
followed  by  local  irritation,  as  well  as  by  its  absorption  into  the 
blood-stream,  especially  in  protracted  operations.  Again,  not 
only  does  the  quality  of  the  skin  vary  in  different  individuals  (as 
may  be  illustrated  by  contrasting  that  of  a  coal-heaver,  who 
probably  bathes  once  a  year,  with  that  of  a  child  or  of  a  lady, 
which  is  soft,  clean,  and  delicate),  but  it  also  differs  in  various 
regions  of  the  body,  and  hence  the  process  of  purification  must  be 
modified  according  to  the  thickness  of  the  integument.     Any  part 


ANTISEPSIS  AND  ASEPSIS  19 

where  dirt  may  accumulate  demands  scrupulous  attention — e.g., 
the  umbilicus,  external  ear,  toes,  or  corona  glandis  in  persons 
with  long  foreskins. 

When  the  operation  has  been  completed,  the  skin  around  is 
again  cleansed  with  warm  carbolic  (1  in  40)  or  sublimate  (1  in 
2,000)  lotion,  after  a  piece  of  dressing  has  been  placed  as  a 
protection  over  the  wound.  This  cleansing  should  always  be 
accomplished  by  wiping  peripherally  away  from  the  centre,  and 
any  sponge  or  swab  which  has  been  utilized  for  this  purpose 
should  not  be  allowed  to  touch  the  wound  until  repurified. 

6.  The  area  of  the  operation  or  wound  is  surrounded  with 
mackintoshes,  and  these  are  covered  by  towels  wrung  out  of  hot 
carbolic  lotion.  The  latter  are  first  soaked  in  a  solution  of 
1  in  20,  and  then  wrung  out  of  the  hot  1  in  40  solution,  and 
kept  warm  until  required  ;  the  skin  may  be  burnt  if  a  stronger 
solution  is  used.  During  the  operation  the  wound  may  be  occa- 
sionally irrigated  with  a  1  in  40  carbolic  solution,  or  with  corrosive 
sublimate  (1  in  2,000)  ;  but  such  is  not  always  advisable,  as 
it  increases  the  amount  of  subsequent  oozing,  and  is  really  un- 
necessary if  one  is  certain  as  to  the  aseptic  condition  of  every- 
thing employed.  When  dealing  with  the  peritoneal  cavity  or  the 
interior  of  a  joint,  the  less  one  employs  antiseptics  the  better, 
since  they  are  always  more  or  less  irritating,  and  lead  to  desqua- 
mation of  the  endothelial  lining,  which  it  is  so  important  to 
maintain  intact.  In  fact,  the  rule  of  practice  which  we  are 
endeavouring  now  to  establish  is  the  strictest  antisepsis  for  the  external 
parts,  but  asepsis  for  the  interior  of  the  wound  ;  one  cannot  always  be 
certain,  however,  that  this  ideal  has  been  attained,  and  then  anti- 
septic irrigation  may  be  resorted  to. 

7.  Before  closing  the  wound,  the  surgeon  must  use  every 
endeavour  to  secure  absolute  haemostasis.  It  must  be  well 
cleansed  with  a  sponge  wrung  out  of  hot  carbolic  lotion,  or, 
if  necessary,  irrigated  with  sterilized  salt  solution  ;  it  may  be 
advisable,  especially  in  large  wounds  of  vascular  parts,  to  insert 
a  suitable  drainage-tube  and  stitch  it  flush  with  the  surface,  but 
in  many  cases  this  is  unnecessary.  The  incision  is  then  closed. 
Wounds  communicating  with  septic  cavities,  such  as  the  mouth 
or  rectum,  should  be  purified  with  a  solution  of  chloride  of  zinc 
(40  grains  to  1  ouncej,  and  then  powdered  with  iodoform,  and 
either  left  open  or  lightly  plugged ;  septic  contamination  is  by 
this  means  delayed,  and  even  when  it  does  occur,  it  may  be  kept 
under  control  by  frequent  dressing  and  irrigation. 

8.  Finally,  a  carefully  arranged  antiseptic  Dressing  is  applied, 
and  the  part  bandaged  and  put  on  a  splint  or  in  a  sling,  as  may 
best  suit  the  requirements  of  the  case,  absolute  rest  and  quiet 
being  essential  if  rapid  healing  is  to  be  obtained. 

As  to  the  different  forms  of  dressing,  we  must  content  ourselves 
with  a  few  words  as  to  those  ordinarily  employed.     Lord  Lister 

2 — 2 


A   MANUAL  OF  SURGERY 


pointed  out  some  years  back  that  the  main  essentials  of  a  good 
dressing  consisted  in  its  containing  some  trustworthy  antiseptic 
ingredient ;  in  this  agent  being  so  stored  up  that  it  cannot  be 
dissipated  before  the  next  dressing  ;  in  its  being  entirely  un- 
irritating  ;  and  in  the  capacity  of  the  fabric  to  readily  absorb 
blood  or  serum  that  may  ooze  from  the  wound.  The  original 
antiseptic  dressings,  viz.,  the  carbolic  and  eucalyptus  gauzes,  and 
even  the  alembroth  gauze  and  wool,  failed  to  fulfil  these  require- 
ments ;  but  in  the  double  cyanide  of  mercury  and  zinc  gauze  we 
have  a  material  which  is  to  all  intents  and  purposes  perfect.  It 
should  be  moistened  with  carbolic  lotion  (i  in  40,),  and  may  then 
be  applied  to  the  wound  without  fear.  Over  this  fresh  portions 
are  placed,  taken  from  the  stock  supply,  which  is  always  kept  in 
a  mackintosh  covering  after  being  damped  with  carbolic  lotion 
(1  in  20),  and  finally  over  all  a  liberal  covering  of  sterilized  or 
antiseptic  wool,  so  as  to  diffuse  the  pressure,  which  is  applied  by 
means  of  careful  bandaging.  The  best  material  for  bandages  is 
butter-cloth,  since  it  is  light  and  adapts  itself  easily  to  the  outlines 
of  the  part. 

Other  dressings,  such  as  boric  lint,  iodoform  gauze,  etc.,  are 
occasionally  employed,  but  they  are  not  so  satisfactory  for  general 
use  as  the  cyanide  gauze. 

9.  After-treatment.- — If  no  drainage-tube  has  been  employed, 
and  the  dressing  is  not  soaked  through,  it  may  be  left  untouched 
for  seven  or  eight  days,  at  the  conclusion  of  which  period  it  is 
removed,  the  stitches  are  taken  out,  and  in  all  probability  the 
wound  will  be  completely  healed.  When  a  drainage-tube  has 
been  inserted,  it  is  usual  to  take  it  out  at  the  end  of  twenty-four 
or  forty-eight  hours  ;  there  is  no  advantage  in  keeping  it  in  longer, 
since  it  is  only  required  for  the  removal  of  the  sero-sanguineous 
fluid  which  exudes  immediately  after  the  operation.  Should  the 
discharge  be  very  abundant  and  soak  through  the  dressings,  there 
is  no  need  to  remove  them  and  redress  during  the  first  twenty- 
four  hours  ;  all  that  should  be  done  is  to  damp  the  stained  external 
bandages  with  1  in  20  carbolic  lotion,  and  then  pack  on  some 
more  gauze  or  wool.  This  may  even,  if  necessary,  be  repeated  a 
second  time. 

Of  late  years  many  Continental  and  American  surgeons  have 
been  attempting  to  eliminate  the  irritating  properties  of  chemical 
antiseptics  by  the  adoption  of  what  is  called  Aseptic  Surgery.  In 
this,  asepsis  is  obtained  by  means  of  heat,  the  most  powerful 
germicide  in  our  possession  ;  the  instruments  are  boiled,  and 
dressings  are  sterilized  by  placing  them  for  an  hour  or  more  in 
a  hot-air  chamber,  raised  to  such  a  temperature  as  to  destroy  all 
germs,  or  by  boiling  them.  Antiseptics  are,  however,  generally 
used  in  order  to  purify  the  skin  of  the  patient  and  the  hands  of 
the  surgeon  and  his  assistants,  as  also  the  ligatures  and  sutures. 
Elaborate   precautions  are  also  taken   as  to  the  dress   both   of 


ANTISEPSIS  AND  ASEPSIS 


the  surgeon  and  his  assistants,  and  even  of  onlookers ;  whilst 
operating  theatres,  tables,  etc.,  are  disinfected  in  a  careful 
manner.  This  plan  has  been  employed  with  much  success, 
but  requires  more  attention  to  details  than  does  the  antiseptic 
method.  Where  our  assistants  are  constantly  changing,  as  in  a 
large  teaching  hospital,  and  where  many  hands  are  engaged  in 
the  work,  there  is  much  greater  risk  of  failure.  It  is  only  natural 
that  we,  who  have  had  the  privilege  of  working  with  Lord  Lister, 
and  have  seen  the  excellent  results  following  the  intelligent  use 
of  antiseptics,  should  still  to  a  large  extent  cling  to  that  line  of 
practice,  which  certainly  can  be  carried  out  with  more  precision 
under  .all  circumstances,  both  in  private  and  hospital,  than  the 
other  plan,  the  objects  of  which  may  at  any  moment  be  defeated 
by  some  slight  inadvertence  or  oversight.  At  the  same  time,  we 
are  free  to  admit  that  aseptic  methods  have  much  to  commend 
them ;  all  antiseptics  are  more  or  less  irritating,  and  there  can  be 
no  question  that  the  less  we  use  them  the  better.  Moreover,  boiling 
the  instruments  is  more  certain  to  disinfect  them  than  immersion 
in  antiseptics  ;  they  are  subsequently  laid  in  a  bath  of  sterilized 
salt  solution,  or  even  water.  Sponges  are  replaced  by  swabs  of 
sterilized  tissue  or  gauze  ;  aseptic  wounds  are  washed  out  with 
salt  solution,  if  any  irrigation  is  required  ;  and  the  towels  around 
the  area  of  operation  are  merely  sterilized  by  placing  them  in  a 
hot-air  chamber  or  are  boiled.  To  sterilize  towels  or  textile 
fabrics  generally,  it  must  be  remembered  that  they  must  be 
placed  loosely  in  the  sterilizer,  as  otherwise  the  heat  cannot  reach 
between  their  various  folds  and  layers.  Dressings  may  be  merely 
sterilized,  but  when  one's  work  lies  in  a  large  city  hospital,  with 
impure  and  often  contaminated  air  around,  we  believe  that  the 
welfare  of  our  patients  is  best  consulted  by  employing  antiseptic 
dressings,  and  the  results  we  have  obtained  with  the  double 
cyanide  gauze  are  such  that  we  can  wish  for  nothing  better. 

A  few  other  micro-organisms  exist  besides  the  bacteria,  but  as 
they  play  a  comparatively  insignificant  part  in  surgery,  no  lengthy 
notice  of  them  is  required. 

i.  Some  of  the  Fungi,  especially  the  Hyphomycetes,  are  characterized  by 
the  growth  of  a  mycelium  or  mass  of  interlacing  fibres  or  threads,  arising 
from  which  are  the  spore-bearing  conidia,  whence  multiplication  of  the  growth 
ensues.  A  great  variety  of  fungi  is  found  in  Nature,  but  the  more  important 
pathological  conditions  due  to  their  development  in  the  body  are  as  follows 
.    Thrush,  due  to  the  Oidium  albicans. 

Ringworm,  due  either  to  the  Microsporon  Audoini  (the  common  type),  or  to 
the  Tricophyton  megalosporon  endothrix  or  ectothrix. 

Favus,  arising  from  the  Achorion  Schonleinii. 

Pityriasis  versicolor,  due  to  the  Microsporon  furfur. 

Keratomycosis,  or  parasitic  ulcer  of  the  cornea,  is  due  to  fungi  of  the 
aspergillus  or  mucor  type  (common  moulds),  which  mav  also  be  found 
developing  in  the  bronchi  (pneumomycosis),  or  in  the  external  auditory 
meatus  (otomycosis). 


A  MANUAL  OF  SURGERY 


Actinomycosis  (p.  148)  is  dependent  on  the  growth  in  the  tissues  of  the  ray 
fungus,  or  Actinomyces,  although  there  is  some  question  as  to  whether  these 
organisms  should  not  be  classed  as  bacteria. 

2.  The  Yeasts  or  Blastomycetes  multiply  by  a  process  of  gemmation  or 
budding.  They  are  responsible  for  many  forms  of  fermentation,  e.g.,  the 
alcoholic  or  acetous,  and  are  found  in  certain  peculiar  forms  of  dermatitis. 
The  hypothetical  parasite  of  cancer  is  now  regarded  as  belonging  to  this  class. 

3.  The  Protozoa  constitute  a  group  which  can  be  classed  either  as  animal 
or  vegetable,  and  consist  in  their  earlier  stages  of  masses  of  naked  nucleated 
protoplasm,  which  may  later  on  become  covered  with  membranous  envelopes, 
through  openings  in  which  pseudopodia  are  protruded.  They  form  a  large 
and  varied  class,  the  simplest  type  being  the  amct'ba  ;  but  their  influence 
in  pathology  is  not  yet  fully  worked  out.  It  is  supposed  that  the  following 
varieties  are  of  pathological  importance  : 

Amoeba  are  known  to  occur  in  certain  forms  of  colitis,  and  also  in  some 
varieties  of  hepatic  abscess. 

Malaria  is  due  to  the  development  of  a  protozoon,  the  Plasmodium  malaria. 

The  Psorospermia,  which  occur  not  unfrequently  in  animals,  are  members 
of  this  group,  and  it  is  still  a  moot  question  whether  the  coccidia-like  bodies 
found  in  Paget's  disease  of  the  nipple  are  really  living  parasites,  and  if  so, 
whether  they  have  any  causative  effect  on  the  origin  of  the  disease  (p.  174). 
Molluscum  contagiosum  is  another  condition  which  has  been  attributed, 
probably  on  very  insufficient  grounds,  to  these  organisms. 


CHAPTER    II. 

INFLAMMATION. 

'  Inflammation  is  the  succession  of  changes  which  occur  in  a 
living  tissue  when  it  is  injured,  providing  the  injury  is  not  of  such 
a  degree  as  to  at  once  destroy  its  structure  and  vitality.'  Such 
was  the  definition  given  in  1870  by  Burdon  Sanderson,  and 
it  is  sufficiently  accurate  if  one  amplifies  the  term  '  injury '  to 
include  bacterial  invasion,  and  excludes  the  final  processes  of 
repair.  Formerly  inflammation  was  looked  on  by  pathologists 
as  always  of  a  destructive  and  harmful  nature,  but  at  the  present 
time  bacteriological  research  has  demonstrated  that  it  is  often 
rather  of  a  protective  or  conservative  character,  being  Nature's 
means  of  limiting  the  advance  of  noxious  micro-organisms,  and 
of  finally  eliminating  them  from  the  system.  Occasionally,  how- 
ever, the  tissue  reaction  called  into  existence  by  bacterial  invasion 
is  so  severe  as  to  increase,  rather  than  diminish,  the  risks  of  the 
patient. 

The  actual  phenomena  of  inflammation  are  perhaps  best  studied 
in  the  web  of  a  frog's  foot.  If  this  is  spread  out  and  examined 
under  the  microscope,  the  following  evidences  of  normal  physio- 
logical activity  may  be  seen  :  (a)  the  flow  of  blood  through  the 
vessels,  as  indicated  by  the  movement  of  the  corpuscles,  the  red 
ones,  each  separate  from  the  other,  flowing  in  the  central  or  axial 
current,  the  leucocytes  occasionally  seen  amongst  the  red,  or  here 
and  there  one  may  be  noticed  rolling  lazily  along  in  the  inert 
corpuscle-free  peripheral  portion  of  the  tube  ;  (b)  the  constant 
rhythmical  changes  in  calibre  of  the  arterioles  independent  of 
the  heart's  action,  and  influencing  in  a  marked  degree  the  flow 
through  the  capillaries  ;  and  (c)  the  changes  which  occur  in  the 
pigment-cells,  which  represent  the  connective  tissues  of  the  part, 
and  which  are  mainly  due  to  the  influence  of  light,  the  cells  con- 
tracting or  expanding  as  the  light  is  increased  or  diminished. 

If  now  a  crystal  of  common  salt,  or  some  such  irritant,  is 
applied  to  the  web,  the  early  vascular  phenomena  contributing  to 
inflammation  may  be  readily  observed. 


24  A  MANUAL  OF  SURGERY 

I. — The  Vascular  Changes  in  Acute  Inflammation. 

A  momentary  contraction  may  perhaps  be  noticed  in  the 
arterioles  of  the  part,  but  this  is  only  apparent  in  inflammations 
produced  artificially,  and  is  of  no  known  significance.  It  is 
followed  by  a  condition  of  Hyperemia  of  the  inflamed  area,  as 
manifested  by  a  rapid  and  lasting  dilatation  of  the  vessels,  accom- 
panied by  an  increase  in  the  rapidity  of  the  blood-flow  (accelera- 
tion). This  is  a  peculiarly  vital  phenomenon,  and  opposed  to  the 
hydrostatic  law  that  when  fluid  is  flowing  through  a  tube  or 
channel  at  a  fixed  pressure,  if  the  lumen  is  suddenly  widened,  the 
rate  of  the  blood-flow  is  diminished.  It  is  probably  brought  about 
by  some  change  in  the  local  vasomotor  mechanism  present  in  the 
smaller  arterioles.  This  increased  rapidity  of  the  flow  lasts  for  a 
while,  and  then  the  current  gradually  becomes  slower  and  slower 
(retardation),  as  if  an  ever-growing  obstruction  existed  to  the 
passage  of  the  blood  ;  then  a  period  of  oscillation  will  be  noticed, 
the  blood-current  swaying  forwards  and  backwards,  and  finally  a 
condition  of  stasis  or  still-stand  is  arrived  at,  which  may  or  may 
not  end  in  actual  thrombosis  or  intravascular  coagulation.  During 
this  period  changes  have  occurred  in  the  behaviour  of  the  blood 
contained  in  the  vessel,  due  in  all  probability  to  certain  invisible 
changes  in  the  vessel  walls  and  not  to  any  alteration  in  the  blood. 
Thus,  almost  as  soon  as  dilatation  occurs,  the  leucocytes  collect 
along  the  walls  in  the  peri-axial  inert  layer,  seeming,  as  it  were, 
to  fall  out  of  rank  ;  this  process  first  commences  in  the  veins, 
but  can  be  observed  in  all  the  vessels.  The  red  corpuscles  also, 
which  formerly  had  flowed  along  separately,  now  tend  to  adhere 
to  the  vessel  walls  and  to  each  other,  running  into  rouleaux. 

The  second  factor  in  the  vascular  changes  must  now  be  con- 
sidered, viz.,  Exudation,  a  proceeding  which  becomes  evident  at 
a  very  early  stage.  Every  element  in  the  constitution  of  the 
blood  participates  in  this  process.  It  has  been  already  mentioned 
that  the  leucocytes  collect  in  the  peri-axial  layer,  a  phenomenon  due 
partly  to  the  retardation  of  the  blood-stream,  whereby  the  relatively 
heavier  bodies  separate  from'  the  lighter,  and  in  part  due  to 
positive  chemiotaxis  (p.  12).  The  next  change  consists  in  the 
passage  of  the  leucocytes  through  the  vessel  walls,  especially 
those  of  the  smaller  veins  and  less  often  of  the  capillaries.  The 
process  is  a  strictly  vital  one,  brought  about  by  amoeboid  move- 
ment ;  a  small  arm  or  outgrowth  of  the  leucocyte  (pseudopodium) 
is  inserted  between  the  endothelial  cells  lining  the  vessel,  whose 
cohesion  has  been  probably  interfered  with  by  the  inflammatory 
process.  Into  this  arm  the  protoplasm  of  the  leucocyte  flows, 
still  further  separating  the  endothelial  elements,  and  thus  the  cell 
passes  through  the  wall  into  the  surrounding  connective  tissues 
(Fig.  2).  The  migration  of  the  leucocytes  only  lasts  as  long  as 
the  blood  in  the  vessel  is  actually  circulating  ;  as  soon  as  throm- 


INFLAMMATION 


25 


bosis  occurs,  migration  ceases.  When  the  white  corpuscle  has 
escaped  into  the  peri-vascular  tissues,  it  may  undergo  various 
changes.  In  the  first  place,  it  may  die  and  be  at  once  dis- 
integrated, setting  free  fibrin  ferment,  and  thus  assist  in  the 
production  of  the  inflammatory  coagulum  to  be  shortly  described  ; 
or,  again,  it  may  serve  as  pabulum  for  the  larger  fibroblastic  cells 
which  soon  make  their  appearance,  arising  apparently  from  the 
multiplication  of  the  connective-tissue  corpuscles  in  the  neighbour- 
hood ;  or,  once  more,  it  may  find  its  way  back  into  the  circulation 


Fig.  2. — Diagrammatic  Representation  of  the  Vascular  Phenomena 
of  Inflammation.     (After  Keen  and  White.) 

Two  thin-walled  venules  are  seen,  and  several  capillaries.  The  red  corpuscles 
are  still  occupying  the  axial  portion  of  the  tubes,  whilst  the  periphery  is 
crowded  with  leucocytes,  which  in  several  places  are  in  process  of  migra- 
tion into  the  surrounding  cellular  tissue. 


through  the  lymphatics,  or  be  transformed  into  a  pus  corpuscle ; 
moreover,  prior  either  to  disintegration  or  transformation  into  a 
pus  corpuscle,  it  may  attack  and  assist  to  remove  any  dead  tissue 
which  exists  in  the  neighbourhood  of  the  inflammatory  focus, 
whilst  a  phagocytic  or  microbe-destroying  function  is  also  sub- 
served. In  fact,  the  leucocytes  may  be  looked  on  as  the  scavengers 
of  the  body,  or  as  advanced  guards,  which,  at  the  onset  of  mis- 
chief, are  thrown  out  from  the  vessels  as  Nature's  first  line  of 
defence  against    the   invading    forces,    their   chief  duty   being   to 


26  A  MANUAL  OF  SURGERY 

remove  all  damaged  and  noxious  material,  and  then,  having 
limited  the  spread  of  the  destructive  process,  they  in  turn  give 
place  to  the  larger  and  more  useful  fibroblastic  cells  which  are  the 
active  agents  in  the  process  of  repair. 

The  red  corpuscles  pass  through  the  walls  of  the  capillaries  by  a 
process  of  diapedesis,  the  result  of  simple  mechanical  pressure ; 
this  usually  occurs  only  in  very  acute  attacks.  When  once 
external  to  the  vessels  they  are  broken  up  and  their  colouring 
matter  diffused  through  the  tissues. 

The  liquor  sanguinis  is  also  extravasated.  This  is  merely  an 
exaggeration  of  a  normal  process,  although  in  health  the  lym- 
phatics are  capable  of  removing  all  the  fluid  exuded.  In  patho- 
logical conditions  the  amount  of  plasma  which  passes  through 
the  walls  is  excessive,  and  although  for  a  time  the  lymphatics  of 
an  inflamed  region  do  increased  work,  yet  the  transudation  is 
soon  greater  than  they  can  deal  with.  If  the  fluid  escapes  into 
the  tissues,  it  undergoes  coagulation  by  meeting  the  necessary 
coagulating  media  developed  from  the  breaking-down  leucocytes ; 
inflammatory  lymph  forms  locally,  whilst  the  serum  collects  in  the 
meshes  of  the  tissues,  constituting  an  inflammatory  form  of 
oedema ;  if  there  is  a  sufficient  breach  of  surface,  the  serum 
drains  away.  If  the  exudation  takes  place  from  a  serous  surface 
— e.g.,  pleura,  peritoneum,  synovial  membrane,  etc. — the  fluid 
distends  the  cavity  ;  it  is  at  first  spontaneously  coagulable  (i.e., 
consists  of  plasma)  ;  if  coagulation  occurs,  the  clot  or  lymph 
either  forms  an  adherent  plastic  mass  on  the  surface  or  floats 
free  in  the  fluid. 

Looked  at,  therefore,  simply  from  a  vascular  point  of  view, 

Inflammation  =  Hyperemia  +  Exudation. 

In  addition,  however,  to  these  vascular  phenomena,  which  can 
be  readily  seen  in  a  frog's  web,  there  are  others  which  cannot  be 
so  easily  observed,  and  which  may  be  described  as 

II.- -The  Tissue  Changes  in  Inflammation. 

Great  differences  of  opinion  have  been  in  existence  as  to  the 
part  played  by  the  tissues  in  inflammation  ;  but  although  there 
may  still  be  points  to  be  elucidated,  yet  the  general  opinion  of 
pathologists  is  at  the  present  day  tolerably  well  defined.  Formerly, 
in  accord  with  Virchow's  cellular  pathology,  it  was  held  that  the 
tissues  were  the  all-important  element,  and  that  the  immense 
number  of  cells  which  collect  in  an  inflamed  area  was  entirely  due 
to  the  proliferation  of  the  connective-tissue  corpuscles.  Lister, 
as  far  back  as  1858,  maintained  the  passive  condition  of  the 
tissues  ;  and  when  Cohnheim,  in  1867,  described  the  migration  of 
the  leucocytes,  everything  in  the  process  of  imflammation  was 
attributed  to  them.     Since  that  date  Senftleben  and  many  others 


IN  FLA  MM  A  TION  25 


have  worked  at  the  same  problem,  and  a  considerable  amount  of 
fresh  light  has  been  thrown  on  the  subject  by  experiments  con- 
sisting in  the  insertion  of  foreign  bodies  into  the  peritoneal  cavity, 
and  by  others  directed  towards  demonstrating  the  phagocytic 
functions  of  leucocytes  and  the  influence  of  chemiotaxis.  Much 
of  the  difficulty  which  has  enshrouded  the  question  has  arisen 
from  a  confusion  between  the  processes  of  inflammation  and 
repair.  At  one  time  repair  was  always  looked  on  as  of  an  inflam- 
matory nature ;  but  it  is  now  admitted  that  although  no  lesion  in 
the  body  can  occur  without  a  certain  amount  of  local  inflammatory 
reaction,  yet  the  true  process  of  repair  is  not  of  that  nature. 
Again,  it  is  important  to  differentiate  between  the  changes  which 
occur  in  acute  and  chronic  forms  of  inflammation,  and  between 
those  met  with  in  superficial  and  deep  parts,  whilst  the  bacterial 
origin  or  not  of  the  process  must  also  be  taken  into  account. 

In  acute  parenchymatous  inflammation  there  is  now  no  question 
that  the  primary  effect  on  the  tissues,  at  any  rate  in  inflammations 
due  to  bacterial  activity,  is  to  paralyze  them  ;  as  they  become 
infiltrated  with  the  products  of  microbic  multiplication,  the  proto- 
plasm within  the  cells  coagulates  and  refuses  to  take  up  the 
ordinary  stains,  constituting  a  condition  known  as  Coagulation 
Necrosis.  This  necrotic  tissue  is  in  time  entirely  absorbed  by  the 
leucocytes,  or  is  liquefied  by  the  activity  of  bacterial  toxins,  so 
that  it  is  replaced  by  a  mass  of  small  round  cells,  sometimes 
known  as  Embryonic  Tissue.  According  to  the  relative  vitality 
and  vigour  of  the  individual  and  the  bacteria,  this  mass  may  in 
turn  either  be  replaced  by  larger  round  cells  derived  from  the 
connective  tissues  (fibroblasts),  by  means  of  which  most  of  the 
leucocytes  are  absorbed,  and  repair  is  brought  about ;  or  the 
whole  mass  may  be  liquefied  and  break  down  into  pus.  In  non- 
bacterial inflammations  of  superficial  parts  the  amount  of  effusion 
between  the  individual  cells  may  be  so  excessive  as  to  separate 
and  disintegrate  them,  and  thus  Colliquative  Necrosis  may  be 
induced,  as  occurs  in  the  formation  of  blisters  after  a  burn.  Once 
more,  acute  inflammation  of  mucous  membranes  may  be  associated 
with  active  proliferation  of  the  surface  epithelium,  as  in  catarrhal 
and  gonorrhoeal  affections. 

In  chronic  inflammations,  on  the  other  hand,  active  cell  pro- 
liferation is  a  most  important  element  in  the  process,  resulting  in 
sclerosis  and  induration  of  the  parts.  This,  however,  mainly 
affects  the  interstitial  tissues,  and  thereby  the  true  structure  of  the 
organ  may  be  impaired. 

Terminations  of  Acute  Inflammation. 

These  vary  according  to  the  cause  of  the  mischief,  the  intensity 
of  the  process,  and  the  powers  of  resistance  possessed  by  .the 
individual  attacked.     The  causes  described  at  p.  33  naturally  fall 


28  A  MANUAL  OF  SURGERY 

into  two  main  classes,  according  to  whether  or  not  they  are  asso- 
ciated with  bacterial  activity.  Speaking  generally,  lesions  not 
caused  by  bacteria,  such  as  those  following  a  blow  or  a  burn,  are 
characterized  by  much  exudation  of  fluid,  which  is  of  low  specific 
gravity,  does  not  contain  much  albumen,  and  does  not  coagulate 
in  the  tissues  ;  the  amount  of  cellular  infiltration  is  slight,  no 
peptonizing  ferment  is  present,  and  the  results  are  usually 
localized.  Bacterial  irritants,  on  the  other  hand,  produce  more 
infiltration  of  the  tissues,  since  the  exudation,  which  is  rich  in 
albumen,  coagulates  in  the  tissues  ;  disintegration  is  likely  to 
follow,  as  peptonizing  ferments  are  often  present,  and  the 
inflammation  is  more  likely  to  be  of  a  spreading  nature.  The 
intensity  of  the  irritant  also  modifies  the  process,  since,  if  slight,  it 
has  a  somewhat  stimulating  effect  on  the  tissues,  whilst  severe 
lesions  may  result  in  tissue  destruction,  even  amounting  to  gan- 
grene. Then,  too,  the  type  of  tissue  affected  is  important,  since 
the  same  cause  may  lead  to  very  different  results.  The  more 
highly  organized  and  important  parts  are  always  more  vulnerable 
than  the  simpler  forms  of  connective  tissue,  and  this  in  spite  of 
the  fact  that  the  former  are  usually  better  supplied  with  blood. 
Thus,  the  growing  end  of  the  diaphysis  in  a  child  is  a  most  deli- 
cately organized  region,  and  hence  is  peculiarly  liable  to  serious 
destructive  inflammation  from  bacterial  agents,  which  would  do 
little  harm  if  developing  under  similar  circumstances  in  the  sub- 
cutaneous connective  tissues. 

The  actual  terminations  of  acute  inflammation  may  be  described 
under  five  distinct  headings  : 

i.  Resolution,  or  the  restoration  of  the  part  to  its  natural  condi- 
tion and  function.  This  can  only  occur  when  the  injury  has  not 
been  so  severe  as  to  destroy  the  vitality  of  the  affected  tissues, 
and  when  the  vascular  changes  have  not  gone  further  than  stasis. 
When  once  thrombosis  has  taken  place  in  a  vessel,  the  parts  can 
never  be  restored  to  the  status  quo  ante.  The  phenomena  of  reso- 
lution are  merely  those  of  inflammation  in  a  retrograde  order — 
viz.,  an  oscillatory  movement  first  manifests  itself  amongst  the 
corpuscles,  and  then  the  blood-stream  is  gradually  restored,  slowly 
at  first,  and  more  and  more  rapidly  afterwards.  The  adhesiveness 
cf  the  corpuscles  disappears  by  degrees,  but  it  will  be  some  time 
before  the  peripheral  inert  layer  can  be  seen.  The  exuded  leuco- 
cytes find  their  way  back  into  the  circulation  either  through  the 
vessel  walls,  or  to  a  greater  extent  via  the  lymphatics,  or  else  they 
are  disintegrated  in  the  tissues  and  absorbed.  The  fluid  exuda- 
tion is  removed  by  the  lymphatics.  For  some  time  after  an  acute 
attack  the  vessels  of  the  part  are  dilated  from  simple  loss  of  tone, 
but  this  also  gradually  disappears. 

2.  Organization,  or  Fibroid  Thickening,  occurs  when  the  in- 
flammatory process  is  not  arrested  until  after  the  supervention 
of  thrombosis,  but  has  stopped  short  of  suppuration.     The  parts 


INFLAMMATION  29 


are  then  not  restored  to  their  original  condition,  but  changes 
take  place  in  the  cellulo-plastic  exudation  and  in  the  connective 
tissue  around,  which  result  in  its  transformation  into  cicatricial 
tissue,  and  hence  the  details  of  the  process  will  be  similar  to 
those  described  under  the  heading  of  '  Repair  of  Wounds  ' 
(Chapter  VIII.).  Very  similar  conditions  follow  when  the  in- 
flammatory process  becomes  chronic,  as  is  not  uncommonly  the 
case. 

3.  Suppuration  is  always  due  to  invasion  of  the  affected  region 
by  pyogenic  organisms,  which  disintegrate  and  liquefy  not  only 
the  tissues  involved,  but  also  in  part  the  exudation  (Chapter  III.). 

4.  Ulceration  is  produced  on  the  surface  of  either  skin  or 
mucous  membrane  by  the  action  of  an  irritant  of  such  nature 
and  intensity  as  to  destroy  its  vitality,  though  without  evident 
sloughing  (Chapter  IV.). 

5.  Gangrene  is  a  less  common  result  of  inflammation,  and  is 
due  either  to  the  intensity  of  the  virus  or  to  the  weakness  of  the 
tissues  attacked  (Chapter  V.).  It  occurs  not  unfrequently  in 
bone,  constituting  the  condition  known  as  necrosis,  and  is  then 
due  mainly  to  the  strangulation  of  vessels  within  the  narrow 
lumen  of  the  Haversian  canals  by  an  exudation  which  is  often 
relatively  small  in  amount. 

Clinical  Signs  of  Inflammation. 

These  may  for  practical  purposes  be  described  under  the  four 
headings  given  by  Celsus,  viz.,  heat,  redness,  swelling,  and  pain, 
with  the  addition  of  a  fifth,  viz.,  impairment  of  function. 

Heat. — An  inflamed  part  feels  hot  to  the  touch,  and  the  tem- 
perature, if  taken  by  a  surface  thermometer,  is  definitely  raised 
above  that  of  the  surrounding  skin.  The  cause  of  this  is  the 
increased  amount  of  blood  flowing  through  it,  for  the  temperature 
of  an  inflamed  area  is  never  higher  than  that  of  the  blood  at  the 
centre  of  the  circulation,  i.e.,  in  the  heart.  Necessarily,  where 
active  chemical  and  pathological  changes  are  occurring,  as  in  an 
inflamed  tissue,  a  certain  amount  of  heat  is  produced  ;  but  it  is 
relatively  so  infinitesimal  in  quantity  that  it  may  be  neglected. 
The  cause  of  the  increased  temperature  of  the  blood  is  noted 
elsewhere  (p.  32). 

Redness  is  due  to  the  hyperaemic  condition  of  the  inflamed  part, 
and  its  intensity  and  characters  vary  considerably.  In  the  early 
active  hyperemia  the  colour  is  a  bright  rosy-red,  fading  quickly 
on  pressure,  and  returning  with  equal  rapidity.  In  the  stage  of 
retardation  the  redness  is  more  dusky,  since  the  blood  is  longer  in 
passing  through  the  capillaries,  and  so  loses  more  of  its  oxygen  ; 
the  colour  does  not  disappear  or  return  so  rapidly,  and  a  slight 
yellowish  tinge  often  remains  from  extravasated  haemoglobin. 
When  stasis  is  reached,  and  a  fortiori  when  thrombosis,  pressure 


A  MANUAL  OF  SURGERY 


does  not  remove  the  red  colour,  and,  should  such  a  state  persist 
for  long,  permanent  pigmentation  may  remain. 

The  redness  is  not  always  most  marked  at  the  focus  of  the 
disturbance,  since  the  portion  inflamed  may  be  non-vascular, 
e.g.,  the  cornea  or  articular  cartilage ;  in  the  former  of  these,  the 
redness  is  most  marked  in  the  ciliary  region  as  a  zone  of  deep 
pink  injection.  The  same  absence  of  redness  is  observed  in  an 
inflamed  iris,  owing  to  the  excess  of  pigment  hiding  the  dilated 
vessels  ;  but  in  both  cornea  and  iris,  the  inflammation  may  in  rare 
cases  be  so  prolonged  or  acute  as  to  cause  these  structures  to 
become  evidently  vascular — in  the  one  case  from  the  formation  of 
new  vessels,  and  in  the  latter  by  the  total  removal  and  absorption 
of  the  pigment. 

Swelling  arises  from  the  same  two  causes,  viz.,  hyperaemia 
of,  and  exudation  into,  the  part.  Necessarily  the  amount  of 
tumefaction  depends  upon  the  acuteness  of  the  disturbance  and 
the  distensibility  of  the  tissue,  and -in  measure  varies  inversely 
with  the  amount  of  pain.  In  some  cases  where  the  inflamed  area 
is  covered  by  a  thick  and  firm  fascia,  not  only  is  the  tensive 
pain  very  considerable,  but  swelling  may  occur  away  from  the 
inflamed  area,  e.g.,  over  the  back  of  the  hand  in  palmar  abscess  ; 
where  the  inflammatory  products  escape  into  lax  tissues,  the 
subjective  phenomena  are  minimized.  Similar  illustrations  of  the 
occurrence  of  cedema  at  a  distance  are  to  be  seen  in  inflammations 
of  the  sole  of  the  foot,  in  the  swelling  of  the  eyelids  when  the 
scalp  is  inflamed,  and  of  the  cheek  in  inflammation  of  the  dental 
periosteum.  Swelling  due  to  inflammation,  though  diminishing 
post-mortem,  does  not  entirely  disappear. 

Pain. — This  results  from  the  mechanical  irritation  of  the  peri- 
pheral nerve  terminals,  both  by  the  increased  arterial  tension  and 
by  the  pressure  of  the  exudation,  so  that  it  is  much  greater  if, 
from  the  density  of  fascial  or  fibrous  investments,  swelling  cannot 
readily  occur,  e.g.,  in  the  palm  of  the  hand,  or  in  the  eye  or  testicle. 
Possibly  the  exudation  may  also  have  some  direct  chemical  action 
on  the  nerve  terminals. 

A  marked  feature  of  inflammatory  pain  is  that  it  is  always 
aggravated  by  pressure,  whether  intrinsic — i.e.,  by  increasing  the 
blood-pressure — or  extrinsic,  from  outside  agencies.  Thus,  if  an 
inflamed  finger  or  hand  is  allowed  to  hang  down,  the  pain  is  much 
increased,  whereas  elevation  causes  speedy  relief. 

The  pain  of  suppuration  is  throbbing  in  character  ;  of  an  inflamed 
mucous  membrane,  scalding,  burning,  or  gritty  ;  of  an  inflamed 
serous  membrane,  stabbing  ;  of  inflamed  bone,  aching  or  boring,  and 
often  worse  at  night  ;  of  an  inflamed  testicle,  sickening.  When 
the  organs  of  special  sense  are  inflamed,  there  may  be  little  real 
pain,  but  much  exaggeration  of  the  special  sense,  e.g.,  flashes  of 
light  in  retinitis  and  noises  in  the  ears  in  otitis  interna. 

The  pain  is  not  limited  only  to  the  inflamed  part,  but  is  some- 


INFLAMMATION 


3i 


times  experienced  in  distant  regions,  either  through  a  similarity 
of  nerve-supply  or  from  the  fact  that  a  sensory  stimulus  is  always 
referred  by  a  patient  to  the  end  of  the  affected  nerve.  For  example, 
in  hip  disease  the  chief  pain  is  often  felt  in  the  knee,  because  the 
two  joints  have  a  similar  nervous  supply.  In  renal  calculus  or 
colic,  pain  is  referred  along  the  course  of  the  genito-crural  nerve 
into  the  groin  and  front  of  the  thigh,  and  is  often  accompanied  in 
the  male  by  retraction  of  the  testicle  on  the  side  affected.  In 
spinal  caries  pain  is  frequently  experienced  in  the  terminal  branches 
of  the  nerves  issuing  from  the  part  affected,  e.g.,  the  so-called 
'  belly-ache  '  of  dorsi-lumbar  disease. 

Impairment  or  Loss  of  Function  is  due  sometimes  to  the 
mechanical  difficulty  of  using  a  swollen  organ,  sometimes  to  the 
pain  elicited  by  such  attempts,  but  often  to  the  paralyzing  effect 
of  the  inflammatory  process,  and  this  in  infective  lesions  results 
from  the  direct  influence  of  the  toxins  on  the  protoplasm  of  the 
cells  affected.  Thus,  an  inflamed  eye  can  see  but  little;  a  muscle, 
when  inflamed,  is  naturally  kept  at  rest;  glandular  organs,  e.g., 
the  liver  and  kidneys,  have  their  functions,  if  not  lost,  at  least 
much  diminished  ;  and  many  similar  illustrations  might  be  added. 

General  or  Constitutional  Symptoms. 

These  vary  considerably  according  to  the  part  involved  and  the 
cause  of  the  inflammation,  (a)  If  an  important  organ,  such  as  the 
heart  or  kidney,  becomes  inflamed,  grave  mechanical  and  physio- 
logical trouble  may  result,  (b)  Inflammations  due  to  traumatism, 
in  which  bacteria  play  no  part,  are  not  uncommonly  associated 
with  a  temporary  pyrexia,  probably  due  to  some  such  substance 
as  fibrin  ferment,  (c)  When  of  septic  or  pyogenic  origin,  inflam- 
mation is  almost  always  associated  with  well  marked  fever,  and  it 
is  sometimes  astonishing  to  note  how  much  disturbance  a  small 
bead  of  pus  under  tension  will  produce,  (d)  In  certain  infective 
inflammations  a  characteristic  toxaemia  is  produced,  due  to  a 
specific  action  of  the  toxin — e.g.,  in  tetanus,  convulsions  are 
caused  ;  whilst  in  diphtheria,  fever  and  perhaps  paralytic  pheno- 
mena are  alike  produced. 

It  is  only  necessary  at  this  place  to  deal  very  briefly  with  the 
subject  of  Fever  or  pyrexia.  The  general  characteristics  of  the 
febrile  state  consist  in  a  greater  or  less  elevation  of  temperature, 
accompanied  with  a  corresponding  acceleration  of  the  rate  of  the 
heart-beat  and  of  the  respirations.  If  it  continues  for  any  length 
of  time,  the  patient  becomes  thin  and  emaciated,  and  loses  muscular 
power.  The  mouth  is  dry  and  the  tongue  furred  ;  and  in  the 
later  stages,  where  a  fatal  issue  is  apprehended,  the  lips  and 
teeth  are  usually  covered  with  sordes  (or  accumulations  consisting 
of  inspissated  mucus  and  food  debris).  The  appetite  is  impaired, 
digestion   is  imperfect,  and  the  bowels  constipated ;  any  motion 


32  A   MANUAL  OF  SURGERY 


passed  is  very  offensive.  The  urine  is  scanty  and  high-coloured, 
and  owing  to  the  excessive  tissue  change  contains  an  unusual 
amount  of  urea  and  urates.  The  excess  of  urea  is  demonstrated 
clinically  by  adding  an  equal  part  of  cold  nitric  acid  in  a  test-tube 
to  some  urine,  when  crystals  of  nitrate  of  urea  will  form  on  the 
top  of  the  fluid,  giving  rise  to  a  mass  somewhat  resembling  sugar- 
candy  in  appearance.     The  skin  of  a  febrile  patient  is  often  dry. 

Causes  of  Fever. — The  temperature  of  the  body,  it  is  well  known,  is  controlled 
by  a  principal  heat-governing  centre  in  the  medulla,  assisted  possibly  by 
accessory  centres  in  the  cord,  and  is  maintained  by  the  establishment  of 
equilibrium  between  the  amount  of  heat  lost  from  the  skin,  by  the  breath,  and 
in  other  directions,  and  the  amount  of  heat  produced  by  the  tissue  metabolism 
occurring  in  the  viscera  generally,  and  especially  in  the  voluntary  muscles. 
Pyrexia  is  necessarily  due  to  one  of  two  causes,  viz.,  a  decreased  loss  of  heat, 
or  an  increased  production.  The  former  is  a  scarcely  tenable  proposition  when 
we  look  at  the  patient's  condition,  and  hence  we  are  driven  to  conclude  that 
fever  is  due  to  increased  activity  in  the  heat-forming  tissues,  especially  the 
muscles,  a  fact  which  explains  the  rapid  emaciation  and  loss  of  strength  under 
such  circumstances,  and  the  presence  of  a  large  amount  of  extractives  in  th-3 
urine.  In  all  probability  this  increased  activity  is  due  to  the  excitement  of 
the  heat-producing  centre  by  some  pyrogenous  body  developed  in  connection 
with  the  local  inflammatory  process.  Experiments  have  shown  that  the  fibrin 
ferment,  as  well  as  many  of  the  toxins  produced  by  the  action  of  micro- 
organisms, if  injected  into  the  circulation  in  a  pure  state,  possesses  such  a 
power. 

In  regard  to  the  symptoms  of  fever,  it  may  be  stated  briefly  that  they  are 
in  large  part  due  to  the  effect  produced  by  the  increased  temperature  or  the 
toxic  products  circulating  in  the  blood  upon  the  constituent  cells  of  glandular 
and  other  organs.  The  phenomena  in  question  are  termed  by  different  path- 
ologists 'acute  or  cloudy  swelling,'  'granular  degeneration,'  'albuminous 
infiltration,'  etc.,  and  are  characterized  by  the  organs  becoming  soft,  friable, 
and  more  or  less  swollen.  The  secreting  cells  of  glands  are  increased  in  size, 
and  the  protoplasm  becomes  markedly  granular,  so  that  the  nucleus  can  only 
be  distinguished  with  difficulty.  The  granules  are  albuminous  in  character, 
clearing  up  completely  on  the  addition  of  acetic  acid.  A  similar  change  is 
also  evident  in  the  fibres  of  the  cardiac  muscle,  which  lose  their  striation  and 
become  granular,  a  condition  which  must  considerably  interfere  with  their 
contractility.  The  effect  produced  upon  the  glands  of  the  digestive  system 
explains  many  of  the  febrile  manifestations,  inasmuch  as  their  function  is 
largely  impaired.  The  salivary  and  buccal  glands  are  unable  to  excrete  the 
normal  amount  of  saliva,  and  hence  the  mouth  becomes  dry.  Gastric  diges- 
tion is  interfered  with  in  the  same  way.  The  bile  is  not  efficiently  produced, 
and  hence  its  fat-emulsifying  properties  are  diminished,  as  also  its  cathartic 
powers,  whilst  the  patient  cannot  properly  digest  fats,  and  is  constipated. 

Various  terms  have  been  applied  to  different  types  of  surgical 
fever,  e.g.,  sthenic  and  asthenic,  which  sometimes  depend  as  much 
upon  the  constitution  of  the  patient  as  upon  the  nature  or  cause 
of  the  affection.  By  Sthenic  inflammatory  fever  (Greek,  a-devos, 
strength)  is  meant  that  condition  in  which  pyrexia  and  all  its 
accompanying  symptoms  are  well  marked.  It  occurs  mainly  in 
young  healthy  adults  of  sound  constitution,  as,  for  example,  when 
a  young  man  is  suddenly  attacked  by  acute  pneumonia,  or  when 
an  acute  abscess  is  forming.  Asthenic  inflammatory  fever  (Greek, 
do-Oevos,  without   strength)  is  characterized    by  the  tendency  to 


INFLAMMATION 


exhaustion  and  collapse  associated  therewith.  It  is  met  with  in 
debilitated  subjects  and  those  exhausted  by  vicious  habits,  but 
may  also  occur  at  the  close  of  a  long  period  of  pyrexia,  e.g.,  in 
the  third  week  of  typhoid  fever  (  =  the  typhoid  state).  The  absorp- 
tion of  products  of  putrefaction  and  the  occurrence  of  acute 
infective  blood-poisoning  also  induce  fever  of  this  type. 

Causes  of  Inflammation. 

Predisposing  Causes. — The  conditions  which  predispose  to  in- 
flammation may  be  conveniently  divided  into  the  local  and  the 
constitutional. 

The  local  causes  include  the  following  more  important  conditions  : 
i.  Defective  circulation   whether  due  to  chronic  anaemia,  as  in 
a  limb  with  rigid  calcareous  arteries,  or  to  passive  congestion,  as 
in  a  leg  with  varicose  veins. 

2.  Loss  or  impairment  of  the  nervous  supply  to  a  part,  render- 
ing it  less  resistant  to  external  irritation  either  from  loss  of 
sensation,  diminished  trophic  control  of  the  nervous  centres,  or 
circulatory  changes. 

3.  One  attack  of  inflammation  often  leaves  a  part  weaker  and 
more  liable  to  recurrence. 

The  general  or  constitutional  predisposing  causes  are  those  which 
tend  to  depress  the  general  vitality,  e.g.  : 

1.  Old  age,  when  the  body  as  a  whole  suffers  in  its  nutrition. 

2.  Weak  action  of  the  heart,  disturbing  the  vascular  supply  of 
the'  organs  and  members  of  the  body. 

3.  An  unhealthy  condition  of  the  blood,  as  from  (a)  the  addition 
of  some  abnormal  constituent,  as  in  alcoholism,  plethora,  lead, 
mercury,  or  phosphorus  poisoning,  septic  diseases,  diabetes,  etc. ; 
(b)  the  insufficient  elimination  of  excreta,  as  in  Bright's  disease 
or  gout ;  (c)  the  absence  of  some  normal  constituents,  as  in  albu- 
minuria or  anaemia. 

4.  The  presence  of  some  constitutional  disease,  dyscrasia  or 
diathesis,  as  syphilis,  tubercle,  rheumatism,  etc. 

Exciting  Causes. — The  active  agent  in  the  production  of  any 
inflammation  is  the  existence  of  some  irritant  which  acts  for  a 
shorter  or  longer  period  upon  the  tissues.  The  different  forms  of 
irritants  are  infinite  in  number,  but  may  be  grouped  under  the 
following  four  headings : 

1.  Mechanical  or  traumatic  causes,  such  as  direct  violence, 
friction,  tension,  pressure,  etc. 

2.  Causes  which  act  through  changes  of  temperature,  either 
heat  or  cold. 

3.  Electricity,  either  as  applied  by  the  surgeon  in  the  form  of 
the  faradic  or  galvanic  current,  or  through  the  agency  of  lightning 
or  the  strong  currents  used  for  lighting  purposes. 

4.  Toxic  irritants,  under  which  may  be  included  : 

(a)  Chemical  agents,  such  as  strong  acids  or  alkalies. 

3 


34 


A   MANUAL  OF  SURGERY 


(b)  Vegetable  irritants,  e.g.,  croton-oil,  oil  of  mustard,  etc. 

(c)  Animal  irritants,   such  as  cantharides,   and   insect   or 

reptile  bites. 
((/)  The  development  of  micro-organisms  within  or  without 
the  body  (see  Chapter  I.). 

Varieties  of  Inflammation. 

Many  different  terms  are  used  to  indicate  the  manifestations  of 
the  inflammatory  process  in  the  body,  and  to  some  of  these  we 
must  now  direct  attention. 

A  Catarrhal  inflammation  is  one  affecting  mucous  membranes, 
which  in  the  early  stages  become  dry,  vividly  red,  and  the  seat  of 
a  burning  or  scalding  pain,  whilst  in  the  later  stages  there  is  free 
secretion  of  mucus,  muco-pus,  or  pus.  Pathologically,  this  pro- 
cess is  accompanied,  as  are  all  active  inflammatory  changes, 
by  hyperaemia  and  exudation.  At  first  the  mucigenous  function 
of  the  membrane  is  abrogated,  and  any  extravascular  exuda- 
tion passes  into  its  substance,  causing  it  to  become  swollen. 
Proliferation  of  the  epithelium  soon  follows,  resulting  in  an 
increased  formation  of  mucus ;  as  the  membrane  becomes  more 
and  more  infiltrated  with  leucocytes,  these  are  added  to  the  dis- 
charge, which  is  thus  transformed  into  muco-pus,  or  even  pus. 
Small  ulcers  may  develop  from  the  loss  of  superficial  epithelium, 
but  this  is  an  exception  rather  than  the  rule.  Microscopic 
examination  of  the  discharge  reveals  pus  cells,  leucocytes,  and 
epithelial  elements  in  various  conditions,  some  containing  globules 
of  mucin,  and  some  of  the  normal  type.  This  form  of  inflamma- 
tion is  caused  by  bacteria,  or  by  the  action  of  local  irritants,  or  to 
what  is  known  as  '  taking  cold.' 

A  Croupous  (or  plastic)  inflammation  is  one  characterized  by 
the  formation  of  a  firm,  false  membrane,  due  to  the  coagulation  of 
the  plasma  exuded  from  the  vessels,  the  resulting  fibrin  being 
deposited  on  the  surface.  When  involving  a  serous  membrane, 
such  as  the  pleura,  peritoneum,  or  synovial  membrane,  it  gives 
rise  to  a  layer  of  plastic  lymph,  which  may  organize  into  adhe- 
sions ;  it  is  also  seen  in  the  alveoli  of  the  lungs  in  lobar  pneumonia. 
On  mucous  membranes,  such  as  the  conjunctiva  or  that  of  the 
pharynx,  it  occasionally  forms  white,  flaky  masses,  which  can 
readily  be  detached,  leaving  an  injected  surface  below,  with  merely 
one  or  more  oozing  points,  and  no  loss  of  substance. 

A  Diphtheritic  inflammation  is  due  to  a  special  organism — the 
Bacillus  diphtheria — and  is  characterized  by  the  formation  of  a 
membranous  exudation  with  which  are  incorporated  the  superficial 
layers  of  the  epithelium,  so  that  it  cannot  be  removed  without 
leaving  a  raw  surface.  The  bacilli  develop  in  this  false  membrane 
and  produce  toxins,  which  by  their  absorption  give  rise  to  the 
constitutional  symptoms  of  the  disease. 


IN  FLA  MM  A  TION 


35 


The  term  Phlegmonous  is  now  but  rarely  employed.  It  was 
formerly  applied  to  any  superficial  inflammation  where  the  local 
phenomena  were  well  marked. 

Parenchymatous  and  Interstitial  are  terms  which  indicate  that 
in  an  inflamed  organ  or  gland  the  process  is  mainly  limited,  either 
to  the  actual  and  active  substance  of  the  organ,  or  to  the  support- 
ing fibrous  tissue. 

The  term  Metastasis  was  formerly  employed  to  indicate  a 
sudden  transference  of  an  inflammatory  attack  from  one  place  to 
another  without  apparent  cause.  Increased  knowledge  of  pathology 
has  explained  away  almost  all  the  formerly-described  illustrations 
of  metastasis,  and,  indeed,  the  use  of  this  term  is  now  almost 
limited  to  the  inflammation  of  testis,  ovary,  or  breast  which 
follows  mumps. 

Treatment  of  Acute  Inflammation. 

It  is  only  possible  to  deal  here  with  the  general  principles 
which  guide  us  in  the  treatment  of  inflammatory  affections.  The 
method  of  application  of  these  to  different  parts  of  the  body  will 
be  described  hereafter. 

The  Local  Treatment  may  be  indicated  under  four  headings  : 
i.  Remove  the  exciting  cause,  if  evident,  and  any  contributory 
causes  when  feasible.  This  is  not  a  difficult  matter  when  the 
lesion  is  a  gross  one,  and  the  exciting  cause  tangible — e.g.,  a 
foreign  body  embedded  in  the  conjunctiva  or  cornea,  or  a  piece  of 
dead  bone  lying  at  the  bottom  of  a  sinus.  Inflammatory  tension 
from  pent-up  effusion  is  readily  relieved  by  an  incision,  or  an 
abscess  opened.  In  some  cases,  due  to  bacterial  invasion,  it  may 
be  practicable  to  totally  excise  a  local  focus — e.g.,  a  malignant 
pustule — whilst  in  others,  such  as  a  carbuncle,  one  has  to  trust 
to  scraping  away  the  sloughy  and  infiltrated  tissue  with  a 
Volkmann's  spoon,  and  then,  after  purification  with  liquefied 
carbolic  acid  or  peroxide  of  hydrogen,  the  wound  is  carefully 
stuffed  with  gauze.  In  bacterial  inflammation  of  a  more  diffuse 
type,  it  is  usually  impossible  to  remove  the  cause,  and  one  has 
then  to  trust  to  other  measures. 

2.  Keep  the  inflamed  part  at  vest.  Wherever  inflammation  exists, 
both  physical  and  physiological  rest  should  be  obtained  as  far  as 
possible.  Thus,  an  inflamed  joint  is  immobilized  by  a  splint ;  an 
inflamed  mamma  needs  both  support  and  the  fixation  of  the  arm, 
whilst  if  in  a  condition  of  physiological  activity  this  must  be 
checked  by  suitable  treatment ;  an  inflamed  cornea  requires  the 
application  of  a  pad  and  bandage  to  prevent  the  friction  of  the 
eyelid  ;  an  inflamed  retina  must  be  given  physiological  rest  by 
exclusion  of  the  light. 

3.  Reduce  the  local  blood -pressure  and  hyperaemia,  and  thus 
diminish  both   exudation   and   pain.      Elevation   of  an   inflamed 


36  A   MANUAL  OF  SURGERY 


limb  may  secure  this  end,  and  is  a  most  essential  element  in  the 
treatment  of  all  inflammatory  conditions  of  the  leg,  for  it  is  a 
well-known  fact  that  emptying  the  veins  by  gravity  in  an 
elevated  limb  leads  to  reflex  contraction  of  the  arteries.  Local 
blood-letting  by  leeches,  punctures,  scarification,  and  wet  or  dry 
cupping,  is  useful  in  suitable  cases,  and  sometimes  gives  imme- 
diate relief.  It  may  be  as  well  to  mention  that  a  leech  can 
withdraw  about  2  to  4  drachms  of  blood,  and  that  it  should  not 
be  applied  over  a  large  subcutaneous  vein,  or  to  parts,  like  the 
scrotum  or  eyelids,  where  there  is  much  subcutaneous  tissue  of  a 
loose  texture,  in  which  extravasation  readily  occurs.  The  bleeding 
from  a  leech-bite  usually  ceases  spontaneously,  but  may  require 
the  application  of  slight  pressure. 

In  diffuse  inflammation  of  the  cellulitic  type  free  incisions  are 
beneficial,  partly  on  account  of  the  relief  of  tension  and  pain 
which  follows  the  escape  of  blood  and  retained  discharges  from 
the  tissues,  but  also  because  it  determines  a  free  flow  of  blood 
serum,  and  as  this  possesses  antitoxic  and  germicidal  properties, 
it  assists  in  bringing  the  inflammatory  process  to  an  end. 

Cold  wisely  utilized  is  of  the  greatest  service  in  combating 
inflammation,  causing  contraction  of  the  arterioles,  and  so  re- 
ducing the  hyperaemia.  It  should  only  be  used  in  the  early  stages, 
and  never  when  suppuration  is  threatening,  as,  although  it  may 
cause  local  depletion  of  the  bloodvessels,  it  at  the  same  time 
depresses  the  vitality  of  the  part,  and  so  may  do  more  harm  than 
good.  Again,  it  should  be  used  with  the  greatest  care  in  old 
people,  from  fear  of  causing  sloughing  of  the  skin.  There  are 
various  methods  of  applying  it,  as  by  means  of  an  ice-bag  ;  or  by 
irrigation  from  a  vessel,  suspended  over  the  part,  containing  iced 
water  or  lotion,  from  which  strips  of  lint  descend  to  envelop  the 
inflamed  area ;  or  a  piece  of  lint  wrung  out  of  evaporating  lotion 
may  be  placed  directly  on  the  part ;  or,  better  still,  the  iced  water 
may  be  run  through  a  coil  of  leaden  pipes  (known  as  Leiter's 
tubes),  fitted  carefully  to  the  inflamed  region.  Under  any  circum- 
stances the  cold  must  be  continuous,  and  not  intermittent,  as 
otherwise  the  alternating  periods  of  anaemia  and  hyperaemia  will 
have  a  baneful  rather  than  a  beneficial  influence. 

Heat,  especially  when  combined  with  moisture,  is  very  largely 
used  in  treating  inflammatory  affections,  and  acts  in  a  diametri- 
cally opposite  way  to  cold  by  relaxing  the  vessels  and  tissues, 
thus  reducing  the  tension  and  pain  ;  it  also  favours  the  activity 
and  vitality  of  the  part  by  increasing  the  vascular  supply  and 
facilitating  lymphatic  absorption.  When  suppuration  is  threaten- 
ing, the  application  of  warmth  and  moisture  hastens  the  process. 
For  subcutaneous  lesions,  fomentations,  medicated  or  not  with 
opium  or  belladonna,  or  spongiopiline  wrung  out  of  hot  water,  or 
simply  dry  heated  cotton-wool,  may  be  employed.  When  an 
abscess  is  forming,  nothing  can  be  more  soothing  and  satisfactory 


INFLAMMATION  37 


than  a  linseed-meal  poultice,  provided  that  the  abscess  is  not 
allowed  to  burst  into  it.  Poultices  should  never  be  applied  to  an 
open  wound  or  abscess,  unless  the  latter  is  in  a  very  septic  con- 
dition, and  then  they  can  be  rendered  more  or  less  aseptic  by 
making  them  with  hot  carbolic  lotion  (1  in  30).  The  boracic 
poultice  or  fomentation  is  most  useful  in  many  superficial  inflam- 
matory affections  due  to  sepsis,  dirt,  and  want  of  attention.  It 
consists  in  the  application  to  the  part  of  a  portion  of  boracic  lint 
wrung  out  of  a  hot  boric  acid  solution  (1  in  20),  and  covered  with 
oiled  silk  or  guttapercha  tissue. 

4.  Prevent  the  access  of  fresh  sources  of  irritation  or  infection,  such  as 
those  due  to  putrefactive  changes  in  an  open  discharging  wound. 

The  General  Treatment  of  inflammation  varies  considerably 
with  the  condition  of  the  patient,  and  as  to  whether  he  is  strong 
and  healthy,  or  weakly.  Those  who  are  depressed  in  health,  or 
who  may  be  expected  readily  to  become  so  from  the  continuance 
of  the  febrile  state,  need  to  be  carefully  supported  by  a  tonic  plan 
of  treatment,  whilst  at  the  same  time  attention  must  be  directed 
to  the  elimination  of  toxic  bodies  by  suitable  purgatives,  dia- 
phoretics, and  diuretics.  Quinine  may  be  given  with  great  benefit, 
as  also  diffusible  stimulants,  such  as  ether  or  carbonate  of 
ammonia,  whilst  the  recovery  of  patients  lying  in  a  typhoid  state 
of  exhaustion  will  absolutely  depend  on  the  administration  at  short 
intervals  of  nourishing  fluids,  combined  with  stimulants.  In  the 
sthenic  type  of  inflammatory  fever,  '  antiphlogistic  '  means  may 
be  freely  employed  so  as  to  reduce  the  general  blood-pressure  and 
remove  irritating  matters  from  the  system,  e.g.,  a  smart  purge, 
followed  by  low  diet  and  abstinence  from  alcohol  for  a  few  days ; 
but  in  other  instances  where  the  blood-tension  is  high,  as  indicated 
by  a  large  and  full  pulse,  and  the  local  signs  (pain,  etc.)  are  well 
marked,  it  may  be  also  necessary  to  administer  such  drugs  as 
antimony,  aconite,  full  doses  of  acetate  of  ammonia,  colchicum  or 
ipecacuanha,  to  reduce  the  general  blood-pressure,  as  also  to 
obtain  diaphoretic  action.  In  a  few  cases,  e.g.,  acute  meningitis, 
venesection  may  be  needed,  and  it  is  possible  that  this  is  an  agent 
too  little  employed  in  the  present  day.  In  some  forms  of  inflam- 
mation due  to  the  specific  diatheses,  suitable  drugs  must  be 
employed  to  combat  such  tendencies — e.g.,  salicylate  of  soda  or 
salicin  in  acute  rheumatism. 

In  inflammation  of  infective  origin  serotherapy  (p.  14)  may  be 
found  of  use,  but  at  present  the  only  diseases  that  are  much 
affected  by  this  means  are  diphtheria,  tetanus,  and  erysipelas. 
(See  on  Erysipelas  and  Tetanus.) 

Chronic  Inflammation. 

The  phenomena  of  chronic  inflammation  are  essentially  the 
same  as  those  of  the  acute  process,  though  the  manifestations  are 


38  A  MANUAL  OF  SURGERY 

somewhat  different.  Hyperemia  and  exudation  occur,  but  the 
tissue  reaction  is  much  more  prominent.  The  main  differences 
between  the  two  are  as  follows : 

i.  The  hyperaemia  is  less  in  amount,  but  longer  in  duration, 
owing  to  the  fact  that  the  causative  irritant  is  less  intense  in  action, 
although  often  applied  for  a  longer  time.  The  local  manifesta- 
tions therefore  are  less  obvious  ;  pain  is  not  so  great  and  mainly 
of  an  aching  character,  whilst  there  is  less  heat,  the  redness  is 
more  dusky,  and  the  tissues  often  become  pigmented.  Consider- 
able loss  of  tone  in  the  vessels,  especially  the  veins,  results  from 
the  prolonged  distension,  and  thus  there  is  a  greater  difficulty  in 
restoring  them  to  a  normal  state. 

2.  The  corpuscles  do  not  adhere  together  or  run  into  rouleaux 
to  the  same  extent  as  in  acute  inflammation,  and  migration, 
though  it  exists,  is  on  a  limited  scale.  The  exudation  is  more 
fluid  in  character,  containing  comparatively  little  albumen  or 
fibrin  ;  in  fact,  in  some  chronic  inflammations  of  serous  mem- 
branes the  cavities  are  distended  with  fluid  of  a  much  lower 
specific  gravity  than  that  of  blood  serum. 

3.  The  greatest  difference  in  the  acute  and  chronic  processes 
lies  in  the  reaction  of  the  tissues.  In  the  former  they  are  in  a 
depressed  or  paralysed  condition,  but  in  the  latter  they  become 
infiltrated  with  round  cells,  derived  rather  from  the  connective- 
tissue  elements  than  from  the  leucocytes,  and  hence  organization 
is  much  more  marked  than  in  the  acute  form.  Tissue  destruc- 
tion, consequently,  is  less  prominent  in  the  early  stage  of  chronic 
inflammations,  although  as  a  secondary  change,  especially  in 
tuberculous  and  syphilitic  diseases,  it  is  often  seen. 

The  Causes  are  similar  in  character  to  those  producing  the 
acute  mischief,  but  slighter  and  more  prolonged  in  their  action. 
The  most  striking  point  in  the  aetiology  is  the  large  part  played 
by  diathetic  conditions  or  constitutional  predispositions.  Most  of 
the  manifestations  met  with  in  surgical  practice  are  due  to  syphilis, 
tubercle,  gout  or  rheumatism,  and  one  should  never  treat  cases  of 
this  nature  without  carefully  inquiring  as  to  the  possible  existence 
of  some  such  taint. 

The  Results  vary  according  to  the  part  of  the  body  affected,  and 
also  with  the  predisposing  diathetic  state,  and  we  can  here  only 
indicate  a  few  points  worthy  of  notice. 

In  Simple  chronic  inflammation  the  part  becomes  infiltrated  and 
enlarged,  mainly  from  proliferation  of  the  connective  tissues,  and 
if  allowed  to  persist,  this  will  result  in  fibrosis  or  sclerosis.  Thus, 
a  bone  is  thickened  and  condensed  in  chronic  osteitis  {osteosclerosis), 
whilst  in  chronic  periostitis  a  new  subperiosteal  formation  of  bone 
may  occur.  Glands  become  enlarged  and  indurated,  mainly  by 
hyperplasia  of  the  connective  tissue,  whilst  if  the  skin  is  involved 
it  may  either  become  hypertrophied  and  thickened,  or  entiiely 
loses  its  characteristic  structure,  being  converted  into  granulation 


INFLAMMATION 


39 


or  fibro-cicatricial  tissue,  with  or  without  an  intervening  ulcera- 
tive stage.  True  suppuration  rarely  occurs,  although  certain 
organisms  of  low  virulence  occasionally  lead  to  its  development. 

In  chronic  Tuberculous  inflammation  the  affected  part  is  occu- 
pied by  pulpy  oedematous  granulation  tissue,  scattered  through 
which  are  definite  tubercles,  which  may  run  together  and  lead  to 
the  formation  of  caseating  foci ;  these  in  turn  may  either  result  in 
suppuration  or  ulceration,  or  may  undergo  calcification,  and  their 
extension  be  limited  by  a  sclerosing  process  around  them.  A 
diffuse  overgrowth  forms  the  earliest  stage,  and  this  is  often 
followed  by  destruction  of  the  involved  tissues,  and  possibly  dis- 
organization of  the  parts,  with  or  without  suppuration. 

In  chronic  Syphilitic  inflammation  (tertiary)  the  most  marked 
feature  is  an  invasion  of  any  of  the  connective  tissues  by  a  fibro- 
cellular  exudation  and  hyperplasia,  which  may  be  diffuse  or 
localized  ;  if  the  former,  general  sclerosis  of  the  part  results,  e.g., 
in  the  stony-hard  tertiary  testicle  ;  in  the  latter,  a  gumma  is 
developed,  which,  owing  to  its  want  of  blood  vessels,  usually 
undergoes  central  degeneration  and  bursts,  giving  exit  to  a 
gummy  fluid,  and  perhaps  leaving  a  leathery-looking  slough  be- 
hind. 

In  all  these  varieties  of  chronic  inflammation  a  marked  pro- 
liferation is  always  found  in  the  tunica  intima  of  the  arteries  of 
the  inflamed  area,  the  result  of  an  associated  chronic  endarteritis. 

Constitutional  symptoms  are  but  little  evident,  beyond  those 
dependent  on  the  diathetic  condition  to  which  the  local  phenomena 
are  due,  or  to  septic  changes  developed  secondarily. 

The  Treatment  of  chronic  inflammation  is  usually  more  pro- 
longed and  difficult  tha.n  that  of  acute  cases,  because  of  the  con- 
stitutional dyscrasia  which  exists  so  frequently  behind  it. 

i .  The  cause  must  be  removed  whenever  possible.  Dead  or  diseased 
bone  must  be  removed,  and  tuberculous  material  got  rid  of,  by 
the  knife  or  sharp  spoon,  whilst  it  is  often  desirable  to  supplement 
this  by  subsequently  swabbing  the  parts  over  with  liquefied  car- 
bolic acid.  A  chronic  abscess  increases  the  action  of  the  original 
irritant  through  the  tension  engendered  by  its  presence,  and  hence 
it  should  be  dealt  with  as  early  as  possible  (p.  54). 

2.  Keep  the  part  at  rest.  This  is  just  as  much  an  essential  as  in 
the  treatment  of  acute  inflammation.  Joints  should  be  immo- 
bilized ;  the  spine  must  have  the  weight  taken  from  it  by  suitable 
appliances,  or,  better  still,  by  maintaining  the  recumbent  position  ; 
secretory  glands  are  not  actively  exercised,  and  the  organs  of 
sense  are  protected  from  irritation. 

3.  Counter-irritation  is  one  of  the  most  useful  forms  of  treatment 
for  chronic  inflammatory  conditions.  It  is  applied  in  many 
different  ways,  according  to  the  character  of  the  disease  and  the 
part  involved.  Thus,  friction  with  the  hand,  or  with  stimulating 
embrocations,  produces  a  hyperaemic  condition  of  the  skin,  and 
promotes  local  activity  in  the  superficial  parts  which  may  react 


4o  A   MANUAL  OF  SURGERY 

beneficially  on  deeper  structures.  Scoffs  dressing  may  be  similarly 
employed  ;  it  consists  in  wrapping  up  the  part  (e.g.,  a  joint)  in 
strips  of  lint  covered  with  ung.  hydrarg.  co.  (containing  over 
10  per  cent,  of  camphor),  and  then  encircling  it  firmly  with  soap 
plaster,  spread  preferably  on  chamois  leather.  Iodine  paint  is 
another  useful  application,  whilst  blisters  are  most  valuable  in 
suitable  cases.  The  moxa,  a  wound  produced  by  burning  a 
spirituous  solution  of  saltpetre  on  the  skin  ;  the  issue,  the  mainte- 
nance of  a  raw  surface,  however  produced,  by  the  constant  presence 
of  some  irritant,  such  as  the  insertion  of  a  bead,  or  the  use  of 
savin  ointment  as  a  dressing ;  and  the  seton,  a  double  thread 
knotted  at  each  end,  passed  for  some  distance  under  the  skin,  and 
drawn  from  end  to  end  daily— all  these  are  but  little  used  now, 
although  they  might  be  occasionally  employed  with  advantage. 
The  actual  cautery  is  the  most  severe  form  of  counter-irritant,  and 
is  especially  useful  in  some  varieties  of  chronic  inflammation  of 
bones  and  joints. 

4.  Pressure  is  a  most  important  element  in  the  treatment  of 
chronic  inflammatory  disorders,  and  probably  acts  by  artificially 
bracing  up  vessels  which  have  become  relaxed  and  atonic  from 
the  prolonged  distension  to  which  they  have  been  subjected.  It 
also  favours  the  absorption  of  inflammatory  exudations.  Firm 
bandaging,  and  especially  the  use  of  an  elastic  support,  are  the 
most  satisfactory  methods  of  application. 

5.  A  most  valuable  means  of  treating  chronic  inflammations, 
and  indeed  many  other  affections,  consists  in  Massage.  It  is 
impossible  in  a  text-book  of  this  size  to  give  a  full  account  of  the 
methods  employed,  but  we  may  state  that  the  chief  of  them  are 
known  as  effleurage,  petrissage,  and  tapotement.  Effleurage  con- 
sists in  plain  up  and  down  rubbing  of  the  limb  with  the  flat  of 
the  hand,  the  up  stroke  being  always  firmer  than  the  down,  so  as 
to  assist  in  the  return  of  the  blood  and  lymph  from  the  part.  In 
this  way  the  circulation  is  quickened,  and  the  vital  activities  of 
the  tissues  are  increased.  The  skin  should  be  lubricated  with  oil, 
vaseline,  or  some  stimulating  embrocation,  and  the  rubbing,  at  first 
light,  so  as  only  to  affect  the  skin  and  subcutaneous  tissues,  should 
gradually  become  firmer  so  as  to  influence  the  deep  structures. 
Petrissage  consists  in  kneading  the  muscles  or  other  tissues  between 
the  finger-tips  and  the  palm  of  the  hand  ;  this  necessarily  should 
be  done  across  the  muscle  fibres,  working  from  below  upwards, 
and  is  especially  valuable  in  hastening  the  absorption  of  exuda- 
tions. In  Tapotement  a  series  of  blows  perpendicular  to  the  surface 
is  rapidly  delivered  by  the  ulnar  side  of  the  open  or  clenched  hand; 
the  circulation  in  the  parts  thus  struck  is  much  quickened,  and 
when  skilfully  done  no  pain  should  be  caused. 

6.  General  or  constitutional  treatment  must  be  adopted  to  meet 
the  specific  diatheses  which  are  commonly  associated  with  chronic 
inflammation,  e.g.,  mercury  or  iodide  of  potash  in  syphilis. 


CHAPTER    III. 

SUPPURATION  AND  ABSCESS. 

When  the  inflammatory  process  results  from  the  action  of  certain 
micro-organisms,  known  as  pyogenic,  liquefaction  of  the  inflamed 
tissue  and  of  the  exudation  follows,  the  liquefied  material  being 
known  as  pus,  and  the  process  which  leads  to  its  formation  as 
suppuration.  Any  localized  collection  of  pus  is  known  as  an 
abscess,  and  of  such  two  chief  varieties  are  described — the  acute 
and  the  chronic.  Sometimes  the  pyogenic  infection  involves  the 
cellular  tissue  to  a  considerable  extent,  and  the  pus  is  widely 
diffused  through  the  substance  of  the  limb  or  part ;  such  a  con- 
dition is  usually  known  as  cellulitis  (p.  90). 

Acute  Abscess. 

Etiology. — A  large  amount  of  experimental  work  has  been 
undertaken  to  ascertain  the  relations  of  bacteria  to  acute  sup- 
puration, and  from  the  mass  of  evidence — mainly  concordant, 
but  occasionally  conflicting — the  following  conclusions  may  be 
drawn  : 

(a)  That  bacteria  are  present  in  all  acute  abscesses,  either  in  the  pus, 
or  in  the  abscess  wall,  or  in  both.  Ogston  of  Aberdeen  was  the 
first  to  proclaim  this  fact,  and  it  is  now  generally  accepted.  In 
some  chronic  abscesses,  notably  in  the  liver,  the  pus  is  occasionally 
found  to  be  sterile ;  this  is  probably  due  partly  to  the  organisms 
having  died,  owing  to  their  low  vitality,  and  partly  to  the  activity 
of  the  surrounding  tissues,  which  has  led  to  the  encapsulation  of 
the  focus. 

(b)  That  such  bacteria  can  reach  the  inflamed  area  either  from 
without  the  body  or  from  within.  The  former  method  is  the  more 
common,  and  is  illustrated  by  the  observations  of  Garre  and 
Bockhardt,  who  rubbed  cultures  of  Staphylococcus  pyogenes  aureus 
into  the  skin  of  their  arms,  and  produced  acute  suppuration 
commencing  in  superficial  pustules,  and  finishing  as  boils  or 
carbuncles.  Suppuration  in  wounds  is  most  commonly  due  to 
infection  from  without,  but  there  can  be  no  question  that  auto- 


42  A   MANUAL  OF  SURGERY 

infection  occurs,  by  means  of  which  an  abscess  can  be  produced  by 
infection  from  within  the  body.  This  can  only  happen  when  the 
vitality  of  the  patient  is  considerably  depressed,  and  some  local 
condition  exists  favourable  to  bacterial  development.  Thus,  given 
a  blood-clot  or  inflammatory  serous  exudation  in  an  unhealthy  indi- 
vidual, whose  germicidal  power  is  low,  suppuration  can  ensue  from 
auto-infection,  the  organisms  being  carried  by  the  blood  to  the 
affected  area  ;  an  abscess  thus  produced  is  termed  an  idiopathic 
infective  abscess.  Occasionally  the  microbes  are  carried  either 
en  masse  (zooglcca  condition),  or  in  the  substance  of  a  small  portion 
of  blood-clot,  as  an  embolus,  from  one  part  of  the  body  where  an 
infected  wound  or  injury  exists  to  some  other  part,  thus  originating 
an  embolic  infective  abscess.  Pyaemic  abscesses  are  of  this  type,  and 
similar  results  occur  after  gonorrhoea,  and  after  typhoid  and  other 
fevers. 

(c)  That  ordinary  irritating  c/iemical  products  or  sterilized  foreign 
bodies  (e.g.,  silver- wire  or  glass  splinters)  do  not  produce  suppuration, 
except  in  the  rarest  of  cases,  by  auto-infection.  Thus,  a  ragged 
splinter  of  glass,  an  inch  and  a  quarter  long,  and  an  inch  and  a 
half  wide,  the  result  of  the  bursting  of  a  soda-water  bottle,  was  cut 
out  of  the  neck  of  a  hotel  porter  ten  months  after  it  had  entered  ; 
it  had  caused  no  suppuration.  Experiments,  moreover,  have  been 
made  with  sterilized  croton-oil  and  other  irritants,  in  which  the 
substance  securely  sealed  up  in  a  thin  glass  capsule  is  implanted 
amongst  the  spinal  muscles  of  an  animal,  and  after  a  delay  to 
allow  the  thorough  healing  of  the  wound  is  set  free  by  a  blow. 
A  collection  of  putty-like  fibrinous  material  is  found  at  the  site  of 
operation,  and  much  discussion  has  arisen  as  to  whether  or  not 
this  is  to  be  looked  on  as  true  pus.  On  the  other  hand,  injections 
of  metallic  mercury,  or  of  the  ptomaines  produced  by  bacteria 
(e.g.,  cadaverin,  putrescin,  etc.)  certainly  result  in  suppuration. 

In  conclusion,  therefore,  although  we  have  to  admit  that 
suppuration  may  be  experimentally  induced  in  animals  in  the 
absence  of  micro-organisms,  in  man  for  all  ordinary  conditions  sup- 
puration does  not  occur  apart  from  the  presence  and  vital  activity  of  specific 
bacteria. 

The  causes  of  an  acute  abscess  may  for  practical  purposes  be 
grouped  under  the  three  following  headings:  (i)  The  individual 
affected  is  possibly  in  a  depressed  and  unhealthy  state,  and  the 
germicidal  properties  of  his  tissues  may  be  defective.  (2)  A  local 
nidus  must  exist,  which  is  in  a  condition  of  lowered  vitality, 
from  injury,  cold  or  otherwise ;  and  (3)  this  spot  must  become 
infected  with  pyogenic  organisms  brought  to  it  either  from  within 
or  without  the  body. 

Bacteriology. — As  already  stated,  the  pus  of  all  acute  abscesses  contains 
living  organisms,  the  nature  of  which,  however,  varies  with  circumstances. 
When  suppuration  occurs  in  wounds  in  which  there  is  but  little  putrescible 
material,  or  arises  idiopathically,  it   almost   always  results  from    direct    in- 


SUPPURATION  AND  ABSCESS 


43 


fection  with  one  or  more  of  the  pus-producing  pathogenic  bacteria.  In  many 
so-called  septic  wounds,  however,  non-pathogenic  bacteria  are  also  present, 
leading  to  putrefaction  of  the  discharge.  The  most  important  Pyogenic 
Organisms  are  as  follows  : 

i.  Staphylococcus  pyogenes  aureus  is  that  commonly  found  in  all  foci  of 
localized  suppuration  (Fig.  3).  It  can  readily  be  cultivated  on  nutrient 
gelatine,  agar-agar,  or  blood  serum.  On  plate  cultures  it  forms  in  two  days 
golden-yellow  colonies,  as  also  in  tube  preparations.  It  is  very  resistant  to 
chemical  and  thermal  reagents,  requiring  several  minutes'  boiling  to  ensure 
its  destruction.  It  produces  no  gas  and  no  stinking  odour  in  its  growth,  and 
is  capable  both  of  peptonizing  albumen  and  of  liquefying  gelatine.  It  is  a 
facultative  anaerobe  (p.    4  ). 

2.  Staphylococcus  pyogenes  albus. 

3.  Staphylococcus  pyogenes  citreus. 

These  two  forms  are  mainly  distinguished  from  the  former  by  the  colour  of 
the  colonies  formed  in  their  growth ;  all  their  other  properties  are  the  same 
except  that  perhaps  the  citreus  is  a  little  slower  in  rendering  gelatine  fluid. 


t*SP       B .  i      ■: 


V,t  '  1:1 


2* 


t 


Tig.  3. — Staphylococci  in  Pus. 
(From  Crookshank's  '  Textbook 
of  Bacteriology.') 


Fig.  4. — Streptococci  in  Pus.  (Re- 
duced from  Crookshank's  '  Text- 
book of  Bacteriology.') 


whilst  the  albus  is  apparently  not  so  virulent.  The  latter  organism  is  very 
similar  to,  if  not  identical  with,  the  Staph,  epidermidis  albus,  which  is  widely 
scattered  over  the  skin,  and  is  usually  found  in  the  small  abscesses  developing 
in  connection  with  tense  stitches. 

The  staphylococci  are  mainly  associated  with  the  formation  of  localized 
abscesses.  Thus,  if  a  culture  is  rubbed  into  the  skin  of  the  forearm,  a  plentiful 
crop  of  boils,  or  perhaps  a  carbuncle,  will  result ;  if  injected  beneath  the  skin, 
a  subcutaneous  abscess  may  be  formed,  or  even  a  typical  carbuncle,  if  a 
sufficient  number  has  been  introduced,  and  if  they  are  unfiltered  so  as  to 
retain  their  toxins;  if  the  peritoneal  cavity  is  infected,  suppurative  peritonitis 
follows,  provided  that  a  sufficient  quantity  of  the  organisms  is  present ;  if  a 
joint,  suppurative  arthritis.  When  injected  into  the  blood-stream,  there  is 
but  little  effect  if  only  a  few  are  introduced  ;  but  when  many,  multiple 
abscesses  in  any  and  every  part  of  the  body  may  occur,  as  in  pyaemia,  or  more 
frequently  true  septicaemia  ;  if,  soon  after  the  injection  of  an  amount  not  large 
enough  to  produce  general  infection,  a  bone  or  joint  is  injured,  acute  infective 
osteomyelitis  or  arthritis  will  follow  ;  whilst  if  the  cardiac  valves  are  arti- 
ficially damaged,  a  typical  ulcerative  endocarditis  ensues.  All  these  con- 
ditions can  be  produced  artificially  in  animals,  and,  from  the  similarity  of  the 
symptoms  and  the  microscopical  appearance  of  the  parts,  we  conclude  that 
similar  affections  in  man  are  due  to  exactly  the  same  causes,  except  that  the 


44  A   MANUAL  OF  SURGERY 

infection  is  not  artificial,  but  comes  either  from  without,  as  a  result  of  local 
injury,  or  from  the  blood-stream. 

4.  Streptococcus  pyogenes  (Fig.  4 )  is  an  organism  of  great  importance  in  path- 
ology, and  it  is  the  main  exciting  cause  of  many  inflammatory  conditions.  It 
is  probable  that  there  are  several  distinct  species  included  under  this  title- 
indeed,  it  is  claimed  that  six  different  forms  have  been  isolated;  further 
researches  are,  however,  needed  to  make  certain  of  this  fact.  It  can  be  readily 
cultivated  on  most  nutrient  media,  but  grows  slowly  at  the  ordinary  tempera- 
ture of  the  air,  and  not  very  rapidly  even  at  blood  heat.  It  does  not  liquefy 
gelatine  nor  produce  any  colouring  reagent,  and  does  not  form  any  proteolytic 
ferment.  It  occurs  in  chains  of  varying  length,  which  may  occasionally 
bifurcate. 

The  Streptococcus  pyogenes  is  mainly  associated  with  spreading  inflammations 
of  the  cellulitic  type,  whilst  it  is  a  common  cause  of  pyaemia,  and  even  of  acute 
septicaemia.  It  has  also  been  found  in  many  acute  localized  abscesses,  in 
empyema,  and  in  some  forms  of  suppurative  arthritis.  It  is  probable  that  the 
streptococcus  of  erysipelas  should  be  included  in  this  group. 

5.  The  Bacillus  coli  communis  is  an  organism  to  which  much  attention  has 
been  directed  of  recent  years.  It  is  identical  with  the  microbes  formerly 
known  as  the  Bac.  pyog.  fcetidus  and  the  Bac.  lactis  aerogenes.  It  exists  normally 
in  the  intestinal  canal,  extending  from  mouth  to  anus,  but  most  frequently 
in  the  duodenum  and  colon,  and  probably  plays  a  considerable  part  in  the 
normal  process  of  disintegration  of  food-stuffs.  So  long  as  it  remains  within 
the  bowel,  it  is  perfectly  innocent;  but  as  soon  as  it  is  able  to  pass  into  or 
through  the  intestinal  wall,  as  a  result  of  any  loss  or  diminution  in  its  vitality 
or  abrasion  of  its  surface,  it  is  liable  to  become  intensely  virulent,  producing 
suppurative  inflammation  of  the  most  acute  type,  or  even  necrosis.  Hence  it 
is  the  most  common  cause  of  acute  suppurative  peritonitis  in  all  cases  where 
the  infection  arises  from  within  the  bowel,  whilst  it  is  mainly  responsible  for 
the  formation  of  abscesses  in  the  neighbourhood  of  the  tube,  as  in  appendi- 
citis, acute  ischio-rectal  suppuration,  etc.  One  of  its  most  characteristic 
features  is  that — even  when  cultivated  in  a  test-tube — it  produces  a  most 
offensive  and  penetrating  odour,  somewhat  similar  to  that  of  decomposing 
fasces;  such  is  also  noticed  in  the  pus  produced  by  the  organism.  It  is  also 
the  most  constant  organism  found  in  the  bladder  in  cases  of  cystitis,  but  has 
no  power  of  rendering  the  urine  alkaline. 

6.  The  Bacillus  pyocyaneus  is  occasionally  met  with  in  wounds,  producing 
what  is  described  as  blue  or  green  pus.  It  is  of  little  clinical  importance, 
except  that  in  a  few  cases  it  has  been  known  to  give  rise  to  general  infection. 

7.  The  Pneumococcus  and  Bacillus  typhosus  may  also  give  rise  to  suppuration 
after  pneumonia  and  typhoid  fever  respectively,  but  they  are  not  specially 
virulent,  and  the  abscesses  are  usually  of  a  subacute  type. 

8.  The  Gonococcus  must  also  be  included  in  this  category. 

Pathological  Anatomy  of  an  Abscess. — The  phenomena  associ- 
ated with  the  formation  of  an  acute  abscess  are  merely  a  further 
stage  of  those  detailed  previously  as  characteristic  of  inflamma- 
tion. The  vessels  of  the  affected  area  become  distended,  and  the 
various  elements  of  the  blood  pass  through  the  walls.  As  the 
organisms  develop,  the  vascular  phenomena  of  retardation  and 
stasis  followed  by  thrombosis  occur  successively,  whilst  the  exuda- 
tion of  cells  becomes  so  great  that  the  original  tissue  of  the  part 
disappears,  after  passing  through  a  stage  of  coagulation-necrosis 
(Plate  II.,  Fig.  1).  This  removal  of  the  infiltrated  tissues,  though 
due  in  part  to  the  defective  blood-supply  resulting  from  the 
pressure  of  the  exudation  and  the  vascular  thrombosis,  is  largely 


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SUPPURATION  AND  ABSCESS  45 

caused  by  their  liquefaction  owing  to  the  peptonizing  power  of 
the  bacteria  present.  In  streptococcal  infections  where  a  proteo- 
lytic ferment  is  absent,  the  solution  of  the  tissues  is  probably 
brought  about  by  the  direct  action  of  the  many  phagocytes 
present  in  the  effusion,  a  process  favoured  by  the  damaged  and 
degenerative  condition  of  the  cells  of  the  part ;  this  absence  of  a 
ferment  may  explain  why  the  onset  of  suppuration  is  sometimes 
slow.  The  inflamed  focus,  therefore,  consists  merely  of  an  irregularly 
shaped  mass  of  round  cells,  the  central  portion  of  which  liquefies 
and  breaks  down  into  pus.  When  once  this  has  commenced  to 
form,  it  depends  entirely  upon  the  character  of  the  irritant,  and  the 
nature  and  behaviour  of  the  surrounding  tissues,  as  to  what  will 
subsequently  supervene  ;  but  there  is  usually  a  tendency  for  the 
pus  to  increase  steadily  in  amount.  It  may  then  find  its  way  to 
the  surface  and  point  ;  it  may  burrow  along  fascial  or  muscular 
planes  ;  or  it  may,  somewhat  less  frequently,  become  circum- 
scribed, and  more  or  less  chronic.  As  soon  as  the  acute  or 
extending  process  comes  to  an  end,  repair  begins  to  manifest 
itself  in  the  vascularization  of  the  embryonic  tissue,  and  its  trans- 
formation into  granulation  tissue.  Should  the  abscess  point,  the 
normal  tissues  in  the  line  it  travels  along  are  in  their  turn  trans- 
formed into  embryonic  tissue,  which  becomes  liquefied  as  soon 
as  it  is  formed,  whilst  granulations  spring  up  from  the  floor  and 
sides  of  the  cavity,  endeavouring,  as  it  were,  to  obliterate  the  track 
the  abscess  has  followed.  Thus,  a  definite  distinction  must  be 
drawn  between  the  structure  of  its  wall  in  the  early  and  late 
stages,  which,  however,  we  often  see  co-existing  in  the  same 
abscess.  In  the  former  or  early  stage  of  tissue  destruction  (Plate  II., 
Fig.  1),  the  following  zones  are  met  with  in  passing  from  the  centre 
to  the  periphery  :  (1)  The  central  collection  of  pus  ;  (2)  a  layer  of 
breaking-down  embryonic  tissue  infiltrated  with  bacteria ;  (3)  em- 
bryonic tissue  showing  a  trace  of  the  original  structure  of  the  part 
in  a  state  of  coagulation-necrosis,  with  the  vessels  thrombosed  and 
many  bacteria  present  ;  (4)  tissue  of  the  part  infiltrated  with  leuco- 
cytes and  organisms,  and  with  the  blood-stream  either  stopped 
completely  or  retarded  ;  (5)  hyperaemic  and  slightly  infiltrated 
tissue  of  the  part,  gradually  shelving  off  into  normal  tissue.  It 
must  be  clearly  remembered,  however,  that  the  inflammatory 
focus  is  at  first  diffuse,  and  that  the  zones  indicated  here  are 
quite  artificial.  The  early  abscess  cavity  is  extremely  irregular  in 
outline,  and  the  lining  wall  very  variable  in  character,  one  part 
being  possibly  thick,  and  another  quite  thin  and  yielding  readily 
to  the  extension  of  the  proces.  In  the  later  stages  (Plate  II., 
Fig.  2),  where  the  inflammation  is  not  spreading,  the  structure 
of  the  abscess  may  be  thus  described:  (1)  The  central  focus  of 
pus ;  (2)  a  layer  of  granulation  tissue  to  a  large  extent  free  from 
bacteria ;  (3)  a  layer  of  fibro-cicatricial  tissue  gradually  merging 
into  (4)  the  normal  tissue,  somewhat  infiltrated  and  hyperaemic. 


46  A  MANUAL  OF  SURGERY 

The  Clinical  Signs  and  Symptoms  of  an  acute  subcutaneous 
abscess  may  be  arranged  under  three  headings  : 

i.  The  local  signs  consist  of  a  patch  of  inflamed  tissue,  indicated 
by  heat,  pain,  redness  and  swelling,  which  latter  is  at  first  hard 
and  brawny,  but  when  pus  forms  the  centre  becomes  soft,  elastic, 
and  fluctuating,  whilst  superficial  oedema  is  more  marked,  and 
the  pain  throbbing  in  character.  Naturally,  the  amount  of  this 
pain  depends  entirely  upon  the  density  of  the  tissue  affected  and 
the  supply  of  sensory  nerves  to  the  part,  suppuration  beneath  a 
resisting  membrane,  such  as  the  palmar  fascia,  being  always 
intensely  painful.  If  left  to  itself,  an  abscess  sooner  or  later 
points  and  bursts.  As  it  increases  in  size,  it  exerts  pressure  in 
all  directions,  and  naturally  seeks  to  find  an  exit  in  the  line  of 
least  resistance,  and  so  may  either  find  its  way  to  the  surface,  or 
may  burrow  along  muscular  and  fascial  planes,  or  into  adjacent 
cavities.  This  is  not  merely  a  mechanical,  but  also  a  vital  process, 
as  already  described.  The  actual  bursting  of  an  abscess  is  often 
due  to  some  injury — it  may  be  a  slight  one — but  is  usually  pre- 
ceded by  ulceration  of  the  integument,  or  perhaps,  if  the  abscess 
is  a  large  one,  by  necrosis. 

2.  Pressure  effects  are  mainly  due  to  the  mechanical  influence  of 
the  swelling  upon  surrounding  structures.  The  most  evident  are 
those  due  to  the  irritation  of  nerves,  as  a  result  of  which  neuralgic 
pain  may  be  present,  or  the  patient  may  refer  the  pain  to  some 
distant  unaffected  region.  In  some  cases,  where  bloodvessels  are 
involved,  the  tissue  around  them  disappears,  and  they  are  left  in 
the  abscess  cavity  as  bands,  surrounded  by  granulation  tissue. 
Thrombosis  and  the  subsequent  obliteration  of  the  vessel  may 
result,  or  occasionally  ulceration  and  haemorrhage  (ulcerative 
periarteritis),  preceded  perhaps  by  an  aneurismal  dilatation  of 
the  vessel,  owing  to  its  loss  of  external  support.  Such  effects  are 
more  common  in  chronic  than  in  acute  abscesses. 

3.  The  general  effects  of  the  formation  of  an  acute  abscess  are 
those  of  increased  fever,  sometimes  amounting  to  a  rigor,  and 
leucocytosis.  A  rigor  consists  of  a  definite  series  of  phenomena, 
the  result  of  some  stimulating  influence  reaching  the  thermogenic 
centres  of  the  medulla,  and  determining  a  sudden  increase  of 
activity.  It  is  very  similar  in  nature  to  an  attack  of  ague,  being 
ushered  in  by  a  feeling  of  intense  cold  and  discomfort ;  the  features 
are  pinched,  and  the  teeth  chatter.  The  skin,  however,  feels  dry 
and  hot,  and  the  temperature  of  the  body  rapidly  rises.  The 
sensation  of  cold  is  partly  due  to  the  contact  of  air  at  a  main- 
tained normal  temperature  with  the  hot,  dry,  unperspiring  skin, 
and  also  possibly  to  the  condition  of  superficial  anaemia  which 
is  present.  After  this  stage  has  lasted  a  variable  period,  the 
patient  gradually  begins  to  feel  warmer,  the  face  becoming 
flushed,  the  thermometer  ceasing  to  rise,  and  the  skin  com- 
mencing  to  act.     Finally  there   is   a  rapid   fall  of  temperature 


SUPPURATION  AND  ABSCESS  47 


accompanied  by  profuse  perspiration,  which  leaves  the  patient 
more  or  less  exhausted. 

Leucocytosis  is  the  term  employed  to  indicate  an  increase  in  the 
number  of  white  corpuscles  in  the  blood.  Normally  about  8,000 
leucocytes  are  found  in  each  c.mm.,  although  the  number  is  some- 
what increased  immediately  after  meals.  When  suppuration  is 
occurring,  the  proportion  may  be  enormously  increased,  even  up 
to  100,000  per  c.mm.  It  is  best  seen  in  cases  of  severe  infection, 
well  resisted,  and  is  not  a  very  obvious  feature  when  the  infec- 
tion is  so  acute  as  to  break  down  all  resistance,  or  so  slight  as  to 
cause  little  constitutional  disturbance.  A  blood-count  may  be 
advisably  undertaken  in  some  cases  of  doubtful  diagnosis. 

Pus  and  its  Constituents. — Normal,  or  as  it  was  formerly  called 
healthy,  or  laudable  pus  is  a  thick,  creamy  fluid,  having  a  specific 
gravity  of  about  1030,  an  alkaline  reaction,  no  smell  (unless  putre- 
fying or  under  special  circumstances),  and  containing  85  to  go  per 
cent,  of  water.  If  allowed  to  settle,  it  separates  into  two  layers, 
the  upper  or  fluid  part,  liquor  puris,  consisting  of  liquefied  tissue 
and  serum,  and  containing  about  6-7  per  cent,  of  proteid  material 
(i.e.,  rather  less  than  in  normal  blood  serum) ;  whilst  the  lower 
layer  includes  the  solid  elements  present,  viz.,  dead  and  living 
pus  corpuscles,  fatty  and  granular  debris,  perhaps  micro-organisms, 
and  possibly  a  few  red  blood  cells.  All  the  pus  cells  look  alike 
when  examined  under  the  microscope  on  a  cold  slide  ;  but  if 
placed  on  a  warm  slide,  a  difference  is  soon  noticed.  Dead  pus 
cells  are  rounded  in  outline,  about  0500  inch  in  diameter,  coarsely 
granular  in  texture,  and  show  two  or  three  nuclei,  which  become 
more  evident  on  the  addition  of  dilute  acetic  acid.  The  living 
pus  corpuscles  are  fewer  in  number,  and,  though  spherical  at 
first,  soon  manifest  amoeboid  movements  ;  their  protoplasm  is 
finely  granular,  and  the  single  nucleus  is  not  readily  observed ; 
the  proliferation  of  the  nucleus  is  always  an  evidence  of  degenera- 
tion and  approaching  death.  It  must  be  clearly  understood  that 
both  the  living  and  dead  cells  are  derived  from  the  same  sources, 
viz.,  principally  from  the  extravasated  leucocytes,  but  also  possibly 
from  proliferation  of  the  fixed  connective-tissue  corpuscles  of  the 
part. 

As  already  stated,  the  pus  in  an  acute  abscess  contains  bacteria,  which  are 
best  demonstrated  in  the  following  way  :  A  drop  of  pus  is  placed  between 
two  cover-slips,  which  are  each  evenly  coated  by  a  thin  layer  of  the  fluid  by 
sliding  one  over  the  other.  These  are  dried  by  passing  them  through  the 
flame  of  a  spii  it-lamp,  only  sufficient  heat  being  employed  to  set  the  albumen 
without  destroying  the  corpuscles.  A  drop  of  methyl-violet  solution  is  now 
placed  over  the  pus  film,  and  allowed  to  remain  for  about  a  minute,  being 
then  washed  away  by  a  stream  of  distilled  water.  The  slip  should  be  again 
dried  slowly,  and  mounted  in  Cana.da  balsam.  The  cocci  will  be  found  stained 
deeply,  whilst  albuminous  and  fatty  granules  are  not  coloured  at  all,  or  but 
slightly  (Figs.  4  and  5). 

When  pus  is  mixed  with  blood,  it  is  termed  saDious  (short  for 


48  A   MANUAL  OF  SURGERY 

sanguineous) ;  when  thin  and  acrid,  it  is  ichorous  ;  curdy,  when 
mixed  with  curdy  shreds,  as  is  more  usually  seen  in  chronic 
suppuration  of  a  tuberculous  nature  ;  muco-pus,  when  mixed  with 
mucous,  arising  from  inflammatory  conditions  of  mucous  mem- 
branes. The  occurrence  of  stinking  pus  apart  from  putrefaction 
has  been  already  explained  as  generally  due  to  the  activity  of  the 
Bacillus  coli  communis. 

Occasionally  an  abscess  is  found  to  contain  not  only  pus,  but 
also  gas.  This  may  be  due  to  the  existence  of  a  direct  com- 
munication with  some  hollow  viscus — e.g.,  the  stomach  or  intestine 
— and  hence  is  met  with  in  subphrenic  abscess  and  in  some  of 
the  many  types  of  abscess  associated  with  appendicitis ;  but  it  is 
sometimes  the  result  of  infection  with  a  gas-producing  organism — 
e.g.,  the  Bacillus  arogenes  capsulatus  or  Bacillus  cedematis  maligni. 
This  latter  type  is  rare  apart  from  spreading  gangrene ;  but  we 
recently  opened  a  perineal  abscess  in  a  diabetic  patient  from  out  of 
which  the  gas  literally  whistled,  whilst  in  a  few  days  emphysema 
had  spread  over  the  whole  trunk,  in  spite  of  incisions  to  limit  its 
progress.  Very  extensive  sloughing  followed,  and  the  patient 
died.     The  Bacillus  adematis  maligni  was  isolated  in  this  case. 

The  Diagnosis  of  an  acute  superficial  abscess  usually  presents 
no  difficulties,  the  sense  of  fluctuation  supervening  in  the  midst 
of  an  area  previously  inflamed  and  brawny  being  quite  charac- 
teristic ;  sometimes,  however,  all  that  can  be  detected  is  a  feeling 
of  elastic  resistance  in  the  centre  of  the  hyperaemic  indurated 
focus,  but  this,  to  the  practised  finger,  is  quite  as  conclusive  of 
the  presence  of  fluid  as  fluctuation.  When  the  pus  is  placed 
deeply  under  muscular  and  fascial  planes,  very  careful  examina- 
tion may  be  needed  in  order  to  determine  its  presence ;  the 
surgeon  must  not  be  misled  by  the  sense  of  fluctuation  obtained 
across  the  fibres  of  a  muscle  ;  none  is  noticed,  however,  by  pal- 
pating along  the  course  of  its  fibres. 

Treatment  of  Acute  Abscess. — When  an  inflamed  area  is 
threatening  to  suppurate,  the  formation  of  pus  can  be  but  rarely 
prevented.  In  the  early  stages,  elevation  and  rest  of  the  part, 
together  with  the  application  of  cold  and  evaporating  lotions, 
may  sometimes  succeed  in  accomplishing  this,  together  with  the 
administration  of  quinine  and  iron.  The  hypodermic  injection 
of  powerful  antiseptics — e.g.,  pure  carbolic  acid — has  also  been 
employed  to  destroy  the  pyogenic  organisms  in  situ,  whilst  in 
some  cases  (e.g.,  in  acute  periostitis)  a  free  incision  through 
the  inflamed  tissues  is  permissible. 

In  a  few  regions  of  the  body,  pus  may  be  absorbed  after  its 
formation,  but  only  when  situated  in  a  cavity  of  highly-absorbing 
powers,  such  as  the  anterior  chamber  of  the  eye  (hypopyon),  or 
perhaps  some  of  the  serous  cavities,  e.g.,  the  peritoneal.  In  the 
former  the  process  of  absorption  may  certainly  be  observed  under 
the  influence  of  local  and  general  treatment. 


SUPPURATION  AND  ABSCESS  49 


As  a  rule,  however,  one  encourages  suppuration  by  applying 
fomentations  or  poultices  to  the  part,  and  then  as  soon  as  pus  is 
evident,  an  incision  is  made  to  evacuate  the  abscess  cavity.  The 
opening  must  be  large  enough  to  prevent  re-accumulation  ;  it 
should  be  placed  at  a  spot  suitable  for  drainage,  but  as  far 
as  possible  from  sources  of  septic  contamination,  and  in  such 
a  direction  that  movements  of  the  part  do  not  close  it.  In 
dealing  with  deep  abscesses  in  dangerous  regions,  Hilton  s  method 
may  be  advantageously  employed.  It  consists  in  merely  dividing 
the  skin  and  superficial  structures,  and  then  thrusting  a  director 
into  the  abscess  cavity ;  a  pair  of  sinus  or  dressing  forceps  is  now 
passed  along  the  groove,  and  on  forcibly  separating  the  blades  a 
sufficient  opening  is  made  to  insert  the  finger,  and  subsequently 
a  drainage-tube. 

Methods  of  Opening  Various  Abscesses. — Axillary  Abscess. — Cut  in  the 
median  line  of  the  axilla  towards  the  chest  from  above  downwards,  and  use 
Hilton's  method,  thus  escaping  the  three  main  sources  of  danger,  viz.,  the 
axillary  vessels  above,  the  long  thoracic  in  front,  and  the  subscapular  vessels 
behind. 

Inguinal  Bubo. — Make  a  vertical  incision  from  below  upwards,  the  patient 
standing  erect  against  a  wall  or  lying  down.  When  he  sits  the  incision  gapes, 
and  so  accumulation  is  prevented. 

Intramammary  Abscess.  —  Cut  in  a  direction  radiating  from  the  nipple  to 
prevent  injury  to  the  galactophorous  ducts,  and  pass  a  finger  in  so  as  to  open 
up  all  the  dilated  lobules. 

Submammary  Abscess. — Open  along  the  lower  margin  of  the  breast,  and,  if 
possible,  towards  the  outer  side,  carefully  avoiding  the  glandular  tissue. 

Retropharyngeal  Abscess. — Incise  along  the  posterior  border  of  the  sterno- 
mastoid  for  about  an  inch  ;  draw  that  muscle  and  the  carotid  sheath  forwards ; 
open  by  Hilton's  method,  pushing  a  director  inwards  to  the  middle  line 
immediately  in  front  of  the  transverse  processes 

Ischio-rectal  Abscess.  —  Place  the  patient  leaning  over  the  back  of  a  chair, 
or  in  the  lithotomy  position  if  an  anaesthetic  is  employed,  and  incise  vertically 
and  very  freely,  as  far  from  the  anus  as  possible ;  healing  may  ensue  without 
opening  the  rectum.  In  some  cases  where  the  skin  is  undermined,  a  crucial 
incision  should  be  made,  the  resulting  corners  of  skin  being  removed. 

In  opening  a  Palmar  Abscess,  care  must  be  taken  not  to  wound  the  super- 
ficial palmar  arch  or  its  digital  branches.  It  is  best  accomplished  by  entering 
the  knife  immediately  in  a  line  with  the  centre  of  the  metacarpal  bones,  cutting 
forwards  to  the  base  of  the  finger ;  the  upper  limit  of  this  incision  should  not 
transgress  the  centre  of  the  palm. 

A  Whitlow  should  be  opened  in  the  middle  line  of  the  finger  by  a  knife  held 
with  its  back  towards  the  wrist,  and  it  often  happens  that  the  patient,  if 
conscious,  unwittingly  assists  at  his  own  operation  by  withdrawing  his  hand, 
thus  effectually  completing  the  incision  ;  care  must,  of  course,  be  taken  hot 
to  let  the  knife  travel  too  far  or  too  deeply. 

It  is  advisable  to  gently  squeeze  an  abscess  after  opening  it, 
especially  if  sloughs  are  present,  or  when  it  has  burrowed ;  if 
the  cavity  is  large,  it  should  be  explored  with  the  finger.  All  that 
is  subsequently  needed,  if  there  is  no  complication,  such  as  the 
presence  of  dead  or  diseased  bone,  is  to  arrange  for  drainage,  as 
by  inserting  a  drainage-tube  or  a  slip  of  protective,  and  to  exclude 
sepsis  by  a  carefully  applied  antiseptic  dressing  ;  in  other  cases 

4 


50  A   MANUAL  OF  SURGERY 

it  may  be  desirable  to  pack  the  cavity  with  gauze  soaked  in  an 
iodoform  emulsion  (10  per  cent.).  There  is  often  a  considerable 
loss  of  blood  during  the  first  twenty-four  hours  from  the  yielding 
of  the  capillaries  in  the  abscess  wall,  owing  to  the  sudden  relief  of 
tension  ;  but  this  usually  ceases  of  itself,  or  yields  to  moderate 
pressure.  When  once  the  abscess  has  been  evacuated,  no  move  pus  is 
formed  if  the  cavity  is  kept  aseptic,  the  discharge  being  merely  serous, 
and  the  wound  rapidly  closing  and  healing.  Our  colleague, 
Mr.  G.  L.  Cheatle,  has  pointed  out  that,  although  no  more  pus  is 
formed,  the  cavity  and  its  lining  wall  still  contain  bacteria,  and 
perhaps  in  a  state  of  virulence,  but  they  are  evidently  unable  to 
develop  or  do  any  harm,  possibly  from  the  tissues  being  immunized 
or  protected  against  them.  Pus  which  stinks  on  its  escape  loses  all 
smell  in  a  day  or  two,  the  wound  pursuing  a  normal  course,  unless 
the  abscess  communicates  directly  with  the  bowel.  In  some  cases 
the  original  opening  at  the  spot  where  the  abscess  pointed  may  not 
give  efficient  drainage ;  a  counter-opening  should  then  be  made  by 
pushing  the  finger,  or  a  probe,  through  the  abscess  wall  amongst 
the  tissues,  making  it  protrude  beneath  the  skin  at  some  dependent 
spot,  and  cutting  down  upon  the  finger  or  probe  in  this  direction. 

Chronic  Abscess  (syn. :  Cold  or  Congestive  Abscess). 

A  chronic  abscess  may  be  defined  as  a  collection  of  pus  which 
forms  slowly  without  any  signs  of  active  inflammation.  Although 
a  few  cases  are  due  to  infection  with  pyogenic  microbes  or  to 
chronic  pyaemia,  yet  the  vast  majority  are  tuberculous  in  origin  ; 
and,  indeed,  when  a  chronic  abscess  is  spoken  of,  it  may  be  taken 
for  granted  that  it  is  tuberculous,  unless  otherwise  stated.  It 
must  be  clearly  understood  that,  although  we  speak  clinically 
of  a  chronic  tuberculous  abscess,  it  is  a  question  whether  the 
term  is  correct,  and  whether  the  fluid  contained  therein  is  pus ; 
certainly  its  method  of  origin  and  characters  are  very  different 
to  those  of  an  acute  abscess.  For  the  present,  however,  it  is 
convenient  to  retain  the  terms  '  pus  '  and  '  abscess  '  in  this  con- 
nection. 

Wherever  tubercle  can  be  deposited,  a  chronic  abscess  may 
form  ;  but  it  occurs  most  commonly  in  connection  with  bones, 
joints,  and  lymphatic  glands.  Into  the  details  of  these  causative 
affections  it  is  unnecessary  to  enter  here  ;  suffice  it  to  state  that 
the  abscess  arises  from  the  degeneration  and  liquefaction  of  a 
tuberculous  focus ;  that  it  forms  a  soft  fluctuating  swelling, 
gradually  increasing  in  size,  and  possibly  by  its  pressure  effects 
becoming  painful ;  that  it  may  come  directly  to  the  surface  if 
there  is  no  dense  fascia  to  prevent  it,  but  that,  being  often  placed 
deeply,  there  is  a  great  tendency  to  burrow  along  fascial  planes, 
and  hence  to  become  superficial  at  a  spot  far  removed  from  its 
original  source.  Thus,  an  abscess  arising  in  connection  with 
tuberculous  disease  of  the  dorsi-lumbar  region  of  the  spine  may 


SUPPURATION  AND  ABSCESS 


51 


travel  in  many  directions :  it  may  pass  backwards,  and  be  opened 
at  the  side  of  the  spine  as  a  lumbar  abscess ;  it  may  infiltrate  the 
superficial  fibres  of  the  psoas  muscle,  and  travel  down  the  sheath 
to  the  groin,  pointing  either  above  or  below  Poupart's  ligament 
(Fig.  5) ;  or  it  may  find  its  way  into  the  pelvis  and  escape  by  the 
side  of  the  rectum.  The  far-reaching  extent  of  these  abscesses, 
the  impossibility  of  dealing  adequately  with  the  lining  membrane, 
together  with  the  infective  nature  of  the  disease  and  the  often 
inaccessible  position  of  the  original  focus  of  the  mischief,  render 
them  most  difficult  to  treat,  and  fully  account  for  the  dread  of 
opening  them  experienced  by  surgeons  in  pre-antiseptic  days ; 
for  should  the  cavity  of  the  abscess  once  become  septic,  there  is 
but  little  hope  of  again  purifying  it,  and  the  result  is  an  increased 
discharge  of  pus,  absorption  of  the  chemical  products  of  putrefac- 
tion, aggravation  of  the  original  disease,  and  only  too  frequently 
death  from  exhaustion  or  blood-poisoning. 

The  pus  contained  in  a  chronic  abscess  may  be  of  the  ordinary 
type,  consisting  of  cells  and  bacteria  ;  but  if  of  tuberculous 
origin,  there  are  only  a  few  cells,  and  those  in  a  condition  of  fatty 

degeneration,  whilst  masses  of 
curdy  debris  of  variable  size  and 
consistency  are  often  present,  if 
the  abscess  is  of  long  standing, 
an  abundance  of  cholesterine 
crystals  is  often  seen,  a  fact  re- 
cognised by  the  naked  eye  by  the 
glistening  sheen  or  greasy  appear- 
ance imparted  to  the  pus  ;  micro- 
scopically, they  appear  in  the 
shape  of  rhomboidal  plates,  with 
one  corner  notched  out.  It  is 
unusual  to  find  either  cocci  or 
bacilli  in  the  pus  of  a  chronic 
tuberculous  abscess,  and  this  in 
spite  of  the  fact  that  inoculation 
of  animals  with  the  pus  results  in 
tuberculosis.  Probably  the  bacilli 
have  been  broken  up  by  the  sup- 
purative process,  but  the  more 
resistant  spores  are  still  present. 

The  microscopic  appearance  of  a 
tuberculous  abscess  wall  is  quite 
characteristic  (Plate  III.,  Fig.  2). 

The  method  of  extension  along  the  The  Cavity  Is  lined  bY  a  layer  of 
psoas  tendon  and  into  the  thigh  gray»  yellowish-gray,  or  pinkish, 
is  well  seen.  pulpy  granulation  tissue,  contain- 

ing miliary  tubercles  perhaps 
undergoing  caseation.  Its  colour  and  vitality  are  dependent  upon 
the  chronicity  or  not  of  the  process  ;  the  longer  the  abscess  is  in 


DUE     TO 


Fig.    5. — Psoas   Abscess 

Disease  of  the  Upper  Lumbar 
Vertebrae.     (After  Albert.) 


52  A   MANUAL  OF  SURGERY 


forming,  the  less  vascular  the  membrane,  owing  to  the  associated 
sclerosis  of  the  surrounding  structures  leading  to  compression  of 
the  bloodvessels,  whilst  it  has  been  already  mentioned  that  endar- 
teritis always  accompanies  a  chronic  inflammation,  and  helps  to 
render  the  parts  non-vascular.  This  lining  membrane,  when 
necrotic,  is  but  loosely  connected  with  a  layer  of  fibro-cicatricial 
material,  which  forms  the  outer  part  of  the  wall,  and  from  which 
it  can  often  be  readily  detached  by  the  finger  or  a  sharp  spoon. 
This,  in  turn,  gradually  shelves  off  into  the  normal  tissue  which 
surrounds  the  abscess.  In  non-tuberculous  cases  the  lining  wall 
consists  of  granulation  tissue  passing  over  into  the  normal 
structure  of  the  part,  which  is  more  or  less  sclerosed,  according 
to  the  duration  of  the  mischief. 

Natural  Cure. — A  tuberculous  abscess,  if  left  to  itself,  does  not 
necessarily  come  to  the  surface  and  burst.  Occasionally  in  the 
dead-house  one  meets  with  a  mass  of  putty-like  consistency  lying 
in  front  of  the  spine  in  the  body  of  a  patient  who  has  been  cured 
of  spinal  disease.  This  is  evidently  the  desiccated  remains  of  a 
chronic  abscess,  the  fluid  portion  having  been  absorbed,  and  the 
solid  elements  left  behind,  encapsuled  and  perhaps  infiltrated  with 
lime  salts.  Such  debris  can  become  the  seat  of  recurrent  inflam- 
matory mischief  when  the  original  disease  has  been  quiescent  for 
years  ;  suppuration  may  suddenly  occur,  giving  rise  to  what  is 
known  as  a  residual  abscess.  Probably  a  large  amount  of  choles- 
terine  will  be  found  amongst  its  contents.  The  prognosis  of  such 
an  abscess  is  good ;  in  more  than  one  instance  we  have  cured 
them  entirely  by  one  tapping  and  free  lavage. 

Results  of  Long- continued  Suppuration. — When  a  chronic  abscess 
is  emptied  antiseptically,  and  maintained  in  an  aseptic  condition, 
the  formation  of  pus  ceases ;  the  wound  may  remain  open  for 
months,  but  the  discharge  is  merely  serous,  and  no  constitutional 
results  will  be  manifested.  The  temperature  is  normal,  and  the 
general  health  unimpaired,  if  no  other  disease  is  present.  Should 
such  an  abscess  become  septic,  the  condition  of  affairs  is  at  once 
changed ;  the  discharge  becomes  profuse  and  purulent,  fever 
supervenes,  and  grave  visceral  changes  occur,  which  sooner  or 
later  may  lead  to  the  patient's  death  from  exhaustion.  Long-con- 
tinued suppuration,  then,  is  always  an  evidence  of  sepsis,  and  from  it  two 
conditions  may  arise,  viz.,  hectic  fever  and  lardaceous  disease. 

Hectic  Fever  may  be  defined  as  a  chronic  toxaemia  or  condition  of 
blood-poisoning,  due  to  the  continual  absorption  of  small  doses  of 
toxins,  and  is  met  with  not  only  after  opening  chronic  abscesses, 
but  also  in  any  condition  of  chronic  sepsis,  e.g.,  after  acute  or 
chronic  suppurative  affections  of  bones  or  joints,  in  tuberculous 
disease  of  the  lungs,  and  in  septic  syphilitic  or  cancerous  disease. 
It  is  characterized  by  a  regular  diurnal  elevation  of  temperature, 
which  runs  a  tolerably  typical  course.  It  commences  to  rise 
during  the  afternoon,  the  face  becoming  flushed  (hectic  flush  of 
the  cheeks),  the  eyes  bright  and  sparkling,  the  pupils  dilated, 


SUPPURATION  AND  ABSCESS  53 


and  the  patient  feeling  better  and  stronger.  The  pulse,  how 
ever,  is  small,  compressible,  and  ten  or  twenty  beats  quicker 
than  it  should  be ;  the  tongue  becomes  red  at  the  edges  and  tip. 
This  condition  continues  till  late  in  the  night,  by  which  time  the 
temperature  may  have  risen  four  or  five  degrees.  It  then  com- 
mences to  fall  as  rapidly  as  it  had  formerly  risen,  and  usually 
drops  to  the  normal,  or  even  below  it,  and  in  the  early  morning  a 
profuse  perspiration  breaks  out  which  soaks  the  patient's  clothes, 
and  leaves  him  in  a  much-exhausted  condition.     Day  by  day  this 


^     %':'%fm^-y 


c- 


Fig.  6. — Amyloid  Kidney  in  Early  Stage.     (Ziegler.) 

(Treated  with  Miiller's  fluid  and  perosmic  acid,  x  300.)  a,  Normal  capillary 
loop;  b,  amyloid  capillary  loop;  c,  fatty  epithelium  of  glomerulus;  Cy  fatty 
epithelium  of  capsule ;  d,  oil-drops  on  the  capillary  wall ;  e,  fatty  epithelial 
cells  in  situ ;  /,  loosened  fatty  epithelial  cells  ;  g,  hyaline  coagula  (forming 
'  casts  ') ;  h,  fatty  cast  in  section  ;  i,  amyloid  artery;  k,  amyloid  capillary ; 
I,  infiltration  of  connective  tissue  with  leucocytes ;  m,  round  cells  (leuco- 
cytes) within  a  uriniferous  tubule. 

continues,  the    fever   and    sweating    together  causing  a  marked 
diminution  in  the  patient's  strength. 

Amyloid,  Albumenoid,  or  Lardaceous  Disease  of  various  organs 
is  also  present  in  cases  of  long-standing  suppuration.  As  to  the 
cause  of  this  curious  condition,  but  little  is  known  ;  either  from 
the  deleterious  effects  of  toxic  compounds  circulating  in  the  blood, 
or  from  the  loss  of  some  special  substance  in  the  discharge, 
e.g.,  alkaline  phosphates,  the  walls  of   the    smaller  arteries  and 


54  A   MANUAL  OF  SURGERY 


the  protoplasm  of  certain  of  the  viscera  are  converted  into  or 
infiltrated  with  a  waxy  substance,  from  which  lardacein,  an 
extremely  insoluble  proteid  body,  may  be  obtained.  The  name 
'  amyloid '  is  an  entire  misnomer,  as  this  material  is  in  no  way 
akin  to  starch.  It  occurs  as  a  waxy  homogenous  material, 
becoming  a  dirty  brown  on  the  application  of  tincture  of  iodine, 
and  an  inky  blue  when  sulphuric  acid  is  subsequently  added. 
With  methyl-violet  the  amyloid  substance  is  coloured  ruby-red, 
whilst  normal  tissues  are  stained  blue  or  indigo.  The  organs 
mainly  affected  are  the  liver,  spleen,  kidneys,  and  villi  of  the 
intestines,  and  the  capillaries  and  muscular  coats  of  the  arterioles 
(Fig.  6,  b  and  i)  are  the  parts  first  attacked,  the  change  gradually 
spreading  to  the  parenchyma  of  the  organ.  The  liver  becomes 
evenly  enlarged  to  a  considerable  degree,  often  reaching  from  the 
fifth  rib  to  the  umbilicus,  or  lower ;  it  is  firm  in  consistency,  like 
indiarubber,  painless,  and  waxy-looking  on  section.  The  arterioles 
and  capillaries  in  the  intermediate  zone  of  the  lobules  are  those 
first  affected,  but  the  cells  soon  participate  in  the  change.  The 
glycogenic  and  bile-producing  functions  are  naturally  interfered 
with,  so  that  the  digestive  process,  and  especially  the  power  of 
absorbing  fats,  is  impeded.  The  kidneys  become  similarly  enlarged, 
the  change  commencing  in  the  arterioles  leading  to  the  glomeruli 
(Fig.  6),  but  the  capillaries  and  the  tubal  epithelium  are  also 
early  affected.  In  this  stage  the  urine  is  very  abundant  (from  the 
increased  filtration  through  the  degenerated  walls),  pale,  limpid, 
and  containing  a  few  hyaline  casts  and  fatty  cells;  later  on, 
when  the  tubules  are  more  largely  involved,  there  is  less  urine, 
with  a  higher  specific  gravity,  and  a  considerable  amount  of 
albumen.  The  spleen  increases  in  size,  but  not  always  to  so  great 
an  extent  as  the  other  viscera  ;  the  Malpighian  bodies  are  the  chief 
seat  of  the  mischief.  The  capillaries  in  the  villi  of  the  intestines 
become  lardaceous,  and  allow  of  an  increased  transudation  of  the 
fluid  parts  of  the  blood,  resulting  in  diarrhoea ;  the  absorption  of 
nutriment  is  thereby  much  lessened,  and  thus  both  by  increased 
excretion  and  diminished  absorption  of  food  the  strength  of  the 
patient  is  steadily  undermined. 

Amyloid  changes  in  the  viscera,  far  from  being  a  contra-indica- 
tion  to  operation,  are  rather  to  be  considered  as  a  sign  that  radical 
treatment  is  urgently  necessary,  unless  the  general  condition  of 
a  patient  is  such  that  he  cannot  stand  the  strain  of  it.  If  by  an 
operation,  e.g.,  excision  or  amputation,  the  local  disease  can  be 
eradicated,  the  amyloid  changes  in  the  viscera  may  totally  dis- 
appear. 

Treatment  of  Chronic  Abscess. — In  former  days  the  rule  always 
given  was  to  leave  a  chronic  abscess  alone  as  long  as  possible, 
and  never  to  interfere  unless  forced  to  do  so ;  sepsis,  followed  by 
hectic  and  increased  rapidity  of  the  disease,  almost  always  resulted 
from  such  interference.     But  when   asepsis  can  be  maintained, 


SUPPURATION  AND  ABSCESS 


there  is  no  reason  to  depart  from  the  ordinary  rule  of  surgery, 
that  the  abscess  should  be  evacuated  as  soon  as  possible  after  its 
formation.  It  is,  however,  most  important  to  recognise  the  fact 
that  one  slip  in  the  technique  may  lead  to  a  fatal  issue,  and 
therefore  none  should  interfere  with  these  cases  unless  they  are 
prepared  to  take  the  time  and  trouble  needed  to  keep  them  aseptic. 
Again,  from  the  risk  of  sepsis  being  admitted  during  the  dressing 
of  the  case,  those  methods  should  be  preferred  which  admit  of  the 
immediate  total  closure  of  the  wound.  Many  plans  of  treatment 
of  chronic  abscess  have  been  suggested  and  practised ;  we  can 
here  only  allude  to  the  more  important. 

1.  Simple  aspiration  has  been  known  to  effect  a  cure,  but  only  in  excep- 
tional circumstances,  viz.,  where  the  causative  lesion  is  absolutely  passive, 
and  when  the  patient's  health  and  constitution  are  vigorous.  It  often  fails 
from  the  blocking  of  the  aspirator  needle  by  curdy  debris,  and  there  is  always 
a  fear  that  much  of  this  material  will  be  left  behind,  forming  a  possible  source 
of  future  re-infection.  The  rapid  emptying  of  the  sac,  moreover,  often  leads 
to  haemorrhage,  and  the  blood  thus  collecting  will  form  a  favourable  soil  for 
the  development  of  the  spores  remaining  in  the  curdy  masses,  or  of  the  bacilli 
within  the  pyogenic  membrane. 

2.  Tapping  the  abscess  with  thorough  irrigation  is  another  plan  of  treatment 
which  under  favourable  circumstances  is  occasionally  successful.  We  have 
seen  a  large  psoas  abscess  cured  by  one  thorough  washing  out.  The  modus 
operandi  is  as  follows :  The  skin  is  incised,  and  through  the  opening  a  large 
trocar  and  cannula  is  inserted  into  the  abscess  cavity,  which  is  emptied  as 
completely  as  possible.  It  is  now  distended  with  a  warm  solution  of  carbolic 
acid  (i  in  80),  or  with  a  sublimate  lotion  (1  in  5,000),  or  simply  with  sterilized 
water  or  salt  solution  (5i.  ad  Oi.),  at  a  temperature  of  1050  to  110°  F.  The 
abscess  is  then  well  kneaded  with  the  fingers,  and  the  fluid  with  the  curdy- 
masses  and  broken-down  pyogenic  membrane  is  allowed  to  escape.  The 
process  is  repeated  again  and  again  until  the  escaping  fluid  is  nearly  clear, 
or  only  slightly  opalescent.  The  cannula  is  now  withdrawn,  the  wound 
firmly  stitched  up,  and  an  antiseptic  dressing  applied,  using  sufficient  pressure 
to  obliterate,  if  possible,  the  abscess  cavity.  The  patient  must  be  kept  quiet, 
and  carefully  watched  for  a  time,  to  ascertain  if  there  is  any  reaccumulation, 
when  the  same  process  may  be  repeated. 

3.  Opening  the  abscess  and  scraping  out  the  interior  with  Barker's  flushing  gouge 
combines  the  irrigation  of  the  previous  method  with  the  more  or  less  complete 
removal  of  the  tubercle-containing  pyogenic  membrane.  The  instrument 
employed  consists  of  a  gouge  or  sharp  spoon  with  a  long  hollow  handle, 
which  communicates  by  a  tube  with  a  reservoir  of  fluid  placed  at  some  height 
above  the  patient.  During  its  application  the  constant  rush  of  water  or  lotion 
through  the  handle  clears  the  gouge,  and  removes  the  debris.  It  is  admirably 
adapted  for  certain  cases,  but  its  use  needs  considerable  care,  as  the  sharp 
edge  can  readily  scrape  through  an  abscess  wall,  and  do  much  mischief.  It 
is  a  convenient  means  of  dealing  with  abscesses  of  bones  and  joints  in  the 
more  superficial  parts  of  the  body.  The  wounds  should  be  subsequently 
closed,  and  an  attempt  made  to  gain  immediate  healing  of  the  denuded  cavity. 

4.  Injection  of  an  antiseptic  into  the  sac  after  tapping  is  a  method  introduced 
by  Professor  Velpeau  in  France,  and  has  been  received  with  much  favour. 
Various  reagents  have  been  employed,  but  the  majority  contain  iodine  either 
in  the  form  of  the  tincture,  or  as  iodoform,  which  latter  may  be  suspended  in 
glycerine  or  olive-oil  (10  per  cent.),  or  dissolved  in  ether  (5  per  cent.).  The 
method  of  introducing  these  compounds  is  quite  simple,  the  amount  varying, 
but  as  a  rule  not  more  than  a  drachm  of  iodoform  should  be  used.    When 


56  A   MANUAL  OF  SURGERY 


the  ethereal  solution  is  injected,  the  ether  immediately  volatilizes  and  hilly 
distends  the  abscess  cavity,  which  becomes  tense  and  tympanitic ;  it  must 
therefore  never  be  used  for  abscesses  communicating  with  the  interior  of  the 
thorax,  death  having  in  one  or  two  recorded  cases  resulted  from  heart  failure, 
due  to  such  distension.  There  is  some  danger,  too,  that  serious  toxic 
symptoms  may  arise  from  absorption  of  the  iodoform.  This  treatment  is 
most  likely  to  be  efficacious  when  all  active  bone  or  joint  disease  has  dis- 
appeared, and  is  frequently  employed  as  an  adjunct  to  one  of  the  above- 
described  plans. 

5.  If  the  above  methods  fail,  or  are  for  any  reason  inapplicable,  the  original 
antiseptic  method  of  simple  incision  with  drainage  can  always  be  adopted.  This 
is  perfectly  safe,  so  long  as  asepsis  is  maintained  ;  but  the  great  objections  to 
it  are  the  length  of  time  (months,  or  even  years)  often  required  to  bring  about 
healing,  especially  in  cases  where,  although  a  free  incision  is  made,  the  actual 
seat  of  the  disease  is  not  reached,  and  the  risk  of  contamination  during  one  of 
the  repeated  dressings  that  are  required. 

6.  In  certain  cases  of  external  chronic  abscess,  especially  when  connected 
with  lymphatic  glands,  it  may  be  possible  to  dissect  out  the  whole  cavity  en  masse, 
and  if  such  is  feasible,  it  is  the  most  satisfactory  plan  to  adopt.  Should  the 
posterior  wall  of  the  cavity  be  adherent  to  important  deep  structures,  it  should 
be  thoroughly  scraped  so  as  to  remove  all  pyogenic  material,  and  disinfected, 
e.g.,  with  liquefied  carbolic  acid  or  solution  of  zinc  chloride  (40  grains  to 
1  ounce).  An  attempt  may  then  be  made  to  gain  healing  by  first  intention, 
or  the  cavity  may  be  stuffed  and  allowed  to  granulate. 

7.  Laying  the  cavity  freely  open,  scraping  away  the  pyogenic  tissue,  perhaps 
purifying  with  carbolic  acid,  plugging  the  wound  firmly  with  gauze  infiltrated 
with  purified  iodoform,  and  allowing  it  to  granulate  from  the  bottom,  or 
the  open  method,  may  be  used  advantageously  in  cases  where  abscesses  have 
burrowed  between  muscles,  and  along  fascial  planes.  Sulphur  has  also  been 
used  instead  of  iodoform,  but  has  no  special  advantage,  whilst  it  causes  a  good 
deal  of  sloughing  of  the  surrounding  tissues  owing  to  its  transformation  into 
sulphurous,  and  finally  into  sulphuric  acid.  Friar's  balsam  (1  part  in  8  of 
castor  oil  or  glycerine)  may  be  employed  in  the  same  way,  and  is  innocuous 
and  useful. 

Sinus  and  Fistula. 

When  an  abscess  has  been  opened,  and  does  not  completely 
heal,  a  communication  often  persists  between  the  original  seat  of 
the  disease  and  the  exterior,  which  is  known  as  a  sinus  or  fistula. 
A  Sinus  is  a  narrow  track  lined  with  granulations,  penetrating 
into  the  tissues,  open  at  one  end  and  closed  at  the  other ;  the  dis- 
charge is  purulent  or  merely  serous  according  to  whether  or  not 
sepsis  is  present.  A  Fistula  is  an  abnormal  communication  be- 
tween two  cavities,  or  between  a  cavity  and  the  external  surface. 
When  such  conditions  result  from  the  non-closure  of  a  chronic 
abscess,  the  walls  consist  of  exactly  the  same  structures  as 
those  of  the  original  abscess,  viz.,  an  external  fibro-cicatricial 
vascular  layer,  merging  into  healthy  tissues,  and  an  internal 
lining  of  pyogenic  membrane  containing  tubercles,  if  the  origi- 
nating disease  was  tuberculous.  If  the  fistulous  track  is  short, 
there  is  a  tendency  for  the  granulating  wall  to  become  covered 
with  epithelium,  and  under  such  circumstances  it  cannot  be  ex- 
pected to  close  until  the  epithelium  has  been  removed,  and  a  raw 
surface  again  exposed. 


SUPPURATION  AND  ABSCESS  57 


It  is  often  a  matter  of  the  greatest  difficulty  to  secure  the  heal- 
ing of  a  sinus  or  fistula,  and  the  following  are  the  main  causes  of 
their  non-closure :  (1)  The  presence  of  some  chronic  irritant  in  the 
depths  of  the  wound,  such  as  a  piece  of  the  clothing,  a  catgut 
ligature,  a  piece  of  silver-wire  used  in  an  operation,  or  of  some 
diseased  tissue,  such  as  a  fragment  of  dead  or  carious  bone : 
(2)  the  irritation  of  discharges  finding  an  exit  through  the 
abnormal  opening,  such  as  urine,  faeces,  or  foetid  pus  ;  (3)  in- 
sufficient drainage  of  a  deep  cavity,  so  that  there  is  always  a 
certain  amount  of  tension  in  the  wound ;  (4)  want  of  rest  to 
the  part,  due  either  to  voluntary  movements,  as  in  the  limbs,  or 
to  involuntary  muscular  action  in  the  immediate  neighbourhood, 
as  in  fistula-in-ano  ;  (5)  tuberculous  infection  of  the  wall,  or  a 
tuberculous  deposit  at  the  bottom  of  the  sinus ;  (6)  the  growth  of 
epithelium  down  the  sinus  or  round  the  margin  of  the  fistula  ;  or 
(7)  constitutional  debility. 

The  orifice  of  a  sinus  is  often  depressed  from  the  amount  of 
infiltration  around,  but  in  cases  where  foreign  bodies  are  lodged 
within,  or  where  diseased  bone  exists,  it  is  usually  surrounded  by 
prominent  fungating  granulations. 

Treatment. — The  removal  of  the  cause  is  the  first  thing  to 
accomplish  in  dealing  with  a  sinus  or  fistula.  The  passage  must 
be  dilated  or  slit  up  to  allow  of  access  to  the  deeper  parts  of  the 
wound,  to  remove  any  foreign  body  which  may  be  present, 
or  to  allow  of  the  satisfactory  drainage  of  a  deep  cavity.  The 
making  of  a  dependent  counter-opening  often  suffices  to  cure  a 
sinus.  A  thorough  purification  of  the  part  by  pure  carbolic  acid 
or  chloride  of  zinc  must  also  be  undertaken,  and  the  wound 
dressed  by  plugging  with  suitable  material  and  kept  at  rest, 
whilst  the  general  health  of  the  patient  is  improved  by  tonics. 
Occasionally,  the  pressure  of  a  roller  bandage  to  immobilize  the 
part  is  all  that  is  required,  or  the  application  of  a  suitable  splint. 
The  most  complete  and  certain  method  is  to  lay  the  sinus  open 
and  thoroughly  destroy  the  lining  granulation  tissue  by  scraping 
or  cauterising,  and  then  to  plug  the  wound,  allowing  it  to  heal 
from  the  bottom  by  granulations. 

Should  a  fistula  have  become  lined  with  epithelium,  the  edges 
will  require  paring,  and  some  form  of  plastic  operation  must  be 
undertaken  to  close  the  opening. 

The  term  '  fistula  '  is  also  applied  to  conditions  other  than  those 
tracks  remaining  from  the  non-closure  of  an  abscess.  Three 
classes  may  be  described  : 

1.  Congenital  fistula,  e.g.,  branchial,  umbilical  urinary  or  faecal, 
etc. 

2.  Traumatic  fistula,  e.g.,  aerial,  pharyngeal,  salivary,  recto- 
vesical, recto-vaginal,  etc. 

3.  Pathological  fistula,  or  those  secondary  to  abscess  or  disease, 
e.g.,  biliary,  faecal,  perineal  urinary,  fistula-in-ano,  etc. 

Each  of  these  will  be  referred  to  later  on  under  its  appropriate 
heading. 


CHAPTER  IV. 

ULCERATION. 

Ulceration  has  been  denned  as  the  '  molecular  or  particulate 
death  of  a  part,'  by  which  is  meant  the  disintegration  of  the  super- 
ficial tissues,  which  liquefy  and  disappear,  and  usually  without 
any  obvious  slough.  It  differs  from  gangrene  in  that  the  latter 
term  is  used  to  denote  the  simultaneous  loss  of  vitality  of  a 
considerable  portion  of  tissue.  The  two  processes  are,  however, 
often  closely  associated — in  fact,  both  signify  tissue  necrosis ;  in 
the  former  the  dead  particles  are  not  always  visible  to  the  naked 
eye,  whereas  in  the  latter  the  necrotic  portions,  if  superficial,  can 
always  be  seen. 

Three  main  classes  of  ulcers  are  met  with  in  surgical  practice  : 

I.  Ulcers  due  to  traumatism  or  to  the  ordinary  pyogenic  bacteria,  e.g., 
the  spreading,  healing,  chronic,  etc. 

II.  Ulcers  due  to  specific*  bacteria,  e.g.,  soft  chancre,  lupoid, 
tuberculous,  syphilitic,  etc. 

III.  Malignant  ulcers,  e.g.,  rodent,  epitheliomatous,  scirrhous, 
and  fungating. 

Causation. — Ulceration  is  due  to  the  application  of  an  irritant 
to  the  surface  of  such  an  intensity,  and  for  such  a  period,  as  to 
lead  to  local  inflammation  resulting  in  the  destruction  of  the 
tissue  affected.  Any  form  of  irritant,  whether  chemical,  thermal, 
mechanical,  or  infective,  may  accomplish  this  end,  and  all  the 
factors  predisposing  to  inflammation  will  hasten  its  occurrence. 
Thus,  faulty  nutrition,  whether  from  anaemia  or  from  long-standing 
congestion,  is  particularly  liable  to  further  the  ulcerative  process. 
Moreover,  when  any  part  becomes  anaesthetic,  or  is  cut  off  from 
its  trophic  centres,  the  continued  presence  of  an  irritant  may  not 
be  appreciated,  and  hence  destructive  inflammation  occurs,  e.g. 

*  It  may  be  well  to  note  that  whilst  the  term  infective  is  applied  to  any 
condition  due  to  an  invasion  with  bacteria,  the  word  specific  denotes  that  the 
lesion  is  due  to  one  special  or  specific  organism.  Nearly  all  inflammatory 
ulcers  are  infective  in  nature,  but  only  those  in  Group  II.  are  specific;  many 
different  types  of  organisms  may  give  rise  to  the  ulcers  in  Group  I. 


ULCER  A  TION  59 


corneal  ulcer  following  section  of  the  fifth  nerve,  or  perforating 
ulcer  of  the  foot  in  tabes.  In  malignant  disease  the  projection  of 
the  mass  of  the  growth  may  expose  it  unduly  to  irritation  ;  but 
the  chief  cause  of  ulceration  is  the  replacement  of  the  deeper 
layers  of  the  skin  or  mucous  membrane  by  the  cells  of  the 
neoplasm,  so  that  when  the  superficial  epithelium  wears  off  or  is 
lost,  it  cannot  be  reproduced. 

I.    Ulcers  due  to  Traumatism  or  to  the  ordinary  Pyogenic 

Bacteria. 

Clinical  History. — Every  ulcer  of  this  class  tends  sooner  or  later 
to  recovery,  and  so  may  be  said  to  pass  through  three  stages,  viz., 
(i)  that  of  ulceration  proper,  or  extension  ;  (2)  a  stage  of  transi- 
tion, or  preparation  for  healing,  which  may  be  short  or  long, 
according  to  whether  the  ulcer  is  running  a  rapid  or  a  slow  course, 
and  persists  until  the  surface  is  covered  with  granulations;  and 
(3)  the  stage  of  healing  or  repair.  It  must  be  clearly  understood 
that  the  first  stage  alone  represents  the  true  ulcerative  process  ; 
when  this  ceases,  the  ulcer  proper  disappears,  and  merely  a 
superficial  loss  of  substance,  the  result  of  the  preceding  ulceration, 
remains.  If  every  simple  ulcer  passes  through  these  three  stages, 
then  every  variety  of  simple  ulcer  must  necessarily  be  in  one  of  the  three 
stages,  and  hence  may  be  described  as  a  modification  of  a  typical 
condition  representing  the  stage  to  which  it  belongs.  Naturally, 
in  a  large  ulcer  the  three  stages  may  co-exist,  or  a  healing  ulcer 
may  from  intrinsic  or  extrinsic  causes  relapse  again  to  the  stage 
of  tissue  destruction. 

Stage  I.  :  Ulceration  proper  or  Extension. — The  special  charac- 
teristic of  this  stage  is  that  destructive  changes  are  progressing 
with  greater  or  less  rapidity,  and  hence  the  ulcers  may  be 
described  as  inflamed,  spreading,  or  sloughing. 

Naked-eye  Appearances. — Surface,  covered  with  ashy  gray  or 
dirty  yellow  material,  partly  slough,  partly  lymph,  partly  breaking- 
down  tissue  ;  no  granulations  are  present ;  the  tendency  to  slough 
is  most  marked  when  the  organisms  are  particularly  virulent,  or 
if  the  resistance  of  the  tissues  is  much  diminished ;  discharge, 
considerable  in  amount,  thin,  sanious,  and  often  irritating  and 
offensive,  rarely  purulent ;  margins,  thickened  and  inflamed,  and 
the  surrounding  tissues  often  cedematous  and  infiltrated  ;  edge, 
sharply  cut  and  well  defined  ;  the  base  of  the  ulcer  is  thickened 
and  fixed  to  the  underlying  structures. 

Microscopically,  all  the  phenomena  of  inflammation  may  be 
observed  progressing  to  thrombosis  and  tissue  necrosis,  so  that 
in  approaching  the  surface  from  the  healthy  tissues  one  would 
pass  through  zones  of  active  hypersemia,  of  retarded  blood-flow 
with  infiltration  of  leucocytes  and  plasma,  of  stasis  and  throm- 
bosis, whilst  the  tissues  are  in  a  state  of  coagulation-necrosis. 


6o  A   MANUAL  OF  SURGE  NY 


Treatment  of  First  Stage. — This  resolves  itself  into  removing 
the  cause,  protecting  the  surface  from  all  sources  of  mechanical 
irritation,  and  purifying  it  from  all  septic  contamination.  The 
inflamed  part  must  be  kept  at  rest,  and  if  necessary  raised  from 
a  dependent  position  (i.e.,  the  leg  must  not  be  allowed  to  hang 
down),  whilst  the  sore  is  dressed  with  moist  and  warm  antiseptic 
applications,  such  as  a  boracic  poultice.  When  the  parts  are 
very  offensive,  a  charcoal  and  linseed-meal  poultice  may  be  first 
employed.  The  state  of  the  bowels  and  constitution  must  be 
attended  to,  and  probably  a  mild  purgative  will  be  needed. 

Stage  II. :  The  Transition  Period  comprises  all  the  changes  which 
occur  from  the  termination  of  the  ulcerative  process  proper  to  the 
time  wrhen  healing  is  fully  established  by  the  wound  becoming 
covered  with  granulations.  In  short,  it  may  be  described  as  the 
stage  of  preparation  for  healing. 

Naked-eye  Appearances. — When  the  destructive  process  has 
ceased,  and  the  septic  element  has  been  eliminated,  the  surface 
of  the  ulcer  begins  to  clean,  and  becomes,  as  it  were,  glazed 
over ;  sloughs  and  portions  of  dead  tissue  are  either  removed 
in  the  dressing  or  absorbed  by  the  activity  of  the  leucocytes  and 
fibroblasts.  The  discharge  becomes  less  abundant  and  more 
serous  in  character,  and  the  angry  red  blush  is  replaced  by  a 
rosy  hyperaemia.  The  infiltration  of  the  base  also  diminishes,  so 
that  the  tissues  around  are  less  fixed  and  more  supple.  The  film 
on  the  surface  becomes  more  and  more  defined,  and  in  the  course 
of  time,  shorter  or  longer,  according  to  circumstances,  little  red 
spots  make  their  appearance  here  and  there ;  these  gradually 
increase  in  number  and  size,  and  coalesce,  until  the  whole  surface 
is  covered  by  what  has  now  become  granulation  tissue.  The 
processes  occurring  in  this  stage  are :  (a)  the  removal  of  the 
sloughs ;  (b)  the  covering  of  the  surface  with  a  cellulo-plastic 
exudation ;  and  (c)  the  vascularization  of  this  newly-formed 
material,  and  its  conversion  into  granulation  tissue. 

Microscopic  Appearances. — When  the  action  of  the  irritant  has 
ceased,  the  migration  of  the  leucocytes  lessens,  and  the  destruction 
of  tissue  comes  to  an  end.  The  surface  of  the  ulcer  is  now 
covered  with  a  layer  of  round  cells,  mainly  derived  from  the  pro- 
liferation of  the  neighbouring  connective-tissue  elements,  and 
intermixed  with  fibrin  in  such  a  way  that  the  cells  lie  in  the 
interstices  of  the  fibrillae ;  this  constitutes  the  film  mentioned 
above.  The  vessels  in  the  area,  where  merely  stasis  has  occurred, 
become  patent,  and  the  circulation  in  the  neighbourhood  of  the 
ulcer  is  thus  restored.  The  vascularization  of  this  superficial 
film  is  next  undertaken,  according  to  the  process  described  in 
Chapter  VIII.  The  wound  thus  becomes  covered  with  granula- 
tion tissue,  and  with  its  formation  the  processes  included  in  the 
second  stage  come  to  an  end. 

All  the  forms  of  chronic  ulcer  which  are  neither  spreading  nor  actively 


ULCERATION  61 


healing  may  be  included  in  this  transitional  stage,  viz.,  the  indolent  or 
callous  ulcer,  the  irritable,  the  varicose,  etc. 

The  Indolent  or  Callous  Ulcer  occurs  most  frequently  on  the 
legs  of  women  about  the  middle  period  of  life.  The  size  varies 
greatly,  but  they  are  sometimes  so  extensive  as  to  involve  the 
whole  circumference  of  the  limb.  It  may  also  follow  large  burns 
on  any  part  of  the  body ;  healing  proceeds  to  a  certain  extent, 
and  then  stops  from  the  fact  that  the  contraction  of  the  cicatricial 
tissue  already  formed  interferes  with  the  vitality  of  the  part  still 
unhealed  by  compressing  the  vessels,  and  so  cutting  off  the 
granulations  from  their  source  of  nutriment.  The  surface  is 
usually  smooth  and  glistening,  and  of  a  dirty  yellow  colour,  with 
perhaps  a  few  badly-formed  granulations ;  the  edges  are  hard 
and  sharply  cut,  and  elevated  considerably  above  the  surface, 
whilst  the  skin  around  may  be  heaped  up  over  the  edge,  and 
either  covered  with  sodden  cuticle  or  congested.  The  skin  of  the 
limb  is  often  deeply  pigmented  from  chronic  congestion,  the  pig- 
mentation starting  in  the  separate  papillae  as  maculae,  which 
gradually  coalesce.  The  discharge  is  purulent  or  serous,  and  may 
be  so  abundant  and  irritating  as  to  cause  eczema  of  the  parts 
around,  and  thus  give  rise  to  one  form  of  eczematous  ulcer.  The 
base  is  adherent  to  the  underlying  tissues,  fasciae,  etc. ;  and  this 
constitutes  one  of  the  main  difficulties  in  healing,  as  contraction 
of  the  sore  is  thus  prevented.  If  the  ulcer  extends  to  the 
periosteum,  as  happens  not  unfrequently  when  placed  over  the 
shin,  chronic  periostitis,  or  even  osteitis,  results,  and  a  sub- 
periosteal node  is  formed,  corresponding  exactly  to  the  size  and 
situation  of  the  ulcer,  forming  a  mushroom-shaped  projection,  and 
possibly  going  on  to  necrosis,  or  to  enlargement  of  the  whole 
bone.  In  some  very  chronic  cases  the  superficial  lymphatics  and 
veins  are  so  much  compressed  as  to  cause  chronic  oedema  of  the 
foot,  often  of  a  very  solid,  brawny  type,  and  the  limb  may  even 
pass  into  a  condition  of  pseud-elephantiasis. 

The  so-called  Irritable  Ulcer  is  usually  met  with  in  this  stage. 
Its  chief  peculiarities  are  the  position,  generally  in  the  neigh- 
bourhood of  the  ankle,  and  the  pain  which  accompanies  it.  The 
surface  of  a  healing  or  chronic  ulcer  can  usually  be  touched  with- 
out the  patient  complaining ;  but  in  this  variety  the  pain  is  ex- 
cessive, especially  at  night.  It  was  pointed  out  by  the  late 
Mr.  Hilton  that,  if  a  probe  is  run  lightly  over  the  surface  of  such 
a  sore,  one  or  more  spots  will  be  indicated  as  the  chief  seats  of 
the  pain,  the  rest  being  insensitive.  In  all  probability,  nerve  fila- 
ments are  there  exposed,  as  the  pain  has  a  very  marked  burning 
or  shooting  character. 

The  Varicose  Ulcer  occurs  in  the  leg  of  a  patient  who  is  the 
subject  of  aggravated  varicose  veins.  The  skin  becomes  passively 
congested,  and  its  nutrition  is  consequently  impaired  ;  any  injury 
or  abrasion,  which  would  readily  heal  in  a  sound  limb,  is  likely 


62  A   MANUAL  OF  SURGERY 

under  such  circumstances  to  give  rise  to  a  chronic  sore.  Again, 
it  may  be  preceded  by  eczema  resulting  from  the  irritation  of  dirt 
or  the  friction  of  hard  trousers,  whilst  occasionally  it  may  be  due 
to  the  yielding  of  the  thinned  skin  which  forms  the  only  covering 
of  a  much  dilated  vein,  an  accident  often  leading  to  severe  haemor- 
rhage. The  characters  of  a  varicose  ulcer  vary  considerably,  but 
in  the  main  they  correspond  to  those  of  the  second  or  transitional 
period,  and  are  usually  found  on  the  inner  and  lower  portions  of 
the  leg,  whilst  syphilitic  sores  are  more  often  placed  nearer  the 
knee  and  on  the  outer  side. 

The  Treatment  of  ulcers  in  this  stage  differs  according  to  the 
conditions  present.  If  it  is  merely  a  passing  phase  in  the  progress 
of  an  ulcer  tending  rapidly  to  repair,  all  that  is  needed  is  to  con- 
tinue the  same  course  of  treatment  as  was  adopted  at  an  earlier 
period  of  the  case,  viz.,  rest  and  protection  from  irritation.  It 
may  be  advisable  to  shield  the  surface  from  contact  with  dressings 
by  the  intervention  of  a  small  portion  of  purified  '  protective  '• — 
i.e.,  oiled  silk  coated  with  dextrin — so  that  the  reparative  material 
may  not  be  damaged  during  their  removal. 

The  Chronic  Ulcer  needs  much  care  in  its  treatment,  and  some 
cases  require  operative  interference.  Rest  in  a  more  or  less 
elevated  position  is  absolutely  essential  in  order  to  relieve  the 
congested  condition  of  the  limb ;  whilst  if  the  surface  is  foul,  a 
charcoal  poultice  may  be  beneficial,  or  the  sore  may  be  dusted 
over  with  iodoform,  and  boracic  poultices  applied.  This  may  be 
preceded  in  some  cases  by  touching  the  surface  with  nitrate  of 
silver,  or  with  a  solution  of  chloride  of  zinc  (40  grains  to  1  ounce). 

Pressure  has  been  found  of  considerable  service  in  the  treatment 
of  these  ulcers ;  an  ordinary  bandage,  reaching  from  the  toes  to 
the  knee,  will  suffice  in  some  cases,  a  suitable  dressing  of  boric 
acid  ointment,  with  perhaps  some  resin  ointment  added  to  make 
it  more  stimulating,  being  applied  beneath  it.  Martin's  india- 
rubber  bandage  is  more  useful  when  the  veins  are  much  enlarged. 

The  method  of  dealing  with  chronic  ulcers  suggested  by  Pro- 
fessor Unna,  of  Hamburg,  has  given  excellent  results.  It  con- 
sists in  the  use  of  an  adhesive  plaster,  made  up  as  follows  : 
Gelatine,  5  parts  ;  oxide  of  zinc,  5  parts  ;  boric  acid,  1  part ; 
glycerine,  8  parts  ;  water,  6  parts ;  to  this  ichthyol  (5  per  cent.) 
may  be  added  with  advantage.  The  limb  is  first  thoroughly 
washed  with  soap  and  water,  and  purified  with  carbolic  lotion 
(1  in  20).  It  is  then  wrapped  round  with  a  single  layer  of  anti- 
septic gauze,  and  the  paste,  liquefied  by  placing  it  in  a  gallipot 
in  a  saucepan  of  boiling-water,  is  applied  over  it  with  a  paint 
or  paste  brush.  Another  layer  of  gauze  is  placed  over  the  paste 
and  a  thin  bandage  over  all,  and  the  whole  allowed  to  dry. 
Where  there  is  much  varicosity  of  the  veins,  the  paste  should 
extend  from  the  ankle  to  the  knee,  the  foot  being  also  included 
in  some  cases.     If  there  is  much  discharge,  the  ulcer  should  not 


ULCER  A  TION  63 


be  covered,  or  the  dressing  should  be  reapplied  in  a  day  or  two  ; 
but  after  it  has  diminished  in  amount,  the  paste  may  be  carried 
right  over  the  sore,  and  the  whole  application  left  in  position  for 
a  week,  or  even  longer. 

When  the  edges  are  very  indurated  and  thickened,  and  all 
action  is  at  a  standstill,  Syme's  suggestion  may  be  followed,  viz., 
the  whole  surface,  as  well  as  the  surrounding  skin,  is  blistered, 
and  then  a  suitable  dressing  applied.  A  more  satisfactory  method, 
but  requiring  an  anaesthetic,  is  to  thoroughly  scrape  the  surface 
with  a  sharp  spoon,  and  then  to  rub  in  a  strong  solution  of 
chloride  of  zinc.  As  soon  as  healthy  action  is  established,  skin- 
grafting  may  be  undertaken,  if  necessary,  but  it  is  useless  to 
undertake  this  unless  the  patient  can  promise  to  rest  up  for  a 
prolonged  period,  and  even  then  elastic  support  will  be  sub- 
sequently required.  In  very  bad  cases  where  a  considerable 
portion  of  the  circumference  of  the  limb  is  involved,  when  the 
ulcer  is  very  callous  and  its  base  attached  to  the  tibia,  causing 
severe  pain  at  night  from  chronic  periostitis,  and  especially  when 
the  patient  is  unable  to  indulge  in  much  rest,  amputation  may  be 
the  best  treatment.  It  will  often  be  found  that  Faraboeuf  s  amputa- 
tion at  the  site  of  election  can  be  undertaken  with  advantage. 

Where  varicose  veins  exist,  treatment  is  of  little  avail  unless 
these  are  efficiently  dealt  with  either  by  operation  or  by  some 
suitable  support.  Unna's  paste  often  answers  this  purpose  most 
admirably. 

The  Irritable  Ulcer  may  be  treated  by  discovering  the  painful 
spots,  and  incising  the  tissues  just  above  them  with  a  knife,  so  as 
to  divide  the  exposed  nerves ;  but  thorough  scraping  under  an 
anaesthetic  is  preferable. 

The  Eczematous  Ulcer  must  be  dealt  with  differently  from  the 
others,  or  the  eczema  will  be  aggravated.  Soothing  applications 
are  needed,  such  as  lead  lotion,  and  when  once  the  acute  stage 
has  passed,  tarry  preparations  (liq.  carbonis  detergens,  1  ounce  to 
1  pint  of  lotio  plumbi),  or  an  ichthyol  ointment  (5-10  per  cent.), 
may  be  beneficially  employed.  A  mixture  of  benzoate  of  zinc 
and  boric  acid  ointments  is  a  very  useful  application,  or  Unna's 
paste  with  ichthyol  may  be  utilized. 

Stage  III.  :  Repair  having  now  been  fully  established,  we  have 
merely  to  deal  with,  not  a  healthy  ulcer,  for  such  a  condition 
cannot  exist,  but  a  healthy  granulating  wound,  the  result  of 
ulceration,  or,  as  we  call  it,  to  avoid  confusion,  a  '  healing  ulcer.' 

A  Healing  Ulcer  is  characterized  by  the  following  conditions : 
Surface,  smooth  and  even,  shelving  gradually  from  the  skin,  and 
covered  with  healthy  granulations  ;  these  present  a  florid  red 
appearance,  are  painless,  and  bleed,  but  not  readily,  on  being 
touched.  The  discharge  varies  according  to  the  plan  of  treatment 
adopted  :  if  the  surface  is  kept  at  rest  and  free  from  all  irritants, 
either  septic  or  antiseptic,  the  discharge  is  merely  serous  ;   but 


64  A   MANUAL  OF  SURGERY 


0/ 


should  the  wound  become  septic,  or  be  dressed  with  irritating 
antiseptics,  ordinary  pus  is  formed.  The  surrounding  skin  is 
soft,  flexible,  and  free  from  inflammatory  congestion  ;  the  base  is 
similarly  free  from  fixity  :  whilst  the  margins  present  a  healing 
edge,  which  has  been  described  as  manifesting  three  coloured 
zones :  within  is  a  red  area  consisting  of  granulation  tissue, 
covered  by  a  single  layer  of  epithelial  cells  which  cannot  be  seen 
except  in  a  good  light ;  next  comes  a  thin  dusky  purple  or  blue 
line,  where  the  granulations  are  covered  by  a  few  layers  of 
epithelium,  and  the  circulation  is  becoming  retarded  owing  to 
cicatricial  development ;  whilst  outside  is  a  white  zone  due  to  the 
heaping  up  of  sodden  cuticle  upon  the  healthy  or  healed  part. 

The  method  of  repair  in  such  a  wound  consists  in  a  change  of 
the  deeper  layer  of  granulations  into  fibro-cicatricial  tissue,  which 
gradually  contracts  and  is  finally  covered  with  epithelium.  For 
full  description  see  Chapter  VIII. 

Occasionally  if  emollient  applications  are  used  too  freely  and 
too  long,  the  granulations  become  pale,  protuberant  and  cedema- 
tous,  and  the  healing  process  is  temporarily  checked.  A  depressed 
general  condition  of  the  patient,  or  a  varicose  condition  of  the 
veins,  may  also  account  for  this,  and  the  term  a  weak  ulcer  is 
applied  to  it,  whilst  the  prominent  flabby  granulations  are  popu- 
larly known  as  proud  flesh. 

The  Treatment  of  a  healing  ulcer  is  simple  in  the  extreme.  All 
that  is  needed  is  to  guard  the  surface  from  irritation,  and  Nature 
will  rapidly  bring  about  a  cure.  The  part  must  be  kept  at  rest, 
and  if  the  leg  is  the  seat  of  the  trouble,  it  should  not  be  allowed 
to  hang  down.  The  wound  is  dressed  with  any  simple  unirritating 
antiseptic,  and  perhaps  boric  acid  lint  is  as  good  as  any  ;  a  piece 
of  protective,  the  exact  size  of  the  sore,  may  with  advantage  be 
interposed  between  the  lint  and  the  wound,  or  boric  acid  ointment 
may  be  spread  on  the  lint.  If  the  granulations  become  too  promi- 
nent, they  may  be  lightly  touched  with  nitrate  of  silver,  and  a 
more  stimulating  lotion  applied,  such  as  that  known  as  lotio  rubra 
(R.  Zinci  sulphatis,  gr.  ii.  ;  tinct.  lavandulae  co.,  spir.  rosmarini, 
aa  TT1_  xx. ;  acidi  borici,  gr.  x.  ;  aquam.  destill.  ad  5  i.). 

Large  ulcers  require  some  assistance  in  order  to  obtain  expe- 
ditious healing,  otherwise  a  time  comes  when  the  contraction  of 
the  cicatricial  tissue  interferes  with  the  nutrition  of  the  granulations, 
and  retards  the  healing  process.  Various  plastic  operations  have 
been  adopted  to  obviate  this  difficulty,  and  also  the  different 
methods  of  skin-grafting. 

Skin-grafting,  or  the  transplantation  of  more  or  less  of  the 
thickness  of  the  skin  from  a  healthy  to  a  healing  part,  was  intro- 
duced by  Reverdin  in  1869,  and  has  since  been  much  elaborated. 
The  following  are  the  chief  methods  employed  : 

1.  Transplantation  of  small  pieces  of  the  cuticle  and  cutis, 
Reverdin's   original    plan.      A    small   portion   of    the   cutaneous 


ULCERATION  65 


tissue  is  pinched  up  with  or  without  forceps,  and  removed  by  a 
pair  of  sharp  curved  scissors.  In  thickness  it  should  include  the 
cuticle  and  a  portion  of  the  cutis  vera,  so  that  a  drop  or  two  of 
blood  will  slowly  ooze  from  the  denuded  surface.  The  graft  is 
placed  cutis  downwards  on  the  surface  of  the  granulations  and 
covered  with  protective,  purified  in  boric  acid.  Many  of  these 
may  be  applied  at  the  same  time,  and  the  whole  wround  carefully 
dressed  and  protected.  If  there  is  much  discharge,  the  grafts  will 
not  'take';  but  if  the  wound  is  merely  discharging  serum,  there 
should  be  no  difficulty  in  getting  them  to  grow.  Usually  they 
disappear  for  a  day  or  two,  from  the  cuticle  becoming  softened  or 
disintegrated ;  but  soon  the  epithelium  of  the  cutis  spreads,  and 
makes  itself  visible  as  a  distinct  centre  of  repair.  The  greatest 
gentleness  is  needed  in  handling  the  graft,  as  it  readily  perishes. 

2.  Transplantation  of  large  portions  of  cuticle  as  suggested  by 
Thiersch.  This  method  consists  in  removing  wide  strips  of 
cuticle  with  a  razor,  and  implanting  them  on  a  fresh  wound  or 
on  a  raw  surface  previously  denuded  of  all  granulations.  The 
ulcerated  surface  is  first  scraped,  and  the  resulting  haemorrhage 
stayed  by  pressure  with  a  sponge,  a  layer  of  protective  being, 
however,  interposed,  so  that  when  the  sponge  is  subsequently 
removed  the  bleeding  shall  not  recur.  The  strips  of  cuticle  are 
then  cut,  care  being  taken  to  make  them  as  thin  as  possible ;  the 
papillae  are  always  encroached  on,  however,  and  hence  some 
amount  of  blood  escapes,  in  which  the  grafts  are  allowed  to 
remain  soaking  until  required  for  use.  When  it  is  thought  that 
sufficient  material  has  been  obtained,  the  sponge  and  protective 
are  removed,  and  the  grafts  gently  transferred,  being  applied  in 
such  a  way  that  they  overlap  each  other  and  also  the  margins  of 
the  defect.  There  is  always  some  tendency  for  the  edges  of  the 
graft  to  turn  in,  and  this  must  be  prevented.  They  are  then 
covered  with  protective,  or  thin  silver-foil,  and  the  whole  dressed 
antiseptically.  There  is  usually  no  need  to  look  at  the  wound  for 
some  days.  The  outer  sides  of  the  thigh  or  arm  are  the  best 
places  from  which  to  take  the  grafts.  By  this  method  subsequent 
contraction  is  to  a  large  extent  prevented. 

3.  The  whole  thickness  of  the  skin  is  used  in  some  instances. 
Thus,  the  preputial  tissue  removed  in  circumcision  is  most 
valuable  for  this  purpose,  being  soft  and  flexible.  All  redundant 
and  fatty  tissue  must  be  removed,  and  only  the  skin  applied. 
The  granulations  should  always  be  previously  scraped  away,  and 
the  graft  stitched  down  to  the  underlying  cicatricial  tissue  with 
fine  catgut.  It  may  also  be  applied  to  the  raw  surface  of  an 
operation  wound. 

II.  Ulcers  due  to  Specific  Bacteria. 

The  different  forms  of  infective  ulcers  met  with  in  surgical 
practice  will    be    described    under    the    appropriate    headings   in 

5 


66  A  MANUAL  OF  SURGERY 

different  parts  of  the  book.  It  will  suffice  here  to  mention 
them  : 

Soft  Chancre  (Chapter  XXXVIII.).— This  may  be  taken  as  a 
type  of  all  infective  ulcers,  clearly  showing  the  stages  of  infection, 
incubation,  ulceration,  and  repair. 

Ulcers  due  to  Syphilis  (Chapter  VI.) : 

(a)  The  primary  sore. 

(b)  Secondary  ulcers,  mainly  of  mucous  membranes,  but 

sometimes  involving  the  skin,  and  due  to  the  breaking 
down  of  so-called  tubercular  syphilides. 

(c)  Intermediate,  rupial,  or  ecthymatous  sores. 

(d)  Tertiary  ulcers   from    the  disintegration  of   gummata, 

either  superficial  and  multiple,  or  deep  and  single. 

In  inherited  syphilis,  any  or  all  of  the  above  varieties  may  be 
seen,  except  the  primary  sore. 

Phagedenic  ulceration  (p.  125)  is  usually  associated  with  syphilis, 
but  whether  the  phagedena  is  itself  due  to  a  specific  organism 
is  a  little  doubtful. 

Ulcers  due  to  Tubercle  : 

(a)  The   lupoid    ulcer,    due   to   a   cutaneous    tuberculosis 

(Chapter  XIV.),  or 

(b)  The   tuberculous   ulcer,    arising   as   a   rule   from    the 

bursting  of  a  subcutaneous  or  submucous  tuberculous 
abscess  (Chapter  XIV.). 

(c)  Various  other  tuberculous  ulcerative  lesions  of  the  skin 

are    described    by   dermatologists   under    the    title 
'scrofulodermia,'  whilst  Bazin's  disease  (or  erythema 
induratum)  is  possibly  tuberculous  in  origin. 
Malignant  Pustule,  due  to  the  Bacillus  anthracis  (p.  1 13). 

III.  Malignant  Ulcers. 

These  are  due,  as  has  already  been  pointed  out,  not  to  any 
inflammatory  process,  but  to  the  actual  replacement  of  the  skin 
by  the  growth,  so  that  loss  of  substance  necessarily  ensues.  It 
is  only  requisite  to  mention  the  varieties  here ;  a  fuller  description 
will  be  appended  later  (Chapter  VII.) : 

(a)  Rodent  ulcer,  a  chronic  cancer  starting  in  the  sebaceous 
glands  or  hair  follicles,  and  accompanied  with  very  little  over- 
growth. 

(b)  Epitheliomatous  ulcer,  arising  from  cancer  of  the  skin  or 
mucous  membranes. 

(c)  Scirrhous  ulcer,  resulting  from  destruction  of  the  skin  over 
a  scirrhous  tumour. 

(d)  Fungating  ulcer,  where  a  neoplastic  growth  protrudes  from 
the  skin.  It  may  be  caused  by  a  soft  encephaloid  cancer,  or  a 
sarcoma,  whilst  a  cysto-adenoma  mammae  gives  rise  to  a  similar 
appearance.  It  constitutes  the  condition  formerly  known  as  a 
'  fungus  haematodes.' 


CHAPTER  V. 

GANGRENE. 

By  gangrene  is  meant  the  simultaneous  loss  of  vitality  of  a  con- 
siderable area  of  tissue.  If  the  process  is  limited  to  the  soft  parts 
of  the  body,  it  is  often  termed  sloughing  or  sphacelation,  and  the 
dead  mass  a  slough  or  sphacelus  ;  if  a  tangible  portion  of  bone  dies, 
necrosis  is  said  to  have  occurred,  and  the  necrosed  mass  is  called 
a  sequestrum  ;  while  the  term  gangrene  is  more  especially  applied 
to  a  necrotic  process  affecting  simultaneously  the  hard  and  soft 
tissues  of  a  limb. 

General  History  of  a  Case  of  Gangrene. 

Signs  of  Death. — Death  of  a  limited  portion  of  the  body  can  be 
recognised  prior  to  the  supervention  of  evident  post-mortem 
changes  within  it  by  five  characteristic  signs  : 

i .   Loss  of  pulsation  in  the  vessels. 

2.  Loss  of  heat,  since  no  warm  blood  is  brought  to  it. 

3.  Loss  of  sensation,  although  much  pain  may  be  experienced 
whilst  death  is  occurring,  and  such  may  be  referred  to  the  dead 
part  through  irritation  of  the  nerves  above. 

4.  Loss  of  function  of  the  gangrenous  mass,  which,  if  it  is  a 
limb,  lies  flaccid  and  motionless. 

5.  Change  of  colour,  the  character  of  which  depends  on  the 
amount  of  blood  in  the  part  at  the  time  of  death  ;  if  the  limb  is 
full  of  blood,  it  becomes  purple  and  mottled  ;  if  anaemic,  a  waxy 
or  cream  colour  results. 

These  five  signs  may  be  in  measure  present  when  the  vitality 
of  a  limb  is  seriously  depressed,  as  by  ligature  of  the  main  vessel 
or  by  its  embolic  obstruction ;  but  if  they  continue  for  any  length 
of  time,  death  is  practically  certain  to  ensue,  and  they  will  then  be 
rendered  more  obvious  by  the  phenomena  about  to  be  described. 

Changes  occurring  in  the  Dead  Tissues.— The  character  of  these 
changes  depends  mainly  on  the  condition  of  affairs  at  the  time  of 
death,  and  whether  or  not  putrefaction  supervenes.  The  following 
conditions  are  described : 


68 


A   MANUAL  OF  SURGERY 


i.  Dry  Gangrene  (  =  death  +  mummification). — Such  can  only 
occur  when  the  tissue  involved  is,  previous  to  its  death,  more  or 
less  drained  of  its  fluids,  so  that  it  readily  shrivels  up  and  loses  its 
moisture.  The  usual  cause  is  chronic  arterial  obstruction,  as 
brought  about  by  atheroma  or  calcification  of  the  terminal  arteries, 
to  which  a  sudden  or  gradual  complete  occlusion  of  the  main 
trunk  is  often  superadded.  The  dead  part  becomes  hard,  dry  and 
wrinkled,  and  is  of  a  dark-brown  or  black  colour  from  the  diffu- 
sion of  the  disintegrated  haemoglobin  (Fig.  7).  The  more  fleshy 
parts  (for  instance,  the  tissues  above  the  ankle)  rarely  undergo 
complete  mummification,  and  the  surrounding  living  tissues  are 
often  considerably  inflamed.  If  sepsis  be  admitted,  the  parts  may 
become  horribly  offensive. 

2.  Moist  Gangrene  arises  when  a  part  of  the  body  full  of  fluid 


Fig.  7. — Senile  Dry  Gangrene,  affecting  both  Feet. 

dies,  and  is  especially  associated  with  any  obstruction  on  the  side 
of  the  veins,  or  with  acute  arterial  thrombosis  in  a  previously 
sound  limb,  e.g.,  in  traumatic  gangrene  due  to  pressure  upon,  or 
rupture  of,  the  main  trunk.  The  loss  of  the  vis-a-tergo  derived 
from  the  heart's  impulse  causes  a  negative  pressure  in  the  capil- 
laries, which  become  filled  by  regurgitation  from  the  veins. 
Obviously,  such  a  condition  is  well  suited  for  the  development 
of  the  organisms,  which  always  exist  in  numbers  on  the  skin,  and 
unless  the  most  vigorous  efforts  are  made  to  render  it  aseptic 
before  or  immediately  after  death,  moist  gangrene  is  certain  to  be 
associated  with  putrefaction.  Unhappily,  this  precaution  is  but 
seldom  adopted,  or  even  available,  and  hence  in  the  majority  of 
cases  putrefaction  occurs  ;  it  must  be  clearly  understood,  however, 
that  it  is  no  essential  part  of  the  gangrenous  process. 

Aseptic  Moist  Gangrene  is  characterized  by  the  dead  tissues 
becoming  more  or  less  discoloured,  either  purple  or  any  shade 
from  black  to  yellow,  green  or  white.  It  remains  of  much  the 
same  size  and  consistency  as  at  the  time  of  death  so  long  as  it  is 


GANGRENE 


69 


kept  from  contamination,  and  is  then  simply  and  quietly  cast  off 
from  the  surrounding  tissues  without  any  obvious  inflammatory 
disturbance,  although  a  certain  amount  of  toxaemia  may  result 
from  the  absorption  of  various  products  from  the  dead  tissues. 

Septic  or  Putrid  Moist  Gangrene  (Fig.  8)  is  necessarily  asso- 
ciated with  a  rapid  breaking-up  and  disintegration  of  the  mass, 
which  becomes  black,  green,  or  yellow.  The  cuticle  is  raised 
from  the  cutis  vera  by  blebs  containing  stinking  serum,  or  even 
bubbles  of  gas,  and  these  can  be  readily  pressed  along  under  the 
epidermis  for  some  distance.  The  tissues  of  the  limb  are  soft 
and  lacerable,  and  on  grasping  it  emphysematous  crackling  is 
usually  noted. 

The  Later  History  of  a  gangrenous  mass  depends  entirely  on 
its  asepticity  or  not,  and  on  its  bulk. 

(a)  If  the  necrotic  area  is  small  in  size  and  aseptic,  it  may, 
under  favourable  circumstances,  be  entirely  absorbed  in  the  same 


f  C 

Fig.  8. — Septic  Moist  Gangrene  of  Leg. 

way  as  is  a  catgut  ligature.  Such  is  often  observed  after  slough- 
ing of  small  portions  of  amputation  flaps  ;  if  the  part  is  kept  dry 
and  aseptic,  it  is  gradually  removed,  and  when  the  process  is 
completed,  a  small  dark  scab  will  fall  or  be  picked  off,  and  a 
cicatrix  found  beneath  it.  In  a  similar  way  dead  bone  may  be 
absorbed,  if  the  sequestrum  is  not  too  large  or  too  dense,  and  if 
it  is  in  close  proximity  to  healthy  vascular  tissue.  Thus,  a  child 
came  to  the  hospital  with  a  portion  of  the  outer  table  of  the  skull, 
as  large  as  the  palm  of  a  man's  hand,  quite  bare  and  dead,  as  the 
result  of  sloughing  cellulitis  ;  it  was  treated  antiseptically,  and 
granulations  gradually  sprang  up  through  the  bone  in  all  direc- 
tions, until  finally  the  whole  was  absorbed,  with  the  exception  of 
merely  a  small  flake,  the  size  of  one's  little  finger  nail,  which 
separated.  The  dead  portion  is  first  invaded  by  leucocytes  from 
the  lymphatic  spaces  or  vessels  of  the  immediately  contiguous 
living  tissues,  and  infiltrated  by  them  and  the  accompanying 
blood  plasma.  By  a  process  of  auto-digestion  this  infiltrated 
portion  disappears,  and  is  replaced  by  granulation  tissue  (for  the 
origin  of  which,  see  Chapter  VIII.),  which  in  turn  is  converted 
into  a  cicatrix,  and  covered  with  cuticle  in  the  usual  way. 


7o  A   MANUAL  OF  SURGERY 


(b)  If  the  mass,  though  aseptic,  is  of  such  a  size,  or  consists  of 
such  tissues,  as  to  prevent  its  total  absorption,  or  if  the  vital 
activity  of  the  patient  is  lowered,  a  modification  of  the  same  pro- 
cess results  in  partial  absorption  of  the  dead  material,  whilst  the  re- 
mainder is  cast  off  and  separated  by  a  simple  process  of  anaemic  ulceration. 
The  dead  part  immediately  contiguous  to  the  living  is  removed  and 
replaced  by  granulation  tissue,  and  this  change  continues  advancing 
into  the  mass  until  the  layer  of  granulations  which  has  penetrated 
furthest  is  at  such  a  distance  from  its  nutritive  basis  as  to  be 
unable  to  derive  from  it  sufficient  pabulum,  owing  to  the  contrac- 
tion of  the  cicatricial  tissue  which  is  forming  behind  ;  and  then  a 
simple  ulcerative  process  from  defective  nutrition  causes  a  line  of 
cleavage  to  form  between  the  living  and  dead,  by  means  of  which 
the  latter  is  separated  from  the  body.  The  size  of  the  portion 
thus  cast  off  is  distinctly  less  than  that  of  the  original  necrotic 
mass.  Whilst  this  is  occurring,  there  is  no  local  inflammatory 
reaction,  and  but  little  resulting  constitutional  disturbance.  It  is 
slow  in  progress,  but  there  are  none  of  the  risks  attaching  to  the 
more  rapid  septic  proceeding.  Of  course,  the  denser  and  harder 
the  tissues,  the  longer  they  take  in  separating,  and  hence  it  is 
possible  for  the  soft  tissues  of  a  limb  to  have  separated,  and  the 
wound  caused  thereby  to  have  cicatrized  before  much  impression 
has  been  made  on  the  bones.  Considerable  retraction  ensues, 
giving  rise  to  a  conical  stump  from  the  apex  of  which  the  bones 
protrude. 

(c)  If  the  gangrenous  portion  is  septic,  its  separation  is  accom- 
plished by  a  distinctly  inflammatory  act  taking  place  in,  and  at  the  expense 
of,  the  surrounding  living  tissues.  The  extent  of  the  gangrene  is 
primarily  indicated  by  a  line  of  demarcation,  due  to  the  change  in 
colour  occurring  in  the  dead  part,  the  living  tissues  retaining  their 
normal  hue.  The  irritation  of  the  chemical  products  formed 
in  the  necrosed  mass  causes  in  a  few  days  inflammation  in  the 
surrounding  structures,  resulting  in  hyperemia  and  subsequent 
exudation  of  plasma  and  leucocytes  ;  the  tissue  of  the  part  dis- 
appears, and  is  replaced  by  a  cell  infiltration,  which  in  turn  breaks 
down  into  pus,  whilst  a  layer  of  granulation  tissue  forms  at  the 
limit  of  the  living  portion,  and  thus  the  final  line  of  separation  is 
produced.  Clinically,  one  notices  in  this  latter  stage  a  bright 
red  line  of  hyperaemia  at  the  extremity  of  the  living  tissues, 
which  gradually  spreads  and  deepens  until  about  the  eighth  or 
tenth  day,  when,  if  the  cuticle  is  intact,  the  living  and  dead  parts 
are  separated  by  a  narrow  white  or  yellow  line,  which  is  proved, 
on  pricking  the  epidermis,  to  be  due  to  the  presence  of  a  layer  of 
pus  ;  as  the  pus  escapes,  a  shallow  groove  is  seen,  running  between 
a  granulating  surface  on  the  side  of  the  living  tissues  and  the 
gangrenous  mass.  This  process,  gradually  extending  through 
the  whole  thickness  of  the  limb,  is  attended  by  the  local  signs  of 
inflammation  and  by  fever,  the  degree  of  the  latter  depending  on  the 


GANGRENE 


71 


amount  of  putrid  material  absorbed.  The  inflammatory  process, 
moreover,  is  not  always  limited  to  the  line  of  separation,  but  may 
spread  upwards  along  the  lymphatics  or  veins,  or  in  the  fascial 
and  muscular  planes,  until,  perhaps,  the  whole  limb  is  involved  in 
an  extensive  suppurative  process. 

The  Constitutional  Symptoms  of  gangrene  may  be  described 
under  two  distinct  headings  : 

(a)  Those  general  conditions  which  predispose  to  the  occurrence 
of  gangrene,  and  which  are  mainly  of  a  debilitating  character, 
affecting  either  the  composition  of  the  blood  or  the  vitality  of  the 
limbs.  Thus,  the  patient  may  be  suffering  from  general  asthenia, 
such  as  results  from  preceding  fevers  ;  or  his  circulation  may  lack 
vigour  either  from  weakness  of  the  heart  muscles  or  from  some 
valvular  lesion  ;  or,  again,  his  arteries  may  be  so  diseased,  or 
rendered  so  rigid  by  atheromatous  or  calcareous  changes,  that, 
although  a  sufficient  supply  of  blood  may  reach  the  extremities 
for  all  ordinary  circumstances  of  life,  yet  any  unusual  demand 
upon  the  circulation  cannot  be  met.  Many  evidences  of  mal- 
nutrition usually  manifest  themselves  before  the  onset  of  gangrene. 
General  diseases,  such  as  diabetes  and  albuminuria,  may  be 
present,  as  also  the  constitutional  results  of  a  vicious  life. 

(b)  Those  conditions  depending  on  the  presence  and  connection 
with  the  body  of  the  dead  tissue.  Various  forms  of  septic  or 
ptomaine  poisoning  result,  usually  causing  fever,  asthenic  in 
type  and  variable  in  amount.  Pain,  moreover,  is  frequently  a 
prominent  feature  in  some  forms  of  gangrene,  and  the  patient 
is  sometimes  liable  to  become  exhausted  from  this  cause,  even 
though  he  is  protected  by  the  surgeon's  care  from  the  dangers  of 
sepsis. 

The  Treatment  of  gangrene  naturally  divides  itself  into  the 
local  and  general.  We  shall  not  discuss  the  question  of  Local 
treatment  at  this  place,  leaving  it  to  be  dealt  with  under  the 
appropriate  headings  hereafter.  As  to  General  treatment,  but 
little  need  be  said  beyond  that  the  strength  of  the  patient  must 
be  maintained  by  plenty  of  easily  assimilable  food,  sufficient 
stimulant,  and  tonics.  Pain  and  sleeplessness  must  be  combated 
by  the  administration  of  a  suitable  amount  of  opium  or  morphia, 
if  the  kidneys  are  healthy.  Diabetes  and  albuminuria  need  dietetic 
and  therapeutic  measures  in  order  to  limit,  if  possible,  the  excre- 
tion of  sugar  and  albumen. 

Varieties  of  Gangrene. 

Having  thus  traced  in  outline  the  general  history  of  a  case  of 
gangrene — the  signs  of  death  in  the  part,  the  various  post-mortem 
changes  which  may  occur  in  it,  the  means  whereby  Nature  rids 
the  body  of  such  an  encumbrance,  and  the  various  dangers,  local 
and  general,  the  patient  runs — we  now  turn  to  the  different  forms 


72  A  MANUAL  OF  SURGERY 


of  the  disease  which  are  met  with,  and  propose  to  discuss  them 
seriatim.  The  following  classification  is  one  which,  though 
admittedly  imperfect,  does  in  a  measure  group  together  allied  types 
of  the  affection,  and  will  serve  as  a  useful  one  for  practical  purposes. 

I.  Symptomatic  Gangrene,  or  that  predisposed  to  by  preceding 
vascular  or  general  conditions,  where  a  trauma,  if  present  at  all, 
is  of  very  slight  significance. 

(a)  Gangrene  from  embolus. 

(b)  Senile  gangrene. 

(c)  Gangrene  from  arterial  thrombosis  (non-senile). 

(d)  Diabetic  gangrene. 

(e)  Raynaud's  disease. 

(/)  Gangrene  due  to  ergot. 

II.  Traumatic  Gangrene,  which  may  be  due  to  direct  or  indirect 
injury,  and  where  the  damage  done  to  the  vessels  or  tissues  by 
the  trauma  is  the  immediate  cause  of  the  loss  of  vitality.  Two 
varieties  of  this  may  be  met  with,  viz. : 

(a)  The  indirect,  where  the  lesion  involves  the  vessels  of  the 

limb  perhaps  some  distance  above  the  spot  where  the 
gangrene  occurs. 

(b)  The  direct,  where  the  gangrenous  process  is  limited  to 

the  part  injured. 

III.  Infective  Gangrene,  which  arises  from  the  activity  and 
influence  of  micro-organisms. 

(a)  Acute  inflammatory  or  spreading  traumatic  gangrene. 

(b)  Wound  phagedena  and  hospital  gangrene. 

(c)  Necrosis  of  bone  (most  cases). 

(d)  Noma  and  cancrum  oris. 

(e)  Carbuncle  and  boil. 

IV.  Gangrene  from  Thermal  Causes — frost-bite  and  burns. 
Each  of  these  varieties  must  now  claim  separate  and  individual 

attention. 

I.  Symptomatic  Gangrene. 

(a)  Embolic  Gangrene.  (For  general  details  as  to  emboli,  see 
Chapter  XI.)  When  the  main  artery  of  a  limb  becomes  blocked 
by  a  simple  embolus,  the  condition  is  exactly  similar  to  that 
which  obtains  after  ligature — i.e.,  the  vitality  of  the  part  is 
diminished  until  such  a  time  as  the  collateral  circulation  is 
established.  Under  ordinary  circumstances  it  should  not  lead  to 
gangrene ;  but  if  either  the  general  or  local  vitality  is  much 
reduced,  the  obstruction  of  the  main  trunk  may  be  sufficient  to 
determine  the  death  of  more  or  less  of  the  limb.  There  are 
two  chief  conditions  under  which  gangrene  is  likely  to  follow 
an  embolus :  (i.)  Where  the  embolus  consists  of  a  fibrinous 
vegetation  detached  from  one  of  the  cardiac  valves  in  a  case  of 
endocarditis  following  rheumatic  or  other  fevers.  The  general 
nutrition  has  been  depressed  by  the  preceding  fever,  the  heart's 


GANGRENE  73 


action-  'is  weak,  and  the  circulation  possibly  impeded  by  the 
valvular  lesion,  so  that  the  block  of  a  main  trunk,  even  in  a 
young  person,  is  often  sufficient  to  determine  gangrene,  (ii.)  It 
also  follows  when  a  detached  atheromatous  plate  blocks  the  main 
vessel  of  a  limb  previously  rendered  anaemic  by  arterial  degenera- 
tion, an  occurrence  not  unusual  in  elderly  people. 

Emboli  are  most  commonly  arrested  at  the  sites  of  division  of 
the  main  trunks  (Fig.  9,  A),  or  where  the  calibre  is  suddenly 
diminished  by  the  origin  of  a  large  branch,  the  embolus  often 
saddling  over  the  bifurcation,  and  thus,  as  it  increases  in  size 
by  the  subsequent  deposit  thereon  of  fibrin,  effectually  closing 
both  branches  (Fig.  9,  B).  In  the  lower  limb  it  occurs  at  the 
division  of  the  femoral  or  popliteal ;  in  the  upper,  at  the  origin 
of  the  superior  profunda,  or  where  the  brachial  divides. 


Fig.  9. — Diagrams  of  Embolus  saddling  the  Bifurcation  of 
an  Artery. 

In  A  the  embolus  is  seen,  and  the  commencement  of  a  thrombus  on  it,  but 
not  yet  obstructing  the  vessel ;  in  B  both  branches  of  the  trunk  are 
blocked  by  the  growth  of  the  clot. 

The  chief  early  Symptom  is  pain  experienced  both  at  the  point 
of  impaction  and  also  down  the  limb  along  the  course  of  the 
vessel.  Pulsation  below  the  block  ceases,  sensation  and  tempera- 
ture diminish,  and  the  part  feels  heavy  and  useless.  If  the 
vessels  are  healthy,  stagnation  of  blood  in  the  veins  is  an  early 
result,  the  terminal  portion  of  the  limb  becoming  congested  and 
cedematous,  and  finally  passing  into  a  condition  of  moist  gangrene. 
If,  however,  the  terminal  arteries  are  calcified  or  atheromatous, 
so  that  the  limb  is  in  a  state  of  chronic  anaemia,  dry  gangrene  is 
likely  to  follow.  The  process  starts  peripherally,  and  spreads 
gradually  upwards  until  it  reaches  a  level  where  there  is  sufficient 
circulation  to  maintain  the  life  of  the  part.  Such  usually  obtains 
in  the  neighbourhood  of  a  joint,  since  there  is  always  a  more  free 
anastomosis  here  than  in  the  inter-articular  portions  of  the  limb ; 


74  A  MANUAL  OF  SURGERY 

thus,  in  the  leg  the  gangrene  is  arrested  either  immediately  above 
the  ankle  or  below  the  knee.  The  subsequent  history  depends 
upon  whether  or  not  the  dead  tissue  is  allowed  to  become  septic, 
and  requires  no  special  notice. 

Treatment. — The  all-important  requisite  in  dealing  with  a  case 
of  this  nature  is  to  prevent  the  advent  of  sepsis,  since  it  may 
transform  what  would  otherwise  be  a.  condition  associated  with 
but  little  danger  into  one  of  the  gravest  moment.  As  soon  as 
possible  after  the  obstruction  has  taken  place,  and  before  any 
absolute  signs  of  death  are  manifest,  scrupulous  care  must  be 
taken  to  purify  the  part.  The  nails  should  be  cut,  and  the 
whole  limb  thoroughly  but  gently  scrubbed  With  carbolic  lotion 
(i  in  20),  special  attention  being  directed  to  the  intervals  between 
the  toes  and  the  semilunar  folds  of  the  nails.  It  should  then 
be  wrapped  in  a  layer  or  two  of  moist  and  purified  gauze, 
swathed  round  with  salicylic,  iodoform,  or  sterilized  wool,  and 
lightly,  though  firmly,  bandaged.  The  limb  is  kept  slightly 
raised,  so  as  to  prevent  venous  regurgitation  without  interfering 
with  the  arterial  supply,  and  by  this  means  gangrene  may  be 
prevented.  If,  however,  these  precautions  are  not  successful,  and 
the  part  dies,  the  same  measures  as  to  the  maintenance  of  asepsis 
must  be  continued  until  a  natural  line  of  separation  forms.  In 
old  people  with  dry  gangrene  similar  rules  are  followed  as  for  the 
senile  type ;  but  in  the  moist  form,  occurring  in  young  people, 
the  natural  process  of  separation  may  be  hastened  by  severing 
the  dead  from  the  living  and  sawing  through  the  bone,  or 
possibly  amputation  through  the  living  tissues  a  little  above  may 
be  considered  advisable,  a  more  shapely  stump  being  thus 
obtained.  Where  sepsis  has  occurred,  it  is  wise  to  amputate 
through  healthy  tissue  as  soon  as  the  gangrenous  process  has 
finally  ceased  to  extend.  If,  however,  spreading  septic  inflam- 
mation exists,  one  may  be  driven  much  higher  up  the  limb 
than  would  be  otherwise  necessary,  whilst  very  acute  septic 
symptoms  may  determine  amputation  before  any  line  of  separa- 
tion has  formed. 

(b)  Senile  Gangrene  is  a  condition  which,  as  the  name  implies, 
occurs  in  elderly  people,  and  is  the  result  of  imperfect  nutrition 
of  the  tissues.  The  toes  are  most  frequently  affected,  but  it  is 
also  seen  in  the  hand,  and  may  attack  the  nose,  ears,  or  even 
the  tongue. 

Causes. — These  are  to  be  found  mainly  in  the  condition  of  the 
circulatory  organs.  (a)  Calcareous  degeneration  (Chapter  X.)  of 
the  smaller  vessels  of  the  limb  or  part  is  always  present,  as  also 
possibly  atheroma  of  the  larger  arteries.  The  vessels  in  con- 
sequence become  pipe -like  and  inelastic,  and  incapable  of  accom- 
modating themselves  to  the  requisite  variations  in  the  blood- 
supply.  Hence  a  fixed  minimal  amount  of  blood  enters  the  limb, 
which  passes  into  a  chronic  state  of  anaemia  and  malnutrition, 


GANGRENE  75 


whilst  the  tunica  intima  is  often  so  rough  as  to  predispose  to 
thrombosis  with  or  without  injury,  (b)  A  iveak  heart  is  generally 
present,  leading  to  low  pulse  tension,  and  increased  difficulty  in 
propelling  the  blood  through  the  rigid  and  narrowed  vessels  ;  and 
(c)  the  condition  of  the  blood  may  be  impoverished  by  albuminuria. 
When  such  predisposing  factors  are  present,  anything  that  results 
in  (d)  thrombosis  either  in  the  main  trunks  or  in  the  peripheral  arterioles 
or  capillaries  is  likely  to  determine  the  onset  of  gangrene.  Throm- 
bosis of  the  main  vessels  may  be  due  to  some  injury  to  the  limb 
which  often  passes  unnoticed,  or  more  frequently  arises  from  a 
gradual  deposit  of  fibrin  on  the  already  roughened  walls.  If  the 
obstruction  originates  in  the  smaller  trunks  or  capillaries,  it  is 
generally  brought  about  by  some  slight  injury,  such  as  striking 
the  ball  of  the  great  toe  against  the  table,  or  even  cutting  a  corn. 
Exposure  to  cold  may  also  act  as  an  exciting  agent.  In  either 
case  the  clotting  extends  for  some  distance,  and  the  height  to 
which  the  gangrene  spreads  will  vary  accordingly. 

Symptoms. — Preliminary  evidences  of  malnutrition  of  the  limb 
will  probably  have  been  noticed  for  some  time  in  the  form  of  cramp 
and  pain  in  the  muscles,  which  become  fatigued  rapidly,  whilst 
sensations  of  pins  and  needles  or  numbness  are  also  complained 
of.  The  circulation  in  the  tibials  may  be  so  slight  as  to  be 
scarcely  perceptible,  and  the  whole  limb  feels  cold  and  heavy. 
The  skin  is  frequently  more  or  less  congested,  and  extremely 
prone  to  low  forms  of  ulceration  or  eczema.  When  the  gangrene 
commences  as  a  result  of  some  peripheral  lesion,  an  area  of  painful 
redness  is  first  noticed,  perhaps  running  on  to  ulceration,  and  in 
the  centre  of  this  patch  a  slough  is  formed,  which  becomes  dry 
and  black.  The  process  gradually  spreads  from  this  focus  with 
more  or  less  inflammation,  so  that  it  is  sometimes  known  as 
inflammatory  senile  gangrene.  If,  however,  it  results  from  throm- 
bosis of  the  main  vessels,  death  occurs  without  the  supervention 
of  local  inflammatory  phenomena,  the  toes  merely  shrivelling  up 
and  dying  {non-inflammatory  senile  gangrene).  The  inner  side  of 
the  great  toe  is  perhaps  the  commonest  situation  for  the  com- 
mencement of  the  mischief,  and  thence  it  spreads  from  one  toe  to 
another,  and  also  along  the  instep  and  up  the  ankle  to  the  leg. 
Pain  is  always  a  marked  feature,  whilst  the  extent  of  the  gan- 
grene is  dependent  partly  on  the  amount  of  general  and  local 
vitality,  and  partly  on  the  asepticity  or  not  of  the  surrounding 
tissues.  As  the  disease  spreads,  the  patient  becomes  exhausted 
by  the  long-continued  pain  and  want  of  sleep  ;  and  septic  fever, 
bedsores,  or  the  intervention  of  some  cardiac,  pulmonary,  or  renal 
complication,  may  also  hasten  a  fatal  termination. 

The  Treatment  adopted  until  within  the  last  few  years  was 
governed  by  the  observation  that  any  attempt  to  remove  the 
dead  tissues  by  amputating  through  neighbouring  living  parts  is 
doomed   to  failure,   since    the  gangrenous  process  is  certain   to 


76  A   MANUAL  OF  SURGERY 

commence  again  in  the  flaps ;  if  merely  cutting  a  corn  suffices 
to  originate  the  malady,  much  more  does  so  severe  an  injury 
as  an  amputation.  The  parts  were  dusted  with  iodoform  or 
some  similar  antiseptic,  and  wrapped  in  cotton-wool  to  keep 
them  warm  ;  the  surgeon  then  waited  for  a  line  of  separation,  and 
even  then  did  not  amputate,  but  merely  assisted  Nature  by 
dividing  tendons  or  bones.  At  the  same  time,  the  general  health 
was  maintained  by  the  judicious  administration  of  suitable 
nourishment,  stimulants  and  tonics,  whilst  pain  was  alleviated  by 
the  use  of  opium  in  such  doses  as  the  condition  of  the  kidneys 
allowed.  In  spite  of  every  care,  however,  the  enfeebled  constitu- 
tion of  the  patients  often  proved  unequal  to  the  task  of  ridding 
the  body  of  the  dead  mass,  so  that  death  from  exhaustion  or 
blood-poisoning  was  the  rule  rather  than  the  exception,  and  even 
if  the  patient  did  recover,  the  prolonged  and  enforced  stay  in  bed 
considerably  diminished  his  vital  powers. 

It  has  now,  however,  been  clearly  demonstrated  that  early 
amputation  performed  under  careful  antisepsis,  and  well  away  from 
the  dead  mass  at  a  point  where  the  surgeon  considers  the  blood- 
supply  sufficient  to  nourish  the  flaps,  and  yet  not  so  near  the 
trunk  as  to  seriously  threaten  life  through  shock,  holds  out  the 
best  prospects  of  relief.  In  order  to  determine  the  most  favour- 
able site  for  the  amputation,  the  pulsation  in  the  main  artery 
should  be  felt  for,  and  if  feasible  no  operation  performed  at  a  spot 
where  it  appears  to  be  occluded.  The  condition  of  the  limb  will 
also  influence  the  surgeon's  decision ;  if  thin,  attenuated,  and 
shrivelled,  it  will  be  wise  to  amputate  high ;  but  if  the  limb  is 
fairly  well  nourished  and  with  plenty  of  adipose  tissue,  the 
operation  may  be  performed  somewhat  lower.  In  operating,  as 
little  damage  as  possible  should  be  inflicted  on  the  parts,  the 
flaps  being  nearly  equal  in  length  and  not  too  flimsy,  a  circular 
amputation,  or  some  slight  modification  of  it,  being  perhaps  the 
best.  In  cases  where  the  mischief  is  limited  to  the  foot,  it  is 
usually  advisable  to  amputate  through  the  lower  third  of  the 
thigh,  or  at  any  rate  in  the  neighbourhood  of  the  knee-joint, 
though  not  through  the  joint  itself,  as  the  flaps  in  that  operation 
are  always  rather  flimsy.  We  have  followed  this  line  of  practice 
for  some  years,  and  have  no  reason  to  be  dissatisfied  with  our 
results.  Dissection  of  the  portions  removed  has  always  shown 
that  the  vascular  trouble  was  fully  as  advanced  as  we  had 
anticipated,  and  that  no  minor  measures  would  have  sufficed. 

(c)  Gangrene  from  Arterial  Thrombosis  (non-senile)  is  not  a 
common  occurrence.  It  arises  as  a  result  of  that  curious  affection 
endarteritis  obliterans,  and  also  develops  in  some  young  people  in 
scattered  patches  about  the  skin  without  any  of  the  characteristic 
phenomena  of  Raynaud's  disease.  It  sometimes  occurs  in  connec- 
tion with  typhoid  fever  and  other  conditions  of  severe  toxaemia  as 
an  outcome  partly  of  the  increased  coagulability  of  the  blood,  partly 


GANGRENE  77 


of  a  localized  endarteritis,  due  to  the  toxins  present  in  it.  The 
femoral  artery  is  most  usually  blocked,  but  occasionally  the 
trouble  will  spread  up  to  the  aorta  and  involve  both  legs  in  the 
gangrenous  process.  Unless  the  vein  is  also  involved,  the  gan- 
grene is  usually  of  the  dry  type.  It  is  wise  to  wait  until  a  line  of 
demarcation  has  formed,  and  then  amputate  well  above. 

(d)  Diabetic  Gangrene  is  mainly  due  to  the  abnormal  condition 
of  the  blood  in  diabetes,  thereby  reducing  the  power  of  the  tissues 
to  resist  bacterial  invasion  ;  but  it  is  also  in  measure  the  result  of  a 
sclerosing  endarteritis  and  peripheral  neuritis.  It  is  not  commonly 
met  with  in  the  subjects  of  acute  diabetes,  nor,  as  a  rule,  in  people 
below  forty  years  of  age.  It  results  usually  from  some  slight 
traumatic  or  infective  injury,  and  often  commences  on  the  under 
side  or  at  the  extremity  of  one  of  the  toes  as  a  bleb,  surrounded 
by  a  dusky  purple  areola.  When  the  bleb  is  opened  or  bursts, 
the  central  portion  of  the  underlying  tissue  is  found  to  be  necrotic, 
and  from  this  focus  the  gangrene  spreads,  taking  on  a  moist  or 
a  dry  type  according  to  the  amount  of  vascular  disease.  Not 
uncommonly  extensive  suppurative  infiltration  of  the  soft  parts  of 
a  limb  may  be  associated  with  a  limited  gangrene  of  a  peripheral 
segment. 

In  the  Treatment  an  attempt  should  be  made  to  reduce  the 
excretion  of  sugar  by  administering  codeia  and  regulating  the 
diet,  but  too  much  time  must  not  be  lost.  A  careful  investiga- 
tion of  the  condition  of  the  vessels  is  necessary.  If  they  are 
tolerably  healthy,  removal  of  the  dead  tissue  by  an  amputation 
not  very  much  above  the  upper  limit  of  the  disease  is  justifiable  ; 
but  should  there  be  evidence  that  the  main  trunks  are  affected, 
then  either  the  separation  of  the  necrosed  mass  must  be  left  to 
Nature,  the  surgeon  merely  assisting  by  the  division  of  bones,  or 
preferably,  if  the  patient's  general  state  is  good,  a  high  amputation 
may  be  undertaken.  Under  the  latter  circumstances,  however, 
there  is  some  risk  of  the  supervention  of  diabetic  coma.  The 
same  practice  would  be  required  if  extensive  inflammatory  mis- 
chief were  present. 

(e)  Raynaud's  Disease,  or  Spontaneous  Symmetrical  Gangrene,  is 
a  condition  usually  met  with  in  anaemic  or  neurotic  young  women 
between  the  ages  of  fifteen  and  thirty.  It  is  due  to  vaso-motor 
spasm,  dependent  either  on  some  deep  unrecognised  lesion  of  the 
spinal  cord,  or  in  some  cases  to  a  peripheral  neuritis.  It  occurs 
in  conditions  of  nervous  exhaustion,  and  has  been  started  by  a 
sudden  fright.  Three  stages  are  usually  described  :  (i.)  local 
syncope  or  anaemia,  arising  as  the  direct  result  of  arterial  spasm, 
and  characterized  by  pallor  and  painfulness  of  the  part ;  (ii.)  local 
asphyxia  or  congestion,  in  which  the  affected  tissues  are  blue  and 
cyanosed  from  venous  regurgitation  ;  and  (iii.)  necrosis,  the  part 
becoming  dry  and  black,  though  it  is  unusual  for  the  gangrene  to 
extend  at  all  deeply.     The  onset  is  often  sudden,  and  the  disease 


78  A   MANUAL  OF  SURGERY 

may  last  for  a  variable  time,  from  days  to  months.  If  gangrene 
supervenes,  the  latter  is  the  limit  more  often  reached,  but  it  by 
no  means  necessarily  follows  that  tissue  necrosis  occurs  in  every 
case.  The  disease  is  usually  symmetrical,  and  affects  the  fingers 
rather  than  the  toes,  but  patches  may  occur  on  any  part  of  the 
body  ;  the  process  is  non-febrile,  but  often  very  painful. 
Paroxysmal  haemoglobinuria  has  been  observed,  and  is  supposed 
to  be  due  to  vaso-motor  disturbance  of  the  kidneys.  Ankylosis 
of  the  smaller  joints,  especially  of  the  terminal  phalanges,  and 
localized  patches  of  anaesthesia,  associated  with  pain  of  a  neuralgic 
type,  are  sometimes  present,  resulting  from  peripheral  neuritis. 
The  condition  somewhat  resembles  the  later  stages  of  a  chilblain, 
but  is  distinguished  by  its  more  dusky  colour,  the  greater  pain, 
the  absence  of  itching,  and  the  fact  that  the  process  is  not  limited 
to  exposed  or  terminal  parts,  or  to  cold  weather. 

The  Treatment  must  in  the  early  stages  be  directed  to  the  pre- 
vention of  gangrene.  The  constitution  should  be  built  up  by 
iron,  quinine,  and  if  need  be  by  stimulants,  whilst  menstrual 
irregularities  must  be  attended  to.  Frictions  with  stimulating 
embrocations,  warm  douches,  and  protection  from  cold  and  injury, 
may  be  employed  locally,  but  probably  the  best  results  will  follow 
the  use  of  electricity.  The  constant  current  is  employed,  and 
preferably  in  the  shape  of  the  electric  bath,  local  or  general  as 
required,  and  repeated  either  once  or  several  times  a  day.  When 
actual  gangrene  is  present,  the  dead  tissue  should  be  kept  aseptic, 
when  sooner  or  later  it  will  be  absorbed  or  separated. 

(/)  Gangrene  from  Ergot  is  a  rare  phenomenon,  but  it  has  been 
known  to  occur  when  diseased  rye  has  been  used  in  the  manu- 
facture of  bread.  The  resulting  gangrene  may  vary  in  extent 
from  the  loss  of  one  or  two  fingers  or  toes  to  the  sacrifice  of  the 
greater  portion  of  one  or  more  limbs. 

II.  Traumatic  Gangrene. 

By  traumatic  gangrene  is  meant  the  loss  of  vitality  of  some 
part  of  the  body  as  the  consequence  of  an  injury,  whether  applied 
to  the  main  bloodvessels  (indirect  traumatic  gangrene),  or  directly 
to  the  tissues  (direct  traumatic  gangrene). 

(a)  Indirect  Traumatic  Gangrene  arises  from  a  considerable 
variety  of  lesions,  and  the  course  and  clinical  history  are  similarly 
variable. 

(i.)  Ligature  of  the  main  artery  does  not  produce  gangrene  in  a 
healthy  limb  ;  but  should  it  be  in  a  state  of  chronic  malnutrition 
and  anaemia  from  preceding  arterial  disease,  death  of  a  certain 
portion  may  ensue,  the  case  running  a  similar  course  to  one  of 
gangrene  due  to  embolus.  It  is  usually  of  the  dry  type,  and 
limited  to  one  or  two  toes  ;  but  if  it  reaches  the  more  fleshy 
portions,  the  moist  variety  supervenes. 


GANGRENE  79 


Where  the  gangrene  is  confined  to  the  toes,  Treatment  consists 
in  waiting  for  a  definite  line  of  separation  to  form  under  an  anti- 
septic dressing,  and  then  in  assisting  the  natural  processes  at  this 
spot  by  dividing  tendons  and  bones.  Where,  however,  a  con- 
siderable area  of  the  limb  loses  its  vitality,  and  especially  if  the 
dead  tissue  is  moist  and  septic,  an  early  high  amputation  is 
required. 

(ii.)  Arterial  thrombosis  from  injury  only  causes  gangrene  under 
special  circumstances,  the  course  and  treatment  being  similar  to 
that  resulting  from  an  embolus. 

(iii.)  Obstruction  to  both  main  artery  and  vein  is  an  almost 
certain  precursor  of  gangrene.  A  few  cases  are  on  record  in 
which  both  vessels  have  been  ligatured,  or  even  portions  of  them 
removed  without  leading  to  gangrene,  as  in  dealing  with  cancerous 
deposits  in  the  axilla,  or  in  the  extirpation  of  aneurisms  ;  but  in 
both  these  instances  obstruction  to  the  circulation  must  have 
previously  existed,  necessitating  the  opening  up  of  collateral 
anastomotic  branches.  In  a  normal  limb  the  occlusion  of  both 
afferent  and  efferent  trunks  is  practically  sure  to  determine  tissue 
necrosis.  It  may  therefore  be  caused  by  the  inclusion  of  both 
vessels  in  a  ligature,  or  by  the  strangulation  of  organs,  either 
within  the  body,  as  in  a  strangulated  hernia,  or  outside  of  it, 
as  when  a  ligature  is  tied  round  the  base  of  the  penis,  or  a 
bandage  applied  too  tightly  round  a  fractured  limb.  It  may 
even  occur  from  the  swelling  up  of  a  limb  under  a  bandage  which 
has  been  originally  applied  with  no  undue  tension. 

A  very  similar  result  may  be  produced  by  the  excessive 
hyperaemia  and  exudation  following  the  sudden  relief  of  a  tight 
constriction  around  a  part,  which  has  thus  been  deprived  of  fresh 
arterial  blood  for  some  time  ;  the  vessel  walls  are  thereby  so 
damaged  that  they  are  unable  to  resist  the  blood-pressure,  and 
the  amount  of  exudation  that  follows  is  so  abundant  as  to  rapidly 
bring  the  circulation  to  a  standstill.  Such  an  occurrence  is  met 
with  after  frost-bite,  and  also  in  a  loop  of  bowel,  which  has  been 
strangulated,  after  removing  the  obstruction  to  the  circulation. 

Gangrene  may  also  result  from  the  rupture  of  a  main  artery  and 
compression  of  the  accompanying  vein  by  the  extravasated  blood, 
an  occurrence  perhaps  most  frequently  seen  after  fractures  and  dis- 
locations;  it  is  then  always  of  the  moist  type.    (See  Chapter  XVII.) 

Treatment  varies  considerably  in  these  cases.  If  the  parts  are 
hopelessly  injured  amputation  should  be  performed  at  once,  so  as 
to  prevent  the  risk  of  sepsis.  In  some  fractures  and  dislocations 
with  vascular  lesions,  it  may  be  possible  to  save  the  limb  by 
cutting  down,  turning  out  clots,  and  securing  the  injured  vessels, 
whilst  the  bony  lesion  is  dealt  with  in  a  suitable  manner.  The 
limb  should  afterwards  be  elevated  slightly,  and  the  peripheral 
segment  kept  warm  and  aseptic.  Should  gangrene  supervene, 
amputation    will    be    required,    its    situation    depending   on   the 


So  A  MANUAL  OF  SURGERY 

character  of  the  local  lesion  ;  if  it  is  not  of  a  serious  nature — e.g., 
a  clean  fracture  or  simple  dislocation — it  is  wise  to  wait  for  a  line 
of  demarcation  ;  but  if  comminution  of  bone  or  other  grave  local 
trouble  is  present,  one  would  amputate  above  the  injury. 

(b)  Direct  Traumatic  Gangrene,  or  that  resulting  from  the  imme- 
diate effect  of  injury  to  the  parts,  is  similarly  due  to  a  variety  of 
lesions. 

(i.)  Severe  crushes  or  blows  are  a  common  cause  of  this  type  of 
gangrene  ;  thus  a  limb  may  become  mangled  between  the  wheels 
of  machinery,  or  by  heavy  weights  falling  on  it,  or  by  the  passage 
of  vehicles  over  it.  Not  only  are  the  parts  crushed,  severely  con- 
tused, or  even  '  pulped,'  but  the  bloodvessels  may  be  torn,  and 
the  resulting  extravasation  contributes  to  the  result.  The  gan- 
grene is  of  the  moist  type,  and  is  more  likely  to  supervene  in 
patients  whose  vitality  is  diminished.  Thus,  a  crush  of  the  foot 
in  an  elderly  person  is  often  followed  by  it,  when  in  a  young  and 
healthy  adult  it  could  be  prevented. 

Treatment. — If  the  part  is  hopelessly  damaged,  there  is  not  the 
slightest  use  in  delaying  operation,  since  the  patient  may  run  con- 
siderable risk  from  the  onset  of  sepsis  ;  and  therefore  immediate 
amputation  should  be  undertaken.  The  question  of  shock  and 
its  influence  in  determining  operation  is  discussed  elsewhere. 
When  there  seems  a  reasonable  chance  of  saving  the  limb,  it  is 
cleansed  and  purified  under  the  strictest  antiseptic  precautions ; 
should  gangrene  supervene,  it  may  be  removed  later. 

(ii.)  Prolonged  pressure  is  also  capable  of  producing  gangrene, 
such  as  that  which  arises  from  injudicious  splint  pressure  or  in 
the  form  of  bedsores.  Splint  pressure  as  a  cause  of  gangrene  can 
only  be  regarded  as  an  accidental  circumstance  or  the  result  of 
carelessness.  Where  there  is  a  marked  tendency  to  displace- 
ment of  fragments  after  a  fracture,  it  may  be  necessary  to  use 
some  considerable  degree  of  pressure  to  counteract  it,  and  then  in 
spite  of  every  precaution  necrosis  of  the  superficial  parts  may 
ensue.  Pain  of  a  neuralgic  type  is  usually  complained  of  for  a 
few  days,  but  even  that  is  not  necessarily  severe  enough  to  attract 
much  attention  ;  when  the  limb  is  freed  later  on,  the  dead  portion 
of  the  skin  is  white,  anaemic,  and  insensitive.  The  necrotic 
process  may  extend  to  some  depth,  and  hence  the  greatest  care 
must  be  taken  to  keep  the  dead  tissues  aseptic,  as  otherwise  diffuse 
suppuration  may  spread  along  the  muscular  and  fascial  planes, 
and  lead  to  considerable  local  and  constitutional  disturbance. 

Bedsores  are  likely  to  occur  in  patients  who  are  kept  for  a  long 
time  in  the  recumbent  posture,  or  in  any  one  particular  position. 
The  parts  most  exposed  to  pressure  first  become  red  and  con- 
gested, and  finally  ulceration  or  actual  gangrene  supervenes.  As 
a  general  rule,  bedsores  are  not  very  extensive  or  deep ;  but 
occasionally  when  the  patient  is  debilitated,  and  especially  if 
a  condition  of  lowered  sensation  is  present,  due  to  impairment  of 


GANGRENE  81 


the  nerve-supply,  as  in  paraplegia,  the  process  may  extend  widely 
and  deeply,  destroying  fasciae,  laying  open  muscular  sheaths,  and 
even  leading  to  necrosis  or  caries  of  bones.  The  spinal  canal 
itself  has  been  opened  in  this  way,  and  death  from  septic  menin- 
gitis has  resulted.  To  prevent  the  occurrence  of  such  sores,  the 
most  scrupulous  attention  must  be  given  to  the  parts  exposed  to 
pressure.  The  nurse  should  see  that  the  draw-sheet  and  bed- 
linen  are  placed  smoothly  and  without  creases,  and  that  no  con- 
tamination by  urine  or  faeces  is  allowed  ;  if  the  patient  is  per- 
spiring freely,  the  sheet  should  be  frequently  changed,  so  as  to 
prevent  decomposition  of  the  sweat.  The  skin  of  the  back  is 
daily  examined,  washed  with  some  unirritating  soap,  and  rubbed 
with  a  soothing,  strengthening,  and  hardening  application,  such  as 
spirit  of  wine,  methylated  spirit,  or  perhaps,  better  still,  a  mixture 
of  brandy  and  white  of  egg.  It  is  then  dusted  over  with  a  mild 
antiseptic  powder,  such  as  boric  acid.  If  the  skin  becomes  red, 
it  should  be  painted  with  collodion,  or  with  a  mixture  of  equal 
parts  of  tincture  of  catechu  and  liquor  plumbi  subacetatis,  which 
when  dry  leaves  a  powdery  film  on  the  surface,  and  protected  from 
pressure  by  means  of  a  circular  hollow  water-pillow.  Paraplegic 
patients  or  old  people  should  at  once  be  placed  on  a  water-bed, 
which  must  be  sufficiently,  but  not  excessively,  distended.  If 
there  is  too  little  water,  the  weight  of  the  body  displaces  it  to  one 
side,  and  no  good  results  ;  whilst  if  there  is  too  much,  the  bed 
becomes  hard  and  resistant,  and  fails  in  the  object  for  which  it 
was  employed.  When  an  open  sore  forms,  it  must  be  kept  aseptic, 
and  dressed  either  with  boric  acid  ointment,  or  in  the  more 
sluggish  cases  with  resin  and  boric  acid  ointments  mixed.  Friar's 
balsam,  mixed  with  castor-oil  (i  part  of  the  balsam  in  8  of  the 
oil),  is  useful  in  this  condition. 

(hi.)  The  action  of  corrosive  or  caustic  chemicals  is  followed  by 
a  localized  traumatic  gangrene,  the  degree  of  which  varies  with 
the  amount  and  character  of  the  irritant  present,  and  the  duration 
of  its  action.  All  that  is  needed  is  to  keep  the  parts  aseptic,  and 
allow  them  to  be  absorbed  or  separated  by  natural  processes. 

III.  Specific  or  Infective  Gangrene. 

All  the  forms  of  gangrene  included  in  this  group  are  charac- 
terized by  their  origin  in  the  development  of  micro-organisms, 
which  by  the  virulence  of  their  products  determine  the  death  of 
the  affected  tissues. 

(a)  Acute  Spreading,  Acute  Emphysematous,  or  Spreading  Trau- 
matic Gangrene. — This  disease  is  one  of  the  most  rapidly  fatal 
and  serious  met  with  in  surgery. 

Causes. — (i.)  The  individual  attacked  is  often  predisposed  to 
septic  inflammatory  conditions,  as  a  result  of  vicious  or  careless 
living,  or  from  simple  malnutrition.     Those  who  are  in  the  habit 

6 


S2  A   MANUAL  OF  SURGERY 

of  consuming  large  quantities  of  alcohol,  even  if  not  actual 
drunkards,  are  especially  liable  to  this  affection  ;  but  some  forms 
of  virus,  which  are  particularly  active,  may  lead  to  its  development 
even  in  a  healthy  person.  It  is  sometimes  seen  in  diabetics,  but 
an  apparent  glycosuria  occasionally  develops  in  the  course  of  the 
disease. 

(ii.)  The  lesion  from  which  it  originates  is  usually  severe,  such 
as  a  compound  fracture  or  dislocation,  especially  if  the  soft  parts 
are  much  contused  or  very  dirty.  Less  frequently  it  originates 
from  small  and  insignificant  pricks,  scratches,  or  abrasions,  if 
thereby  a  virulent  organism  gains  access  to  the  tissues.  In  this 
way  post-mortem  porters,  nurses,  or  pathological  demonstrators 
may  become  infected,  and  the  gravest  consequences  ensue. 

(iii.)  An  organism  frequently  present  is  the  Bacillus  of  malignant 
ccdema,  first  isolated  by  Koch.  It  is  a  rod-shaped  microbe, 
somewhat  longer  and  more  slender  than  that  of  anthrax.  It  is 
anaerobic,  and  in  its  growth  liquefies  gelatine,  and  produces  an 
unpleasant  penetrating  odour.  On  injection  into  the  subcutaneous 
tissues  of  a  mouse,  the  animal  dies  in  eight  to  fifteen  hours ; 
locally,  a  spreading  oedema  is  produced,  the  connective-tissue 
spaces  being  filled  with  fluid  containing  bacilli,  and  perhaps  gas- 
bubbles.  Bacilli  are  also  found  in  the  exudations  which  occur  in 
the  serous  cavities,  in  the  connective-tissues  of  important  organs, 
and  in  the  blood  for  some  time  after  death.  The  Bac.  pyogenes 
capsulatus  and  the  Bac.  osdematis  cevobius  are  also  responsible  for  this 
affection.  The  former  is  anaerobic,  the  latter  aerobic.  Careful 
investigation  of  fifty-eight  cases*  of  spreading  gangrene  resulted 
in  the  discovery  of  the  facts  that  in  only  fourteen  cases  was  the 
infection  pure,  and  that  with  an  anaerobic  organism  ;  in  forty- 
four  cases  the  infection  was  mixed,  various  septic  organisms  being 
present  in  addition  to  the  gas-producing  microbe,  which,  according 
to  latest  researches,  is  more  frequently  the  Bac.  cewgenes  capsulatus 
than  the  Bac.  cedematis  maligni.  A  special  feature  of  infection  with 
the  former  is  the  large  amount  of  gas  produced,  which  is  found 
not  only  in  the  tissues,  but  also  po3t-mortem  in  the  vessels,  and 
notably  in  the  liver,  from  which  it  can  easily  be  squeezed,  con- 
stituting the  '  foaming  liver  '  of  some  writers. 

The  Symptoms  are  those  of  a  hyperacute  cellulitis,  accompanied 
by  general  septicaemia.  The  wound  early  takes  on  an  unhealthy 
action,  the  surface  becoming  covered  with  sloughs,  and  a  thin 
serous  or  sero-sanguineous  discharge  escaping.  The  inflamma- 
tory process  rapidly  spreads  along  the  connective-tissue  planes  of 
the  limb,  which  becomes  swollen,  painful,  and  brawny.  At  first 
it  is  of  a  dusky  purplish  colour,  but  soon  the  signs  of  actual 
gangrene  supervene,  and  the  necrotic  tissues  become  crepitant 

*  See  Corner  and  Singer  on  '  Emphysematous  Gangrene,'  Trans.  Path.  Soc. 
Lond.,  vol.  Iii.,  1901,  p.  42;  Welch's  '  Shattuck  Lecture,'  Philadelphia  Med. 
Journ.,  August  4,  1900. 


GANGRENE  S3 


and  emphysematous,  partly  from  simple  putrefaction,  partly  from 
the  gaseous  developments  associated  with  the  growth  of  the 
specific  organism.  Occasionally  the  emphysema  spreads  widely 
and  rapidly,  with  at  first  no  other  local  evidence  of  mischief; 
sloughing  will,  however,  follow  if  the  patient  lives  long  enough. 
Evidences  of  profound  toxic  disturbance  soon  manifest  themselves, 
the  patient  perhaps  having  a  high  temperature  and  being  delirious; 
but  not  uncommonly  fever  may  be  entirely  absent,  the  tempera- 
ture being  subnormal  and  coma  present.  The  outlook  is  exceed- 
ingly grave,  death  usually  ensuing  in  from  five  to  seven  days 
after  the  onset. 

The  only  Treatment  which  holds  out  any  hope  in  dealing 
with  a  limb  where  the  disease  is  rapidly  extending  is  a  high 
amputation,  even  through  the  shoulder  or  hip-joint.  Any  delay 
is  dangerous,  although,  in  spite  of  the  greatest  promptitude,  the 
infection  may  have  progressed  so  rapidly  that  death  follows  from 
septicaemia,  even  after  the  limb  has  been  removed.  Perhaps  it 
may  be  wise  to  leave  the  wound  widely  open  for  a  day  or  two  so 
as  to  permit  the  free  discharge  of  secretions.  In  a  few  cases, 
where  the  patient  is  seen  early,  it  has  been  possible  to  save  both 
life  and  limb  by  freely  incising  the  affected  tissues,  and  immersing 
them  in  a  continuous  warm  antiseptic  bath.  At  the  same  time 
the  general  health  must  be  attended  to  by  giving  plenty  of  fluid 
nourishment,  together  with  diffusible  stimulants,  such  as  ether 
and  ammonia. 

(b)  Wound  Phagedena  and  Hospital  Gangrene  are  conditions 
affecting  wounds  which  were  seen  often  enough  in  the  pre-anti- 
septic  era,  but  are  now  practically  unknown,  thanks  not  only  to 
antisepsis,  but  to  the  increased  care  directed  to  ventilation  and 
hospital  hygiene.  They  consisted  in  a  rapidly  spreading  ulcera- 
tion or  gangrene,  which  attacked  operation  wounds  a  few  days 
after  their  infliction,  and  as  a  rule  led  to  rapid  death.  It  is 
fortunately  unnecessary  to  describe  or  discuss  them  nowadays. 

(c)  Necrosis  of  Bone  is  practically  always  due  to  the  develop- 
ment of  organisms,  and  may  be  either  acute  or  chronic.  In  the 
former,  the  inflammatory  reaction  is  so  severe  that  the  vessels 
are  strangled  within  the  bony  alveoli ;  in  the  latter,  it  is  largely 
due  to  an  obliterative  endarteritis,  which  accompanies  the  various 
specific  processes.     (See  Chapter  XVIII.) 

(d)  Cancrum  Oris  and  Noma. — Cancrum  oris  is  an  infective 
gangrenous  stomatitis,  affecting  young  children  living  in  squalid 
surroundings  in  over-populated  districts  of  large  cities.  The 
patients  are  always  in  a  low  state  of  health,  and  frequently  con- 
valescing from  one  of  the  exanthemata,  particularly  measles. 
Various  special  organisms  have  been  described  from  time  to  time 
as  responsible  for  cancrum  oris  ;  but  it  appears  that  any  of  the 
many  forms  found  in  the  mouth  may  be  present,  and  probably 
the    Streptococcus    pyogenes    acting   in    conjunction    with    various 


84  A  MANUAL  OF  SURGERY 

saprophytic  bacilli  is  the  most  important.  The  process  starts  in 
an  abrasion  of  the  mucous  membrane,  which,  being  infected  from 
a  diseased  or  dirty  tooth,  becomes  inflamed  and  gangrenous.  A 
foul  ashy-grey  pultaceous  slough  forms  on  the  inside  of  one  of  the 
cheeks,  and  from  this  the  most  offensive  discharge  is  poured  into 
the  mouth  and  swallowed,  the  breath  in  consequence  being 
intensely  fcetid.  The  gangrenous  process  gradually  spreads  both 
superficially  and  deeply  ;  the  cheek  becomes  swollen,  shiny,  and 
tense,  and,  should  the  process  extend  through  its  whole  substance, 
a  black  slough  appears  on  its  outer  aspect,  and  gradually  increases 
in  size.  In  the  worst  cases,  the  adjacent  bones  of  the  face  may 
be  affected  and  die,  and  the  tongue,  palate,  and  even  the  fauces, 
may  also  be  involved. 

The  general  phenomena  are  those  of  a  severe  sapraemia,  since 
not  only  are  the  toxic  products  swallowed,  but  they  are  also 
absorbed  by  the  lymphatics,  and  may  be  inhaled,  in  the  latter 
case  giving  rise  to  septic  pneumonia.  Moreover,  the  patient  runs 
a  considerable  risk  of  developing  pyaemia,  from  implication  of  the 
facial  or  other  veins  in  the  necrotic  process,  whilst  infective 
septicaemia  may  also  supervene.  Rigors  and  high  fever  often 
occur  early  in  the  case,  but  death  is  usually  preceded  by  symptoms 
of  collapse  and  coma  with  a  subnormal  temperature. 

The  Treatment  must  be  prompt  and  energetic  if  the  child's  life 
is  to  be  saved.  The  patient  should  be  at  once  anaesthetized,  and 
all  the  pultaceous  slough  scraped  from  the  interior  of  the  mouth 
by  means  of  Volkmann's  spoon,  until  healthy  bleeding  tissue  is 
reached.  The  denuded  surface  is  then  freely  rubbed  over  with 
pure  carbolic  or  strong  nitric  acid.  If  the  bones  of  the  face  are 
involved,  they  must  be  removed,  as  also  any  offending  teeth. 
Afterwards  the  child  should  be  well  fed  up,  and  of  course  for  a 
time  with  fluids  ;  the  mouth  is  to  be  frequently  washed  out  with 
antiseptic  lotions,  such  as  a  solution  of  sanitas  (i  in  10),  boro- 
glyceride  (i  in  20),  or  permanganate  of  potash,  or  with  a  gargle 
of  chlorate  of  potash  (10  grains  to  1  ounce).  A  mixture  containing 
chlorate  of  potash,  dilute  hydrochloric  acid,  and  infusion  of  cin- 
chona, may  be  administered  for  a  few  days,  and  then  iron  and 
quinine.  In  the  most  severe  cases  the  same  treatment  should  be 
adopted,  even  if  the  whole  thickness  of  the  cheek  has  been  en- 
croached on  ;  loss  of  substance  must  be  made  good  by  subsequent 
plastic  work.  Necessarily,  the  cicatrization  following  this  de- 
structive process  results  in  a  good  deal  of  permanent  impairment 
to  the  movements  of  the  jaw. 

Noma  is  the  name  given  to  a  similar  process  occurring  about 
the  genital  organs  of  children,  especially  the  vulva.  The  Treat- 
ment is  practically  the  same,  except  that  here  it  may  be  possible 
to  immerse  the  patient  in  an  antiseptic  bath,  thereby  diluting  the 
toxic  products,  and  possibly  preventing  the  necessity  for  having 
recourse  to  more  serious  surgical  procedures. 

(e)  For  Carbuncle  and  Boil,  see  Chapter  XIV. 


GANGRENE  85 


IV.  Gangrene  from  Thermal  Causes. 

1.  Frost-bite. — This  condition  is  not  very  frequently  seen  in 
this  country,  but  is  by  no  means  uncommon  in  regions  where  the 
winter  is  more  severe.  It  occurs  in  those  who  are  exposed  to  the 
cold,  and  the  symptoms  are  induced  more  readily  if  a  high  wind 
is  blowing,  the  heat  of  the  body  being  thereby  more  quickly  dis- 
persed.    It  may  originate  in  one  of  two  ways  : 

(a)  From  the  direct  effect  of  cold  on  the  tissues,  which  become 
shrunken,  hard,  and  of  a  dull,  waxy  appearance.  No  pain  is 
experienced  in  the  freezing  process,  so  that  onlookers  are  more 
likely  to  recognise  the  condition  than  the  individual  himself. 
The  extremities  of  the  body,  where  the  circulation  is  a  little 
sluggish,  and  exposed  parts,  are  chiefly  liable  to  be  attacked,  and 
thus  the  nose,  ears,  fingers,  and  toes  are  most  often  involved.  It 
is  more  likely  to  occur  in  the  young  and  in  old  people,  whose 
vita!  powers  are  not  very  great.  Gradually  the  part  shrivels  up, 
turns  black,  and  is  either  absorbed  or  separated  by  a  process  of 
ulceration  with  or  without  suppuration.  The  most  marked  feature 
of  gangrene  from  frost-bite  is  the  more  extensive  implication  of 
the  superficial  parts  on  account  of  their  greater  exposure. 

(b)  From  the  subsequent  inflammation  that  arises  in  parts  which, 
though  frozen,  are  not  immediately  killed.  The  thawing  of  such 
structures  is  accompanied  by  the  severest  pain,  and  the  prolonged 
anaemia  causes  such  a  lowering  of  the  vitality  of  the  vessel  walls 
that  the  re-admission  of  the  circulation  is  only  too  likely  to  be 
followed  by  an  acute  inflammation,  which  terminates  in  necrosis 
from  compression  of  the  vessels  by  the  rapidly-formed  exudation. 
If  it  escapes  actual  death,  the  part  remains  red,  congested,  and 
painful  for  some  time,  and  superficial  ulcers  may  even  develop  ; 
eventually,  however,  it  recovers. 

Treatment. — The  frozen  parts  must  be  thawed  very  gradually, 
and  the  blood  admitted  into  the  tissues  slowly,  if  inflammatory 
gangrene  is  to  be  avoided.  They  should  be  gently  rubbed  with 
snow  or  cold  water,  and  warmed  by  being  held  in  the  hands  of 
the  manipulator,  whilst  the  patient  should  be  placed  in  a  cool 
room,  the  temperature  of  which  is  slowly  raised.  As  reaction 
comes  on,  a  small  amount  of  warm  drink  may  be  cautiously  given. 
Excessive  pain  or  congestive  oedema  may  be  limited  by  elevation 
of  the  part.  If  actual  gangrene  occurs,  the  dead  tissue  must  be 
rendered  and  kept  aseptic,  and  the  case  carefully  watched  until  a 
definite  line  of  separation  has  formed. 

2.  Burns  and  Scalds. — These  may  be  considered  as  a  special 
variety  of  wound,  not  necessarily  ending  in  gangrene,  brought 
about  by  the  action  of  heat ;  burns,  either  by  the  close  proximity 
to,  or  direct  contact  with,  flame  or  heated  solid  bodies  ;  scalds,  by 
the  action  of  boiling  water,  superheated  steam,  or  other  hot  fluids 


86  A  MANUAL  OF  SURGERY 

or  gases,  the  difference  in  the  effects  being  comparable  to  the  dis- 
tinction between  roasting  and  boiling.  Naturally,  fluids  such  as 
oil,  which  boil  at  a  higher  temperature  than  water,  produce 
increasingly  severe  results. 

The  Effects  of  burns  and  scalds  vary  with  the  source  of  heat,  its 
intensity,  and  the  duration  of  its  application.  Six  different  degrees 
of  burn  were  described  by  Dupuytren,  and  his  classification  may 
still  be  retained  with  advantage.  The  first  degree  consists  merely 
in  a  scorch  or  superficial  congestion  of  the  skin,  without  destruc- 
tion of  tissue  ;  the  part  may,  however,  remain  red,  painful,  and 
prone  to  ulceration  for  a  time.  Should  the  scorch  be  often 
repeated,  as  by  people  constantly  warming  their  legs  before  the 
fire,  the  skin  becomes  chronically  pigmented  and  indurated 
(erythema  ah  igne).  In  the  second  degree  the  cuticle  is  raised  from 
the  cutis,  and  a  bleb  or  blister  results.  When  this  bursts,  and  the 
cuticle  is  removed,  the  cutis  vera,  red  and  painful,  is  exposed  below. 
In  the  third  degree  the  cuticle  is  destroyed,  as  is  also  part  of  the 
cutis  vera,  but  the  tips  of  the  interpapillary  processes,  including  the 
exquisitely  sensitive  nerve  terminals,  are  laid  bare  and  left  intact ; 
consequently  this  is  a  most  painful  form  of  burn.  The  deeper 
structures  of  the  skin — viz.,  the  sweat  and  sebaceous  glands,  and 
the  hair  follicles — remain  untouched,  so  that,  although  the  surface 
during  the  healing  process  becomes  covered  with  granulations, 
the  integument  is  very  rapidly  replaced,  since  there  are  so  many 
epithelial  elements  from  which  it  can  grow.  The  cuticle  is  able 
to  form  not  from  the  edge  only,  as  must  occur  wherever  the  whole 
of  the  cutaneous  envelope  is  destroyed,  but  also  from  innumer- 
able foci  scattered  over  the  wound  surface.  The  resulting  scar, 
though  often  white  and  visible,  undergoes  no  contraction  ;  it  is 
supple  and  elastic  from  containing  all  the  elements  of  the  true 
skin.  In  the  fourth  degree  the  whole  thickness  of  the  integument 
is  destroyed,  as  well  as  part  of  the  subcutaneous  tissues.  In  the 
fifth  the  muscles  are  also  encroached  upon,  whilst  in  the  sixth  the 
whole  limb  is  charred  and  disorganized.  In  the  last  three  forms 
healing  can  only  occur  by  removal  of  sloughs  and  the  formation 
of  a  cicatrix,  which  by  its  contraction  may  lead  to  subsequent 
deformity. 

The  Local  History  of  a  burn  may  be  described  in  three  stages, 
corresponding  to  the  three  stages  through  which  an  ulcer  or  a 
lacerated  wound  passes  :  (i)  The  stage  of  destruction  or  burning, 
the  various  degrees  of  which  have  been  just  alluded  to;  (2)  the 
stage  of  inflammation  and  sloughing,  whereby  the  dead  tissue  is 
removed,  and  the  wound  converted  into  a  healthy  granulating 
sore;  (3)  the  stage  of  repair,  which  follows  the  course  described 
elsewhere  (p.  209).  There  are  no  special  characteristics  of  these 
processes  which  call  for  particular  note,  except  that  they  are 
usually  of  a  septic  nature,  unless  the  burn  is  a  small  one.  The 
skin  is  usually  dirty  (from  a  surgical  standpoint)  at  the  time  of 


GANGRENE  87 


the  accident ;  it  may  be  infected  from  the  clothes  which  are  being 
worn,  and  immediate  attention  may  be  impossible.  Moreover, 
the  extent  of  the  lesion  and  the  terrible  pain  associated  with  it  often 
render  complete  sterilization  impracticable. 

The  General  or  Constitutional  Conditions  which  correspond  to 
these  three  stages  require  a  little  fuller  notice. 

1.  As  an  immediate  result  of  the  burning  and  destruction  of 
tissue,  the  patient  lies  for  a  time  in  a  state  of  shock,  the  intensity 
of  which  depends  not  so  much  on  the  depth  of  the  burn  as  on  its 
extent,  so  that  total  charring  of  a  limb  will  probably  cause  less 
depression  of  the  system  than  an  extensive  superficial  scorch, 
especially  if  the  latter  involves  the  abdomen.  It  frequently  passes 
into  a  condition  of  collapse,  due  in  measure  to  the  absorption  of 
toxic  products  from  the  burnt  tissues.  During  this  stage  the 
internal  viscera,  especially  those  connected  with  the  portal  system, 
become  intensely  congested. 

2.  Whilst  the  separation  of  the  sloughs  is  being  effected,  a 
period  of  inflammatory  fever  follows,  usually  of  an  asthenic  type. 
Any  and  every  form  of  internal  complication  due  to  sepsis  may 
arise  during  this  stage,  which  usually  lasts  from  four  to  fourteen 
days.  Congestion  of  the  brain  or  lungs  is  not  uncommonly  seen, 
but  the  gastro-intestinal  tract  is  that,  perhaps,  most  generally 
and  seriously  affected.  The  mucous  membrane  of  the  stomach 
and  intestines  becomes  engorged  with  blood,  leading  to  vomiting 
and  diarrhoea,  whilst  ulceration,  or  even  peritonitis,  may  super- 
vene. 

During  the  later  days  of  this  stage  a  peculiar  form  of  Duodenal 
Ulcer  is  liable  to  occur,  although  it  is  admittedly  not  at  all 
common.  Its  presence  is  suggested  by  pain  in  the  epigastrium 
after  food,  perhaps  some  vomiting,  which  may  be  blood-stained, 
and  possibly  the  passage  of  a  motion  containing  a  good  deal  of 
altered  blood ;  but  occasionally  the  first  sign  of  such  mischief  is 
the  sudden  collapse  of  the  patient,  followed  by  death,  with  or 
without  peritonitis,  owing  to  perforation  or  excessive  haemorrhage 
(Chapter  XXXII.).  The  bleeding  generally  arises  from  erosion  of 
the  superior  pancreatico-duodenal  artery.  The  ulcers  usually 
occur  in  the  second  part  of  the  duodenum,  close  to  the  entrance 
of  the  common  bile-duct.  In  appearance  they  present  a  cleanly 
punched-out  loss  of  substance  with  little  or  no  surrounding 
inflammation,  and  their  distinct  limitation  suggests  that  they  are 
due  to  the  auto-digestion  of  a  distinct  arterial  area,  the  vitality  of 
which  has  been  diminished  by  a  preceding  thrombosis  of  the 
vessel.  They  probably  result  from  the  elimination  by  the  liver 
of  some  irritating  substance  derived  from  septic  or  other  changes 
in  the  burnt  tissues  which  is  capable  of  inducing  thrombosis  in 
the  structures  in  close  contiguity  to  the  entrance  of  the  bile-duct, 
or  at  any  rate  of  producing  ulceration.  Thus,  in  a  fatal  case 
recently  under  observation,  the  post-mortem  examination  revealed 


A  MANUAL  OF  SURGERY 


a  patch  of  well-marked  ecchymosis  in  the  duodenal  mucosa  exactly 
opposite  the  orifice  of  the  bile-duct.  Obviously,  it  was  the  early 
stage  of  this  condition,  and  would  have  gone  on  to  ulceration  had 
the  patient  lived. 

3.  When  healthy  repair  is  occurring  locally,  and  the  parts  are 
kept  aseptic,  no  abnormal  constitutional  condition  should  be 
present,  although  there  may  be  a  certain  amount  of  asthenia  or 
anaemia.  Where,  however,  the  wounds  are  septic  and  suppurating 
freely,  this  tendency  will  be  much  more  marked,  and  the  patient 
may  develop  hectic  fever  and  amyloid  changes  in  the  viscera,  and 
finally  die  of  exhaustion. 

Causes  of  Death  from  Burns. — If  an  individual  is  burnt  to  death, 
the  fatal  event  is  usually  occasioned  by  asphyxia  from  the  smoke 
and  noxious  fumes  of  the  fire ;  shock  and  syncope  from  fright 
may  perhaps  be  adjuvants,  especially  if  the  heart  is  weak  or 
diseased.  Within  the  first  few  days  death  results  from  shock  or 
collapse  from  toxaemia;  in  the  second  stage,  from  sepsis,  internal 
complications,  ulceration  of  the  duodenum,  etc. ;  in  the  third 
stage,  from  exhaustion  or  intercurrent  maladies.  The  prognosis 
in  children  is  always  more  unfavourable  than  in  adults. 

Treatment. — In  the  superficial  scorches  without  vesication,  all 
that  is  required  is  the  protection  of  the  affected  parts,  e.g.,  by 
dusting  them  over  with  boric  acid  powder  mixed  with  starch. 
Where  blisters  have  formed,  the  cuticle  should  be  washed 
antiseptically  and  then  punctured,  so  as  to  allow  the  contained 
serum  to  escape,  and  then  the  area  should  be  dusted  with  boric 
acid  powder,  and  covered  with  aseptic  wool.  Carron-oil  (i.e.,  a 
mixture  of  equal  parts  of  linseed-oil  and  lime-water)  is  also  much 
used,  applied  on  lint ;  it  is,  however,  not  an  antiseptic,  although 
by  adding  a  small  proportion  of  eucalyptus  oil  (1  to  10)  this  can 
be  corrected.  Latterly  some  French  authorities  have  commended 
the  use  of  picric  acid  as  a  dressing  in  cases  of  burns  where  the 
cutis  vera  has  not  been  entirely  destroyed ;  the  vesicles  are 
punctured,  and  then  a  piece  of  lint,  soaked  in  a  solution  of  picric 
acid  (20  grains  to  1  ounce  of  sterilized  water),  is  applied  to  the 
burnt  surface,  and  over  this,  in  turn,  a  pad  of  salicylic  or  sterilized 
wool  is  bandaged.  Thus  a  dry  dressing  is  produced,  which  may 
be  left  in  situ  for  some  days,  when  it  is  reapplied.  We  have  used 
this  plan,  and  have  been  much  pleased  with  the  results. 

Where  the  burn  includes  deeper  structures,  the  clothes  must  be 
removed  with  as  little  dragging  as  possible,  being  cut  away  if 
necessary  ;  the  damaged  tissues  are  then  well  bathed  with  some 
antiseptic,  such  as  carbolic  lotion  (1  in  40),  and  covered  up  as 
rapidly  as  possible  with  lint  soaked  in  eucalyptus  oil  or  weak 
carbolised  oil  (1  in  40).  In  some  cases,  where  the  skin  and  surface 
are  exceedingly  dirty,  it  is  well  to  anaesthetize  the  patient,  and 
then  to  cut  away  parts  which  must  obviously  slough  and 
thoroughly  purify  the  wound,  which  is  covered  with  protective, 
and  dressed  with  cyanide  gauze,  or  some  such  material. 


GANGRENE 


At  the  same  time,  the  general  condition  of  the  patient  must  not 
be  overlooked ;  he  is  possibly  in  a  state  of  considerable  shock, 
and  therefore  should  be  put  to  bed  and  covered  with  warm  blankets 
or  rugs,  whilst  perhaps  a  little  warm  stimulating  fluid  is  ad- 
ministered ;  in  bad  cases  an  intravenous  injection  of  hot  saline 
solution  is  advisable,  and  it  may  often  be  repeated  with  advantage 
more  than  once.  In  the  case  of  children  with  very  extensive 
burns,  it  is  sometimes  useful  to  put  them  into  a  hot  bath,  to 
which  some  eucalyptus  oil,  if  obtainable,  has  been  added  ;  the 
clothes  are  then  removed  or  cut  away,  and  the  patient  allowed  to 
remain  for  some  time,  or  until  the  shock  has  subsided,  in  the 
warm  water,  which  should,  if  necessary,  be  replenished.  The 
wounds  are  then  dressed,  and  the  little  patient  removed  to  bed. 
It  may  be  desirable  to  repeat  the  immersion  at  every  dressing. 

When  a  limb  has  been  hopelessly  charred  or  burnt  to  the  bone, 
it  is  useless  to  retain  it,  and  amputation  through  the  nearest 
healthy  tissues  should  be  undertaken  at  the  first  favourable 
opportunity. 

When  the  next  stage,  viz.,  that  of  inflammation  and  sloughing, 
has  been  reached,  the  only  requisite  is  to  keep  the  parts  as  free 
from  sepsis  as  possible,  assisting  the  natural  processes  of  repair 
by  warm  moist  applications,  and  snipping  away  sloughs  as  they 
loosen.  Generally,  attention  to  the  ordinary  rules  of  personal 
hygiene,  and  a  simple  diet,  are  all  the  precautions  that  need  be 
taken. 

When  the  stage  of  cicatrisation  is  reached,  the  granulating 
wounds  are  treated  on  general  principles.  The  granulations  often 
become  prominent,  and  stimulating  applications,  such  as  touching 
them  with  lunar  caustic,  may  be  necessary.  In  large  wounds, 
healing  should  be  assisted  by  skin-grafting,  according  to  Thiersch's 
method ;  unless  some  such  proceeding  is  instituted,  the  wound  is 
likely  to  become  chronic,  and  healing  may  be  delayed  perhaps 
indefinitely. 


CHAPTER  VI. 
INFECTIVE  DISEASES. 

Cellulitis. 

Cellulitis  (or,  as  it  used  to  be  termed,  diffuse  phlegmon)  is  a 
disease  characterized  by  the  existence  of  a  spreading  inflammation 
of  the  subcutaneous  or  cellular  tissues,  due  to  the  activity  of 
micro-organisms,  and  running  on  to  suppuration,  sloughing,  or 
even  to  extensive  gangrene. 

Causation. — The  one  essential  is  the  infection  of  the  cellular 
tissues  with  some  organism  capable  of  multiplying  locally,  and 
of  developing  toxic  compounds,  which  not  only  act  at  the  site  of 
inoculation,  but  are  also  carried  along  the  lymphatics,  and  by 
their  absorption  into  the  general  circulation  give  rise  to  toxaemic 
phenomena.  The  entrance  of  the  organisms  may  result  from  an 
operation  wound  which  has  been  allowed  to  become  septic,  or 
from  an  accidental  breach  of  surface  which  has  not  been  rendered 
aseptic,  or  even  from  the  slightest  graze,  prick,  or  scratch.  Deep 
septic  wounds  which  are  not  properly  drained  are  amongst  the 
most  favourable  for  the  development  of  this  condition,  especially 
if  the  general  health  of  the  individual  is  bad,  if  he  is  suffering  from 
albuminuria  or  diabetes,  or  if  his  surroundings  are  of  an  insanitary 
nature.  Wherever  much  loose  cellular  tissue  is  present,  inflam- 
matory phenomena  readily  supervene  owing  to  the  absorption  of 
septic  material  from  neighbouring  contaminated  structures,  e.g., 
pelvic  cellulitis  arising  from  a  septic  uterus. 

Bacteriology. — The  less  severe  types  are  generally  due  to  the  Staphylococcus 
pyogenes  aureus  or  alius,  whilst  the  more  severe  are  caused  by  the  Streptococcus 
pyogenes,  which,  as  will  be  stated  hereafter,  is  probably  identical  with  the 
organism  of  erysipelas,  and  in  these  cases  the  cellulitis  has  more  of  an 
erysipelatous  character.  In  many  instances  various  forms  of  non-pathogenic 
organisms  may  accompany  the  above.  The  most  acute  manifestation  of  the 
disease  is  usually  described  as  acute  emphysematous  gangrene  (see  p.  81). 

Clinical  History.  —  The  symptoms  in  any  particular  case 
necessarily  differ  somewhat  according  to  the  site  of  inoculation 
and  the  virulence  of  the  causative  microbes,  and  hence  anything 
from  a  localized  suppuration  to  the  acutest  form  of  spreading 
gangrene  may  result.     In  a  case  of  moderate  severity,  due  to  a 


INFECTIVE  DISEASES  01 


prick  or  abrasion  which  has  become  infected,  there  is  often  a 
period  of  quiescence  for  a  day  or  two,  during  which  the  virus  is 
incubating  and  the  site  of  inoculation  shows  but  slight  signs  of 
inflammation,  beyond  being  a  little  tender.  The  patient,  though 
feeling  somewhat  seedy,  is  able  to  continue  his  work,  but  is 
finally  obliged  to  give  up,  owing  partly  to  the  increased  pain, 
partly  to  his  general  condition.  Fever  will  almost  always  be 
present  to  a  greater  or  less  degree,  and  in  the  more  severe  types 
one  or  more  rigors  occur.  Occasionally,  however,  the  tempera- 
ture is  subnormal,  owing  to  the  depressing  effects  of  the  toxic 
substances  absorbed.  The  affected  part  is  found  to  be  hot, 
tender,  and  infiltrated  ;  if  superficial,  it  looks  red  and  angry,  and 
feels  brawny.  The  course  of  the  case  depends  to  a  very  large 
extent  upon  the  treatment  adopted  ;  if  freely  incised,  the  process 
becomes  limited,  and  although  suppuration  may  occur,  there  is 
but  little  sloughing,  and  hence  repair  is  readily  effected.  If,  how- 
ever, it  is  left,  or  is  merely  poulticed,  the  process  rapidly  spreads, 
and  may  even  involve  the  whole  limb,  which  becomes  greatly 
swollen,  cedematous,  red,  and  brawny.  Intense  pam  and  sleep- 
lessness, accompanied  perhaps  with  delirium,  form  the  most 
prominent  symptoms,  and  these,  together  with  the  toxic  fever, 
rapidly  exhaust  the  patient's  strength.  Finally,  suppuration  occurs 
beneath  the  skin,  whilst  the  cellular  tissue  sloughs,  perhaps  the 
whole  of  the  subcutaneous  areolar  tissue  being  thereby  destroyed, 
although  the  skin  only  gives  way  in  places.  Hence  it  is  often 
possible  to  pass  a  probe  between  the  skin  and  the  deep  fascia  over 
a  considerable  area.  Sometimes  the  inflammation  skips  a  part  of 
the  limb,  the  chief  focus  of  mischief  being  found  at  a  distance 
from  the  original  site  of  inoculation,  whilst  the  intervening  portion 
is  but  little  affected.  Occasionally  the  trouble  spreads  along  the 
deeper  areolar  planes,  involving  muscular  bellies,  which  may  be 
infiltrated  with  pus  or  may  actually  slough.  This  is  most  likely 
to  occur  when  the  disease  is  due  to  septic  inflammation  fol- 
lowing a  penetrating  wound,  such  as  a  gunshot  injury  or  a  bad 
compound  fracture.  In  all  these  more  severe  forms  the  patient 
runs  a  considerable  risk  of  developing  general  septicaemia,  or  even 
pyaemia. 

Treatment. — With  the  exception  of  cases  of  emphysematous 
gangrene,  cellulitis  results  from  the  activity  of  organisms  which 
are  readily  destroyed,  and  over  which  the  germicidal  properties  of 
the  body  have  considerable  control.  Hence  careful  attention  to 
the  dicta  of  antiseptic  surgery  can  prevent  its  occurrence  to  a 
very  large  extent.  Abrasions  and  small  punctured  wounds  should 
always  be  carefully  protected,  and  all  penetrating  injuries  dis- 
infected, especially  if  the  patient  runs  exceptional  risk  of  infection 
owing  to  his  occupation  or  surroundings.  Should  inflammatory 
phenomena  supervene,  the  application  of  antiseptic  fomentations, 
such  as  the  boracic  poultice,  may  prevent  their  extension,  whilst 


92  A  MANUAL  OF  SURGERY 


the  bowels  should  be  freely  acted  upon  and  the  general  health 
attended  to.  Failing  this,  and  if  there  is  any  tendency  for  the 
inflammation  to  spread,  incisions  should  be  made  into  the  brawny 
tissues,  so  as  to  give  exit  to  the  serous  and  irritating  discharges ; 
the  wounds  thus  made  are  dusted  with  iodoform  and  lightly 
packed  with  gauze,  over  which  the  usual  dressings  are  applied. 
The  object  of  this  is  to  drain  the  fluids  from  the  parts  by  capillary 
action,  and  hence  an  effective  junction  must  be  maintained  be- 
tween the  gauze  drain  and  the  surrounding  dressing.  It  is  often 
wise  to  incorporate  a  piece  of  mackintosh  in  the  outer  folds  of  the 
dressing,  so  as  to  keep  the  parts  moist  and  encourage  a  free  dis- 
charge. Under  such  a  regime  sloughing  may  be  entirely  pre- 
vented, or,  at  any  rate,  limited.  At  the  same  time  the  patient's 
health  and  strength  must  be  maintained  by  the  administration 
of  suitable  food  and  stimulants,  whilst  quinine  is  very  useful 
internally. 

Another  excellent  plan  of  treatment  is  to  immerse  the  wounds, 
after  freely  incising  the  infiltrated  parts,  in  a  continuous  warm 
bath,  by  this  means  diluting  the  toxins  to  such  an  extent  as  to 
render  them  innocuous.  Warm  water  does  perfectly  well,  although 
it  may  be  boiled  before  use  with  advantage.  Antiseptics  are 
practically  useless  in  checking  the  disease  when  once  started  ; 
the  surgeon  has  to  depend  mainly  on  relief  of  tension,  the  removal 
of  toxic  discharges,  and  the  antiseptic  power  of  the  tissues.  At 
the  same  time  the  utmost  care  must  be  taken  to  prevent  fresh 
infection  of  wounds  or  decomposition  of  discharges. 

Antistreptococcic  serum  (p.  99)  has  also  been  employed  as  a 
curative  agent  with  a  view  to  destroy  the  streptococci  and 
immunize  the  system  to  their  further  development,  but  the 
results  hitherto  obtained  have  not  been  very  encouraging.  The 
dose  varies  from  5  to  10  c.c.  (1  c.c.  =  fl\_  i£),  injected  two  or 
three  times  a  day  beneath  the  skin  of  the  back  or  abdominal  wall. 

Special  Varieties  of  Cellulitis. 

Cellulitis  of  the  Axilla  not  unfrequently  follows  an  infected  wound  of  the 
hand,  such  as  occurs  in  the  post-mortem  room,  and  hence  is  not  uncommon  in 
medical  practitioners,  students  or  nurses.  It  may  also  be  caused  by  extension 
from  a  primary  axillary  lymphadenitis.  The  tissues  of  the  armpit  become 
hard  and  brawny,  the  pain  is  severe,  and  the  disease  is  liable  to  spread  towards 
the  chest  walls  under  or  between  the  pectoral  muscles ;  it  may  also  travel 
upwards,  and  lay  open  the  shoulder  joint  from  sloughing  of  the  capsule,  and  so 
give  rise  to  an  acute  arthritis.  Extensive  incisions  are  required  in  order  to 
prevent  such  complications,  but  respect  must  be  paid  to  the  important  vessels 
and  nerves  contained  in  the  cavity. 

Submammary  Cellulitis  is  usually  due  to  an  extension  of  inflammation  from 
the  deeper  parts  of  the  breast,  or  perhaps  from  the  cartilages  or  bones  of  the 
chest  wall.  The  areolar  tissue  beneath  the  breast  becomes  infiltrated  and ' 
brawny,  and  the  gland  itself  is  lifted  up,  and  somewhat  swollen  and  tender. 
(See  Submammary  Abscess.)  Free  incisions  must  be  made  into  the  infected 
area  along  the  lower  portion  of  the  circumference  of  the  organ. 


INFECTIVE  DISEASES  93 

Cellulitis  of  the  Scalp  results  from  a  septic  wound  which  has  traversed  the 
occipito-frontalis  aponeurosis,  and  opened  up  the  subjacent  layer  of  loose 
areolar  tissue.  Suppuration  extends  to  the  limits  of  attachment  of  this 
structure,  and  hence  abscesses  are  likely  to  point  in  the  forehead  just  above 
the  eyebrows,  over  the  zygoma,  or  along  the  superior  curved  line  of  the 
occipital  bone  ;  in  addition  to  the  severe  general  disturbance,  the  patient  runs 
a  risk  of  necrosis  of  the  skull  and  of  various  intracranial  complications. 

Cellulitis  of  the  Orbit  is  not  an  uncommon  sequela  of  penetrating  wounds  in 
this  region,  owing  to  the  difficulty  of  rendering  them  aseptic  and  of  draining 
them.  The  whole  of  the  orbital  tissues  become  infiltrated  and  swollen,  the  lids 
are  cedematous,  and  the  eyeball  is  thrust  forwards.  There  is  a  considerable 
likelihood  of  the  inflammation  spreading  to  the  meninges,  owing  to  the  dura 
mater  being  continuous  with  the  orbital  periosteum  through  the  foramina  by 
which  the  nerves  and  vessels  enter.  Necrosis  of  the  orbital  walls  may  also 
occur,  whilst  the  eye  itself  may  suffer  either  from  an  infective  panophthalmitis 
due  to  lymphatic  infection,  or  from  optic  neuritis  secondary  to  retro-ocular 
inflammation  and  pressure,  or  at  a  later  date  from  optic  nerve  atrophy 
secondary  to  cicatricial  contraction  around  the  nerve.  If  the  cellular  tissue 
of  the  orbit  sloughs,  the  subsequent  movements  of  the  globe  may  be  much 
hampered,  or  indeed  lost,  whilst  the  lids  may  be  drawn  back  to  such  an  extent 
as  to  prevent  their  complete  closure.  Treatment. — No  penetrating  wound  of 
the  orbit  ought  to  be  closed  if  there  is  any  question  of  its  infection  ;  indeed,  it 
is  often  wise  to  slightly  increase  its  size,  so  as  to  enable  the  deeper  parts  to  be 
cleansed.  Drainage  must  always  be  provided  for,  and  in  many  cases  this  is 
best  accomplished  by  stuffing  it  lightly  with  gauze.  If  cellulitis  follows,  the 
original  wound  must  be  opened  up,  and  possibly  fresh  incisions  made  either 
through  the  lids  or  through  the  fornix  conjunctivas.  Antiseptic  fomentations 
or  poultices  are  then  applied.  If  panophthalmitis  supervenes,  the  eyeball 
must  be  incised  crucially  ;  this  is  a  safer  proceeding  than  enucleation,  which 
is  more  liable  to  be  followed  by  meningitis. 

Submaxillary  Cellulitis,  or,  as  it  is  sometimes  termed,  Ludwig's  Angina, 
from  the  name  of  the  surgeon  who  first  called  attention  to  it,  is  an  infective 
inflammation  of  the  cellular  tissue  beneath  the  deep  cervical  fascia  which 
occurs  in  elderly  and  weakly  individuals  or  in  children,  without,  as  a  rule, 
any  apparent  reason,  although  probably  it  spreads  from  some  buccal  focus. 
It  occasionally  results  from  inflammation  extending  beyond  the  capsule  of 
glands,  and  may  originate  in  disease  of  the  middle  ear,  the  mischief  travelling 
downwards  along  the  digastric  muscle.  It  commences  as  a  brawny  induration 
in  the  submaxillary 'region,  which  is  tender,  painful,  and  hot;  there  is  a 
certain  amount  of  fever,  and  this  increases  pari  passu  with  the  extent  of  the 
area  inflamed ;  it  tends  to  spread  to  the  front  of  the  neck  and  base  of  the 
tongue,  even  causing  the  latter  to  protrude  from  the  mouth.  Dangerous 
symptoms  arise  from  pressure  on  important  vessels  and  nerves,  from  extension 
of  the  inflammation  to  the  glottis,  causing  cedema  and  consequent  dyspnoea,  or 
from  the  supervention  of  pyaemia  owing  to  venous  thrombosis.  The  process 
usually  ends  in  sloughing  of  the  cellular  tissue  and  suppuration,  the  pus 
burrowing  widely  if  a  free  exit  by  incisions  through  the  deep  fascia  is  not 
provided ;  occasionally  a  large  sublingual  abscess  may  form,  causing  the 
gravest  constitutional  and  respiratory  disturbance,  whilst  in  rare  instances  the 
mass  may  remain  stationary  and  indurated  for  a  considerable  time. 

The  Treatment  must  be  prompt  and  energetic;  a  free  incision  is  made 
through  the  median  line  into  the  midst  of  the  brawny  tissue,  or  along  any  line 
of  safety  where  pus  is  threatening  to  form.  A  sublingual  abscess  may  be 
opened  from  the  mouth  ;  but  it  is  better,  if  possible,  to  do  so  from  below,  so 
as  to  exclude  sepsis.  Prior  to  suppuration,  fomentations  may  be  used,  whilst 
tonics,  stimulants,  quinine,  and  plenty  of  good  food  are  needed. 

Pelvic  Cellulitis  arises  from  extension  of  inflammation  from  the  pelvic 
viscera  to  the  loose  cellular  tissue  ensheathing  them.  It  may  be  due  to 
lymphatic  absorption  from  septic  material  contained  in  the  uterus,  or  it  may 


94  A  MANUAL  OF  SURGERY 

spread  from  the  ovary,  Fallopian  tube,  or  prostate.  Injuries  to  the  bladder  or 
rectum  may  also  light  up  the  trouble.  It  is  associated  with  all  the  "local  and 
general  signs  of  deep  inflammation,  and  often,  indeed,  with  peritonitis,  giving 
rise  to  a  tense,  firm,  painful  swelling  to  be  felt  per  vaginam  or  per  rectum,  and 
sometimes  to  an  indurated  mass  of  inflammatory  effusion,  dull  on  percussion, 
above  the  pubic  arch.  Abscesses  may  form  in  this  effusion,  bursting  either 
externally  or  into  some  of  the  viscera,  or  possibly  in  both  directions,  producing 
very  intractable  forms  of  urinary  or  faecal  fistulae,  whilst  venous  obstruction 
and  pyaemia  are  very  likely  to  develop. 

The  surgeon  may  be  called  on  to  deal  with  such  cases  either  in  the  early 
pre-suppurative  stage,  when  rest,  limitation  of  diet,  small  doses  of  opium,  and 
fomentations  to  the  hypogastrium,  conjoined  perhaps  with  hot  antiseptic 
vaginal  or  rectal  douches,  should  be  adopted ;  or  at  a  later  date,  when  pus  has 
formed  and  the  abscesses  need  to  be  opened.  An  incision  is  generally  made 
just  above  Poupart's  ligament  and  close  to  the  pubic  spine;  the  abdominal 
muscles  are  divided  to  a  sufficient  extent  to  enable  the  surgeon  to  work  down- 
wards between  the  transversalis  fascia  and  the  peritoneum,  which  must  be 
pushed  aside  in  order  to  reach  the  broad  ligament,  where  pus  is  frequently 
found.  As  soon  as  the  subperitoneal  tissue  is  opened,  the  knife  should  be  dis- 
carded, and  only  blunt  instruments  or  the  fingers  employed.  The  cavity  of 
the  abscess  should  be  well  washed  out  and  efficiently  drained,  and  possibly  a 
counter-opening  through  the  vagina  may  be  required. 

Intestinal  obstruction  may  develop  as  a  remote  sequela  from  the  contraction 
of  cicatrices,  and  hydronephrosis  may  arise  in  the  same  way  from  pressure  on 
the  ureter. 

Erysipelas. 

Erysipelas  is  a  specific  and  contagious  infective  disease  due  to 
the  development  of  the  Streptococcus  erysipeloids  (Fehleisen)  in  the 
smaller  lymphatics  of  the  skin  and  occasionally  of  mucous  mem- 
branes, with  a  decided  tendency  to  spread  and  to  recovery  without 
loss  of  tissue,  the  constitutional  symptoms  being  due  to  the 
absorption  of  toxins  developed  locally.  Occasionally  the  sub- 
cutaneous connective  tissue  is  also  involved,  constituting  the 
variety  known  as  cellulo -cutaneous  erysipelas. 

There  has  been  considerable  discussion  as  to  whether  there  is 
any  difference  between  the  erysipelas  microbe  and  the  ordinary 
Streptococcus  pyogenes  found  in  spreading  suppuration.  The 
microscopical  characters  are  indistinguishable,  and  the  growth 
in  various  reagents  is  very  similar.  Inoculation  experiments, 
"moreover,  certainly  seem  to  indicate  that  they  are  closely  allied 
species,  and  the  majority  of  bacteriologists  consider  them  to  be 
identical,  the  differing  effects  depending  merely  on  the  methods  of 
inoculation  and  the  virulence  of  the  particular  organism.  The 
chief  objection  to  this  theory  is  the  great  difference  which  exists 
between  the  '  infectiousness '  of  erysipelas  and  cellulitis.  No 
surgeon  can  complain  of  the  presence  of  the  latter  in  his  wards  , 
none  permit  the  presence  of  the  former,  except  on  compulsion. 

The  Causes  of  erysipelas  may  be  briefly  stated  as  follows  : 
(i.)  The  existence  of  an  abrasion  or  wound  in  most  cases,  and 
particularly  of  an  unprotected  septic  wound.  Thus,  it  is  not 
uncommon  to  find  it  associated  with  neglected  scalp  wounds  or 


INFECTIVE  DISEASES  95 


with  those  communicating  with  the  mouth.  (ii.)  A  weak, 
depressed  state  of  the  constitution,  as  from  alcoholism,  vicious 
living,  diabetes,  albuminuria,  etc.  Some  people,  moreover,  seem 
naturally  predisposed  to  the  disease,  particularly  plethoric  and 
gouty  individuals,  and  one  attack  renders  the  subject  more  liable 
to  recurrence  after  a  short  period  of  immunity,  (iii.)  Bad  hygienic 
surroundings  are  a  most  important  additional  factor  in  its  produc- 
tion, especially  overcrowding  in  hospitals  and  bad  ventilation. 
But  these  are  all  merely  predisposing  conditions ;  the  only  ex- 
citing and  absolute  cause  is  (iv.),  the  infection  with  the  specific 
micro-organism,  which  is  very  widely  diffused  in  Nature.  An 
idiopathic  form  used  to  be  described,  in  which  the  disease  starts 
without  any  apparent  local  origin;  but  when  one  considers  that 
infection  may  occur  through  the  slightest  abrasion,  and  even 
through  sound  skin  or  mucous  membrane,  and  that  the  cocci  do 
not  exist,  as  a  rule,  in  the  blood,  it  is  evident  that  the  theory  of 
local  infection  is  in  all  cases  the  more  probable.  When  once  an 
entrance  has  been  effected,  the  cocci  develop  in  the  superficial 
lymph  channels,  producing  a  transient  inflammatory  condition  of 
the  skin,  and  a  concurrent  pyrexial  state  of  the  individual  from 
the  absorption  of  specific  toxins. 

The  Symptoms  of  the  disease  are  usually  ushered  in  by  a  slight 
chill,  scarcely  amounting  to  a  rigor,  and  by  a  period  of  headache 
and  malaise  for  about  twenty-four  hours,  with  some  degree  of 
pyrexia.  These  symptoms  are  followed  by  the  development  of  a 
bright,  rosy-red  rash,  spreading  either  from  the  margin  of  the 
wound,  or  showing  itself  in  apparently  unbroken  skin  in  the 
so-called  idiopathic  variety.  If  there  is  a  wound,  it  usually 
presents  a  yellowish,  unhealthy-looking  surface,  with  very  little 
evidence  of  repair.  If  the  erysipelatous  virus  is  unmixed  with 
other  organisms,  the  healing  process  may  continue  until  the  rash 
appears,  about  the  fourth  or  fifth  day,  when  the  young  cicatrix 
will  break  open  again,  exposing  a  dry  and  sluggish  surface,  with 
a  thickened  margin  ;  it  may  occur,  however,  at  an  earlier  date. 
The  rash  is  generally  of  a  characteristic  vivid  red  colour,  always 
disappearing  on  pressure,  and  is  accompanied  by  a  sensation  of 
stiffness  or  burning,  scarcely  amounting  to  pain,  except  when 
dense  structures,  such  as  the  scalp,  are  involved,  and  then  the 
pain  may  be  very  severe.  Swelling  is  not  very  marked,  except  in 
lax  areolar  tissues,  such  as  in  the  scrotum  or  eyelids  ;  the  oedema 
may  then  attain  considerable  proportions.  The  rash  continues  to 
advance  more  or  less  rapidly,  with  a  continuous  margin,  and  as  it 
spreads  to  new  regions  it  fades  away  from  those  already  involved, 
leaving  a  slight  brownish  stain  and  a  fine  branny  desquamation. 
In  some  cases  it  does  not  spread  evenly,  but  appears  to  leap 
over  an  interval,  and  then  the  intervening  lymphatics  are  found 
to  be  thickened.  Vesicles  and  bullae  form  superficially,  containing 
serum,  which   speedily  becomes  turbid,  but  suppuration  is  un- 


96  A  MANUAL  OF  SURGERY 

common,  except  in  lax  oedematous  tissues,  such  as  the  eyelids, 
Occasionally,  from  the  severity  of  the  inflammation  or  the  low 
state  of  vitality  of  the  tissues,  the  skin  may  become  gangrenous 
and  slough,  especially  about  the  umbilicus  and  genitals  of  young 
children.  Neighbouring  lymphatic  glands  are  always  enlarged 
and  painful,  and  this  may  even  be  noted  at  a  period  when  the 
rash  has  not  appeared.  Periphlebitis  may  also  be  caused,  leading 
to  pyaemic  complications.  Fever  is  present  as  long  as  the  rash 
persists,  and  merely  shows  slight  diurnal  variations.  It  is  not 
uncommon  for  the  temperature  to  rise  to  1040  F.,  but  anything 
above  that  is  of  grave  significance.  At  first  the  fever  is  of  a 
sthenic  type,  the  pulse  full,  and  the  delirium  noisy  and  active  ; 
but  later  on  the  pulse  becomes  quick  and  weak,  accompanied  by 
low,  muttering  delirium  and  great  prostration  of  the  vital  powers. 
Delirium  is  usually  a  well-marked  feature  in  erysipelas  of  the 
scalp,  but  this  is  due  to  the  general  rather  than  to  any  local 
condition,  unless  meningitis  supervenes.  The  duration  of  the 
attack  is  most  variable,  lasting,  as  a  rule,  from  one  to  three  weeks, 
but  relapses  are  not  uncommon. 

The  so-called  Idiopathic  Erysipelas  mainly  affects  the  head, 
and  occurs  in  predisposed  individuals ;  it  is  characterized  by 
the  great  oedema  of  the  subcutaneous  tissues  of  the  face,  which 
causes  the  features  to  become  almost  unrecognisable.  Large 
blebs  form,  and  even  abscesses  about  the  eyelids.  There  is  a 
great  tendency  to  recurrence  about  the  same  time  of  the  year  in 
these  cases,  and  pain  and  delirium  are  prominent  symptoms. 

Cellulo-cutaneous  Erysipelas  is  due  to  an  infection  of  the  skin 
and  subcutaneous  tissues  with  the  specific  virus,  and  results  in 
suppuration  and  sloughing  both  of  the  skin  and  subjacent  cellular 
tissue.  The  signs  are  those  of  a  diffuse  spreading  inflammation, 
e.g.,  heat,  pain,  redness,  and  swelling  of  a  brawny  type  at  first, 
but  which  soon  softens  and  becomes  boggy,  the  skin  giving  way, 
and  allowing  exit  to  the  pus  and  sloughs.  The  general  symptoms 
are  correspondingly  severe,  and  pyaemia  may  also  be  present.  As 
distinguishing  features  from  ordinary  erysipelas,  it  is  stated  that 
the  margin  of  the  redness  is  less  defined,  that  the  lymphatic 
glands  are  less  enlarged,  and  that  it  is  doubtful  whether  or  not 
the  disease  is  contagious  ;  the  whole  nature  of  this  affection  is 
still  more  or  less  sub  judice. 

Erysipelas  of  the  Fauces  causes  a  diffuse  inflammation  of  the 
mucous  membrane  of  the  fauces,  often  spreading  to  the  glottis 
and  larynx,  and  arising  either  by  extension  from  without,  or  in 
association  with  some  external  manifestation  of  the  disease  else- 
where. The  fauces  and  soft  palate  become  of  a  dusky  scarlet 
colour,  and  are  much  swollen.  The  voice  is  either  husky  or 
absolutely  disappears,  whilst  severe  spasmodic  dyspnoea  may 
arise  from  the  oedema  extending  to  the  glottis.  The  parts  are 
very  prone  to  ulcerate  or  slough,  and  the  glands  at  the  angle  of 


INFECTIVE  DISEASES  97 

the  jaw  are  enlarged.  Fever  is  usually,  though  not  invariably, 
present,  and  great  depression  of  the  vital  powers. 

Erysipelas  of  the  Scrotum,  or,  as  it  is  sometimes  termed,  acute 
inflammatory  oedema,  is  characterized  by  the  part  becoming 
greatly  distended  by  serum,  but  without  any  marked  redness. 
Suppuration  and  sloughing  are  not  unlikely  to  follow.  It  thus 
somewhat  simulates  the  appearance  produced  by  extravasation 
of  urine,  but  is  distinguished  from  it  by  the  facts  that  micturition 
is  usually  not  interfered  with,  and  that  the  swelling  is  not  limited 
in  the  same  way  as  in  the  latter  affection. 

Diagnosis. — There  is  not  much  difficulty  in  recognising  a  case 
of  erysipelas  if  we  remember  the  distinguishing  features  of  the 
rash,  viz.,  its  method  of  extension  by  a  broad,  sharply-defined, 
slightly  raised  and  infiltrated  red  margin.  Thus,  the  exanthemata 
are  never  limited  to  one  part  of  the  body,  and  rarely  form  one 
continuous  red  patch.  Lymphangitis  is  characterized  by  streaks 
or  lines  of  redness,  not  by  an  area  of  uniform  hyperaemia.  In 
phlebitis  the  skin  is  seldom  red  over  the  inflamed  vein,  which  can 
be  felt  as  a  hard  knotted  cord  below.  A  septic  wound  with  pent-up 
discharge  closely  simulates  erysipelas  ;  but  the  margin  of  the 
redness  is  not  so  accurately  defined,  and  lymphatic  enlargement 
does  not  so  constantly  occur.  Diffuse  erythema  nodosum  is  recog- 
nised from  it  by  the  slight  degree  of  the  febrile  disturbance,  and 
the  presence  of  outlying  patches  of  redness,  which,  moreover,  are 
not  so  clearly  limited.  There  is  always  considerable  pain  in  this 
affection,  which  often  involves  both  legs,  and  usually  occurs  in 
young  women  of  a  rheumatic  temperament.  The  so-called 
erythema  solare  follows  exposure  to  the  sun's  rays,  especially  when 
reflected  from  water,  of  parts  of  the  body  which  are,  as  a  rule, 
protected  ;  though  usually  of  slight  importance,  it  may  some- 
times give  rise  to  so  much  pain,  cedema,  and  constitutional 
disturbance  as  to  simulate  erysipelas.  It  is  readily  distinguished 
by  the  facts  that  it  is  limited  to  the  parts  exposed  and  has  no 
tendency  to  spread.  In  acute  eczema  ruhum  the  presence  of  a 
honey-like  exudation  is  quite  characteristic. 

Pathological  Anatomy. — If  a  person  dies  of  erysipelas,  one 
merely  finds  the  general  signs  common  to  all  septic  cases  detailed 
elsewhere  (p.  7).  The  rash  will  have  faded,  but  on  microscopic 
section  of  the  skin  colonies  of  cocci  arranged  in  chains  will  be 
found  invading  the  lymphatics  just  beyond  the  spreading  margin 
(Fig.  10),  whilst  in  the  parts  which  the  inflammation  has  recently 
attacked  there  will  be  a  considerable  excess  of  leucocytes,  pre- 
sumably connected  with  the  destruction  and  removal  of  the  cocci. 
The  lymph  glands  will  also  be  found  enlarged  and  congested. 

Prognosis. —  Erysipelas  is  not  peculiarly  dangerous  in  itself 
(Osier  gives  the  death-rate  as  7  per  cent,  in  hospital  patients),  but 
may  become  so  from  the  complications  which  attend  it.  The 
most  important  of  these  are  inflammatory  conditions  of  the  brain, 

7 


A   MANUAL  OF  SURGERY 


lungs,  and  other  viscera,  especially  of  the  kidneys.  Pyaemia  and 
general  septic  intoxication  are  also  met  with.  Erysipelas  is 
usually  attended  with  danger  to  life  in  old  people,  drunkards,  and 
infants,  whose  vital  powers  become  rapidly  exhausted.  As  a 
local  complication,  erysipelas  is  not  always  an  unfavourable 
occurrence,  since  wounds  which  have  become  chronic  and  sluggish 
will  sometimes  manifest  marvellous  reparative  power  after  an 
attack.  Chronic  lupoid  and  syphilitic  ulcers  may  rapidly  cicatrize, 
and  even  malignant  sores,  especially  sarcomata,  have  been  known 
to  be  cured. 

The  Treatment  of  erysipelas  is  mainly  conducted  on  general 
principles.  Prophylaxis  must  be  strictly  attended  to  by  observing 
every  antiseptic  detail  in  the  treatment  of  wounds,  especially  if 
any  erysipelas  cases  are  under  treatment  at  the  time.  When  the 
disease  is  prevalent,  all  operations  that  can  be  delayed  should  be 


Fig.  ii.  —  Section  of  the  Spreading  Edge  of  a  Patch  of  Erysipelas, 
showing  the  lymphatics  occupied  by  chains  of  cocci,  which  as  yet 
have  produced  but  little  effect  on  the  tissues. 

postponed.  Single  cases  should  be  isolated,  and  kept  out  of 
surgical  wards  if  practicable.  If,  unfortunately,  a  case  develops 
in  the  wards,  and  cannot  be  completely  isolated,  the  bed  should  be 
placed  as  far  away  from  others  as  possible,  and  especially  from 
those  with  open  wounds  which  from  their  position  (e.g.,  the  mouth) 
cannot  be  properly  protected  from  sepsis.  It  is  usual  to  surround 
the  bed  with  sheets  kept  moist  with  carbolic  lotion,  and  the  floor 
around  should  be  sprinkled  with  the  same.  Special  nurses  must 
be  told  off  to  attend  to  the  case,  and  house-surgeons  and  dressers 
must  take  extra  precautions  to  prevent  the  spread  of  the  disease. 

Local  Treatment. — When  one  considers  the  bacterial  origin  of 
the  affection,  it  is  evident  that,  except  in  the  mildest  cases,  the 
old-fashioned  plan  of  merely  protecting  the  part  from  the  air,  as 
by  painting  it  with  collodion,  or  covering  it  with  a  thick  layer  of 
starch  or  flour,  mixed  perhaps  with  boric  acid,  was  very  inefficient, 
whilst  it  is  equally  obvious  that  the  local  application  of  cold  is 


INFECTIVE  DISEASES  99 


absolutely  harmful,  as  tending  still  further  to  depress  the  vitality 
of  the  part.  Where  tension  and  pain  are  severe,  fomentations 
containing  opium  or  belladonna  (e.g.,  1  ounce  of  laudanum  to 
1  pint  of  lotio  plumbi)  may  be  applied,  or  the  parts  should  be 
scarified  and  antiseptic  compresses  applied,  e.g.,  gauze  soaked  in 
carbolic  acid  (1  in  30)  or  in  sublimate  solution  (1  in  1,000).  Perhaps 
the  best  local  applications  are  ichthyol  or  thiol,  the  latter  being  an 
artificial  sulphur  compound  much  resembling  ichthyol,  but  without 
the  objectionable  smell.  A  20  to  40  per  cent,  aqueous  solution  is 
painted  over  the  affected  area,  possibly  after  scarification,  as  well 
as  over  the  neighbouring  healthy  skin  several  times  a  day  until 
the  fever  disappears;  such  treatment  is  stated  to  be  usually 
successful  in  checking  the  disease  in  two  or  three  days,  whilst  the 
stickiness  of  the  preparation  hinders  the  diffusion  of  the  virus. 

Pressure  may  be  of  some  value  in  limiting  the  spread  of  the 
mischief,  probably  by  compressing  the  lymphatics.  A  wide  band 
of  adhesive  plaster  wound  around  a  limb  beyond  the  margin  of  the 
rash  is  often  effectual,  and  it  may  be  possible  in  this  way  to  check 
its  advance  from  the  scalp  to  the  face  or  neck. 

Anything  that  tends  to  produce  a  local  accumulation  of  leuco- 
cytes in  the  skin  beyond  the  spreading  edge  should  be  beneficial 
in  checking  its  advance,  and  therefore  good  may  be  derived  by 
painting  around  the  rash  with  strong  solutions  of  nitrate  of  silver 
or  with  lin.  iodi,  granting  that  it  is  done  sufficiently  far  off  to  be 
on  healthy  skin.  The  most  efficient  plan  based  on  this  idea  is 
Kraske's,  in  which  the  skin  is  scarified  all  round  at  a  distance  of 
an  inch  or  two,  the  knife  going  just  deeply  enough  to  draw  blood ; 
antiseptic  compresses  are  then  applied. 

An  antistreptococcic  serum,*  prepared  by  immunizing  a  horse  with 
the  Streptococcus  pyogenes,  and  then  withdrawing  its  blood  serum, 
has  been  used  a  good  deal,  especially  in  France,  where  Marmorek 
and  others  have  elaborated  this  plan  of  treatment.  Ten  or 
fifteen  c.c.  of  this  serum  are  given  subcutaneously  as  a  dose,  and 
repeated  once  or  twice  a  day.  In  favourable  cases  the  pain 
rapidly  diminishes,  the  rash  ceases  to  spread,  the  temperature 
falls,  and  in  twenty-four  to  forty-eight  hours  the  disease  may  be 
at  an  end  ;  but  this  result  is  not  always  obtained,  possibly  owing 
to  some  defect  in  the  preparation  of  the  serum. 

Constitutional  Treatment  must  be  of  a  tonic  and  supporting 
character.  Good  food,  easy  of  assimilation,  stimulants  and 
quinine  should  be  freely  administered,  whilst  the  tincture  of  the 
perchloride  of  iron  in  -^-drachm  doses,  repeated  three  or  four 
times  a  day,  is  still  looked  on  by  many  as  a  specific. 

In  cellulo -cutaneous  erysipelas  early  and  free  incisions  must  be 
made  to  relieve  tension,  and,  if  possible,  anticipate  suppuration. 

*  Obtainable  at  a  few  hours'  notice  by  telegraph  from  the  Jenner  Institute 
of  Preventive  Medicine,  and  many  large  chemists. 


A  MANUAL  OF  SURGERY 


The  tissues,  when  incised,  look  gelatinous  from  the  oedema 
present,  and  much  fluid  of  a  seropurulent  type  will  escape.  If 
this  is  not  undertaken,  considerable  portions  of  skin  and  sub- 
cutaneous tissue  may  slough.  Antiseptic  poultices  should  be 
employed  after  the  incisions  have  been  made,  until  granulations 
have  developed. 

In  erysipelas  of  the  fauces  the  parts  must  be  painted  or  freely 
sprayed  over  several  times  a  day  with  antiseptic  lotions,  such 
as  liquor  argenti  nitratis  (10  grains  to  i  ounce),  liq.  hydrarg. 
perchlor.  (i  in  2,000),  or  liq.  soda?  chlorinatae  (1  part  to  15  parts 
of  water),  whilst  tracheotomy  may  be  needed  if  the  glottis  is 
involved.  Diffusible  stimulants  and  plenty  of  nourishment  are 
urgently  necessary  to  combat  the  depressing  effects  of  this  disease. 


Septicaemia. 

Septicaemia  is  an  acute  general  infective  disorder,  arising  from 
the  development  of  some  variety  of  pyogenic  organism  in  the 
blood.  It  differs  from  pyaemia  in  the  absence  of  secondary 
abscesses  (although,  as  explained  later,  it  may  be  associated 
with  it),  and  from  sapraemia  or  septic  intoxication  by  the  fact 
that  the  latter  is  merely  a  chemical  toxaemia.  In  septicaemia,  if 
a  comparatively  minute  trace  of  the  blood  taken  at  a  distance 
from  the  local  focus  of  mischief  is  inoculated  into  another  animal 
or  individual,  the  disease  is  almost  certainly  transmitted,  and  often 
with  increased  virulence ;  in  sapraemia,  injection  of  the  blood, 
except  in  large  quantities,  does  no  harm. 

As  to  the  ultimate  cause  of  septicaemia  in  man,  much  discussion  has  arisen 
owing  to  the  divergence  of  the  results  obtained  by  experimental  research. 
Koch  and  Davaine  succeeded  in  isolating  bacilli  which  produce  fatal  septi- 
caemia in  rabbits  and  mice  respectively ;  but  neither  of  these  is  necessarily 
pathogenic  to  other  animals,  and  neither  is  the  same  as  the  organisms  usually 
found  in  human  septicaemia,  although  the  symptoms  are  practically  identical. 

In  man  various  bacteria  seem  capable  of  producing  this  disease  under  suit- 
able conditions — viz.,  the  ordinary  Streptococcus  pyogenes  of  acute  spreading 
suppuration  ;  the  Streptococcus  septicus  of  Fliigge,  which  is  probably  identical 
with  the  above,  though  more  active ;  the  Streptococcus  septopy 'amicus,  which  is 
more  nearly  allied  to  the  erysipelas  organism  ;  or  even  the  Bacillus  of  malignant 
oedema  (Koch). 

If  a  mouse  is  infected  with  its  specific  bacillus,  it  remains  apparently  un- 
affected for  a  period  of  twenty-four  hours  (incubation  stage),  but  then  becomes 
languid,  its  eye  loses  lustre,  it  refuses  to  eat  or  run  about,  the  respirations 
become  slower,  and  in  about  another  twenty-four  hours  it  dies,  all  its  functions 
appearing  to  be  more  or  less  paralyzed.  Anatomically,  one  discovers  but  few 
naked-eye  changes,  except  a  little  local  inflammatory  exudation  at  the  point  of 
inoculation,  and  slight  swelling  of  the  spleen.  Microscopically,  many  of  the 
red  corpuscles  are  found  to  be  invaded  and  broken  up  by  bacilli  which  may 
even  be  seen  within  them,  and  the  capillaries,  especially  in  the  lungs,  are  more 
or  less  blocked  by  aggregated  masses  of  organisms. 

The  pathological  processes  in  human  septicaemia  are  inferred  to  be  of  a 


INFECTIVE  DISEASES 


similar  character — viz.,  development  of  organisms  in  the  blood,  with  dis- 
integration of  corpuscles,  especially  of  the  red  ;  obstruction  to  capillaries, 
particularly  in  the  lungs  ;  formation  of  toxins  as  a  result  of  this  development ; 
and  paralysis  of  the  functions  of  the  nerve  centres  thereby. 

Clinical  History.  —  Septicaemia  occurs  most  commonly  from 
direct  inoculation  with  suitable  organisms  through  small  lesions, 
such  as  post-mortem  wounds,  or  from  scratches  or  punctures 
with  infected  pins  or  instruments ;  it  also  in  rarer  cases  follows 
operation  wounds  and  severe  lacerated  injuries.  It  is  the  usual 
accompaniment  of  acute  spreading  gangrene,  and  may  be  met 
with  in  cellulitis  and  cancrum  oris.  As  a  rule,  the  individual 
attacked  is  in  a  depressed  and  debilitated  condition,  often  deterio- 
rated by  alcoholic  or  other  excesses,  so  that  the  inherent  germi- 
cidal activity  of  the  tissues  is  markedly  insufficient  to  cope  with 
the  inroads  of  the  disease. 

The  point  of  inoculation  may  be  the  seat  of  any  of  the  forms 
of  local  trouble  which  we  have  already  described  under  the  title 
of  cellulitis,  and  this  may  vary  from  a  mere  slight  inflammatory 
blush  to  the  acutest  form  of  spreading  gangrene. 

The  General  Symptoms  are  those  of  fever,  often  ushered  in  by 
a  distinct  and  severe  rigor ;  the  temperature  reaches  1040  or 
1050  F.,  and  usually  remains  high,  with  but  slight  remissions  and 
no  intermissions.  Malaise  is  present,  with  loss  of  appetite  ;  the 
tongue  is  brown  and  parched,  the  pulse  quick  and  feeble,  whilst 
the  skin  has  often  a  slight  icteric  tinge.  Diarrhoea  usually  ensues, 
and  may  be  blood-stained,  whilst  the  urine  is  albuminous,  and 
contains  blood.  Petechias  appear  under  the  skin,  and  the  patient, 
after  a  period  of  delirium,  becomes  comatose,  and  dies.  Dyspnoea 
sometimes  precedes  the  fatal  issue,  whilst  the  temperature  may 
be  exceedingly  high,  or  occasionally  subnormal ;  the  association  of 
a  low  temperature  with  a  very  rapid  pulse  is  always  of  grave 
import. 

Illustrative  Cases. — A  servant-girl,  aged  about  twenty-two,  complained  one 
hot  summer's  day  that  she  had  been  stung  near  the  inner  canthus  by  a  fly  ; 
possibly  the  insect  had  come  from  some  infected  material,  and  thus  poisoned 
the  wound.  In  twenty-four  hours  she  was  feeling  ill  and  feverish,  and  had 
some  chills  and  flushes;  a  painful  swelling  developed  at  the  inner  canthus, 
which  rapidly  increased  in  size  and  spread  downwards.  At  the  end  of  four 
days,  when  we  saw  her,  the  eye  was  protruding  and  much  congested,  and  a 
definite  band  of  inflammatory  thickening  could  be  felt  reaching  from  the  roof 
of  the  nose  across  the  face  to  the  neck  and  jugular  region,  probably  the  throm- 
bosed facial  vein,  the  clot  doubtless  extending  to  the  cavernous  sinus.  The 
temperature  was  high,  and  the  girl  was  delirious.  An  incision  was  made  into 
the  orbit  with  the  view  of  relieving  tension  and  giving  exit  to  any  pus  that 
might  be  present,  but  with  no  result.  She  rapidly  became  unconscious,  and 
died  within  a  week. 

An  elderly  man,  addicted  to  drink,  fell  in  the  street,  and  grazed  the  inner 
side  of  his  hand.  Within  twenty-four  hours  the  whole  arm  was  puffy  and 
swollen,  and  in  two  days  gangrene  had  manifested  itself,  the  infiltration  reaching 
beyond  the  shoulder.  The  patient  was  dead  from  acute  septicaemia  in  five 
days. 


A  MANUAL  OF  SURGERY 


The  Post-mortem  Signs  are  those  found  in  all  cases  of  acute 
septic  poisoning,  described  above  (p.  7),  with  the  addition  that 
on  microscopical  examination  bacteria  can  be  demonstrated  in  the 
blood  and  internal  organs. 

The  Diagnosis  has  to  be  made  from  the  more  virulent  forms 
of  the  acute  exanthemata,  in  which  the  patient  is  destroyed  before 
the  characteristic  appearances  are  manifested  ;  in  such  cases  a 
definite  opinion  as  to  the  nature  of  the  affection  is  often  impossible, 
if  there  is  no  clue  as  to  the  origin  of  the  infection.  Saprcemia  is 
always  associated  with  some  very  obvious  focus  of  putrefaction, 
whilst  septicaemia  may  occur  with  but  slight  local  manifestations. 
Septic  traumatic  fever,  due  to  wound  infection,  may  be  so  severe  as 
to  cause  grave  anxiety  for  a  time  as  to  whether  or  not  septicaemia 
is  present ;  but  if  the  wound  is  freely  opened  up  and  drained,  the 
rapid  disappearance  of  the  fever  proves  that  the  mischief  was 
merely  a  local,  and  not  the  more  serious  general,  affection.  From 
pycemia  it  is  known  by  the  absence  of  repeated  rigors  and  secondary 
abscesses. 

The  Prognosis  of  septicaemia  is  always  very  grave,  but  it  is  to 
be  hoped  that  the  modern  plans  of  treatment  mentioned  below, 
especially  serotherapy,  may  prove  beneficial  in  diminishing  the 
mortality. 

The  Treatment  consists  in  dealing  actively  with  any  local  focus 
of  inflammation,  either  by  amputation,  or  by  free  incisions,  purifi- 
cation, and  drainage  ;  but  unfortunately  this  is  seldom  likely  to  be 
successful,  as  blood  infection  has  probably  already  occurred.  In 
addition  to  such  means,  tonics  and  stimulants,  with  plenty  of 
suitable  nourishment,  must  be  administered. 

It  is  possible  that  even  this  grave  disease  may  become  amen- 
able to  some  of  the  therapeutic  measures  which  have  been  sug- 
gested of  recent  years.  Thus,  the  antistreptococcic  serum  (p.  89) 
may  be  utilized,  and  cases  have  been  already  reported  as  cured  by 
its  agency.  Another  plan  which  has  been  adopted  is  that  of  the 
intravenous  injection  of  considerable  quantities  of  normal  saline 
solution,  repeated  two  or  three  times  a  day ;  by  this  means 
diuresis  and  diarrhoea  are  induced,  and  it  is  hoped  that  thereby  the 
organisms  and  their  products  may  be  eliminated.  This  treatment 
has,  however,  been  introduced  so  lately  that  no  dogmatic  state- 
ments can  be  made  about  it ;  it  will  probably  be  of  greater  value 
in  cases  of  sapraemia  than  in  those  of  true  infective  septicaemia. 


INFECTIVE  DISEASES 


>03 


Fig.  ii.  —  Disinte- 
grating Clot 
lying  in  a  Vein  in 


Pyeemia. 

Pyaemia  (Greek  ttvov,  pus,  and  aifxa,  blood)  is  a  disease  charac- 
terized by  fever  of  an  intermittent  type,  associated  with  the 
formation  of  multiple  abscesses  in  different 
parts  of  the  body,  arising  from  the  diffusion 
of  pyogenic  materials  from  some  spot  of  local 
infection. 

It  was  supposed  not  long  ago  that  pyaemia  was  due 
to  some  specific  micro-organism,  but  it  has  now  been 
definitely  proved  by  Rosenbach  that  any  of  the  pyo- 
genic organisms  can  give  rise  to  it ;  in  fact,  theoretically, 
pyaemia  may  arise  as  a  complication  following  any 
acute  abscess,  which,  as  we  have  already  seen,  is 
always  due  to  bacterial  activity.  As  a  rule,  however, 
there  is  a  sufficiently  rapid  development  of  granula- 
tion tissue  to  limit  the  spread  of  infection.  The 
organism  most  commonly  found  is  the  Streptococcus 
pyogenes,  but  in  a  few  cases  the  Staphylococcus  pyogenes 
aureus  has  been  observed.  The  mere  injection  of 
cocci  into  the  circulation  is  not  sufficient  to  give  rise 
to  pysemia;  if  they  are  few  in  number,  a  transient 
a'caskof'Pyamia  Pyrexia  maY  .supervene,  and  then  the  germicidal 
fTii    manns  \  "    Power£  latent  in  the  blood  destroy  them  ;    but  if  the 

*  '  dose  is  large,  or  the  individual  is  not  in  a  very  re- 

The  apex  of  the  clot    sistant  condition,  septicaemia,  and  not  pyaemia,  results, 
projects  into  a  larger    unless  special  conditions  are  present  which  determine 
trunk,  in  which  cir-    the  formation  of  embolic  abscesses.      If  the  cocci  to 
culating     blood     is    be  injected  are  mixed  with  such  a  material  or  aggre- 
present,  and  from  it    gated  into  such  masses  that  the  organisms  are  carried 
infected   emboli    on  particles  too  large  to  pass  through  the  terminal 
would  be  detached,     arterioles  and  capillaries,  wherever  they  lodge  abscesses 
develop.      In  human   pathology  the  infective  emboli 
consist  of  zoogloea  masses  of  organisms,  or  of  infected  particles  of  disinte- 
grating blood-clot  (Fig.  n). 

The  Cause  of  pyaemia  may  be  stated  to  be  any  condition  which 
leads  to  the  formation  and  detachment  of  infective  emboli  in  the 
circulation,  such  conditions  occurring  mainly  in  the  veins  from 
infiltration  and  disintegration  of  a  thrombus  (infective  phlebitis), 
but  occasionally  in  the  heart  (malignant  endocarditis).  The  venous 
contamination  which  was  formerly  so  much  dreaded  after  opera- 
tions by  surgeons  has  now  been  practically  banished  from  surgery 
by  antisepsis ;  but  the  disease  is  still  occasionally  met  with  in 
casualty  work,  where  efficient  asepsis  is  difficult.  Acute  infective 
inflammation  of  the  cancellous  tissue  of  bones,  whether  idiopathic 
or  traumatic,  is  very  commonly  associated  with  pyaemia,  owing 
to  the  veins  being  abundant  and  thin-walled,  and  considerable 
tension  present  from  the  unyielding  condition  of  the  surrounding 
bony  structures.  Inflammation  of  the  cranial  bones  coming  on 
in  the  course  of  middle-ear  mischief,  and  causing  thrombosis  of 
the  lateral  sinus,  also  leads  to  its  development.  The  presence  of 
large  open-mouthed  veins  in  the  puerperal  uterus  also  explains 


io4  A  MANUAL  OF  SURGERY 


the  onset  of  the  disease  after  parturition  if  septic  material  is 
allowed  to  collect  or  remain  in  their  vicinity. 

When  an  infective  embolus  lodges  in  any  region  of  the  body,  a 
thrombus  forms  upon  it,  and  in  this  the  micro-organisms  rapidly 
develop,  and  thence  pass  through  the  vessel  wall  into  the  sur- 
rounding tissues,  causing  inflammation,  which  is  at  first  of  a 
plastic  type,  but  later  on  becomes  suppurative.  In  the  lung 
many  such  foci  may  occur,  distributed  mainly  along  the  posterior 
border  and  near  the  surface ;  each  is  sharply  limited  to  a  wedge- 
shaped  area  of  tissue,  with  the  base  directed  towards  the  periphery. 
It  is  at  first  reddish  in  colour,  from  effusion  of  blood  (a  hemorrhagic 
infarct),  but  soon  becomes  greyish -yellow,  from  the  formation  of 
pus.  These  abscesses  are  small,  and  rarely  give  rise  to  any  physical 
signs.  Similar  collections  of  pus,  preceded  or  not  by  an  infarct, 
may  be  found  in  any  organ  of  the  body.  The  lungs,  acting  as  a 
filter  to  emboli  derived  from  the  systemic  veins,  are  naturally  the 
first  organs  to  be  affected,  and  from  the  abscesses  formed  therein, 
infection  of  the  arterial  system  may  take  place,  resulting  in  fresh 
suppurative  foci  in  the  liver,  spleen,  kidneys,  brain,  and  in  or 
around  joints,  etc.  If,  however,  the  causative  phlebitis  is  situated 
in  the  portal  area,  the  emboli  are  lodged  primarily  in  the  liver, 
giving  rise  to  what  is  known  as  pylephlebitis.  When  the  emboli 
are  many  in  number,  the  symptoms  are  severe,  constituting  acute 
pyaemia;  this  is  sometimes  associated  with  a  development  of 
micro-organisms  in  the  blood,  producing  pyosepticamia,  the  patient 
perhaps  dying  before  the  secondary  abscesses  have  fully  developed. 
In  other  cases  the  general  symptoms  are  due  rather  to  the  absorp- 
tion of  toxins  from  the  local  foci  than  to  the  development  of 
organisms  in  the  blood.  If  the  emboli  are  few  in  number,  and 
there  is  little  or  no  development  of  -microbes  in  the  blood,  the 
disease  is  termed  chronic  pyaemia. 

Clinical  History. — The  most  marked  symptom  indicating  the 
onset  of  a  case  of  Acute  Pyaemia  is  the  occurrence  during  a  period 
of  febrile  disturbance  of  a  severe  rigor,  which  is  repeated  with  a 
sort  of  irregular  periodicity,  most  frequently  at  intervals  of  about 
twenty-four  to  forty-eight  hours,  somewhat  simulating  an  attack 
of  ague.  The  rigors  do  not  differ  from  those  occurring  in  other 
diseases,  but  they  are  very  severe,  and  usually  followed  by  profuse 
sweating.  Between  the  rigors  the  temperature  may  fall  to  the 
normal,  but  more  commonly  remains  above  it.  The  skin  is  hot 
and  soon  develops  an  earthy  or  dull  yellow  tint,  together  with 
erythematous  or  petechial  patches.  A  sweet,  mawkish,  hay-like 
smell  of  the  breath  is  very  characteristic.  Symptoms  of  grave 
depression  supervene,  and  the  patient  rapidly  wastes.  The  pulse 
becomes  soft  and  weak,  the  excretions  are  diminished,  and  a 
certain  amount  of  nocturnal  delirium  is  noticed,  but  no  loss  of 
consciousness.  The  presence  of  a  bruit  in  the  precordial  region 
may  suggest  the  existence  of  an  infective  endocarditis,  which   is 


Infective  diseases  105 


not  very  uncommon.  The  tongue  varies,  but  is  often  red  with 
very  prominent  papillae,  and  becomes  dry  and  brownish.  Towards 
the  end  of  the  first  week  secondary  abscesses  appear  ;  they  are 
sometimes  unaccompanied  by  local  pain  or  tenderness,  and  form 
very  rapidly ;  thus,  a  knee-joint  may  fill  with  pus  in  the  course  of 
a  night  of  quiet  sleep.  They  are,  as  a  rule,  small  and  numerous  ; 
if  they  occur  in  vital  organs,  death  may  result  from  their  local 
development.  When  situated  in  the  subcutaneous  tissues,  they 
are  characterized  by  the  almost  total  absence  of  a  barrier 
of  granulation  tissue,  and  hence,  even  when  opened  early  and 
aseptically,  are  likely  to  extend  and  continue  secreting  pus, 
instead  of  following  the  usual  course  of  rapid  contraction  and 
repair  which  succeeds  the  aseptic  opening  of  an  ordinary  acute 
abscess. 

Not  uncommonly  in  these  cases  painful  patches  occur  here  and 
there  in  the  subcutaneous  tissues,  accompanied  by  hyperaemia, 
which  fades  away  after  a  few  days ;  such  are  probably  due  to  the 
impaction  of  small  infective  emboli,  which  the  patient  has  sufficient 
vitality  to  get  rid  of  without  suppuration. 

In  Chronic  Pyaemia  the  febrile  symptoms  are  much  less  marked  ; 
the  abscesses  are  few  in  number,  and  not  dangerous  unless  form- 
ing in  important  structures.  Thus,  a  fatal  result  ensued  from  a 
single  abscess  which  developed  in  the  lateral  ventricle  of  the  brain 
of  a  patient  who  had  no  other  symptom  of  pyaemia  except  an 
oscillating  temperature :  it  followed  an  operation  on  a  septic  sinus 
leading  to  a  kidney  already  disorganized. 

The  condition  of  the  wound  at  the  onset  of  pyaemia  is  always 
very  unsatisfactory.  It  gapes  open  and  presents  an  inactive 
surface,  and  any  newly-formed  scar  tissue  readily  breaks  down. 
A  layer  of  healthy  granulations  is  an  almost  certain  barrier  against 
the  occurrence  of  pyaemia,  on  account  of  the  germicidal  power  of 
the  cells  constituting  it.  If  the  disease  arises  in  connection  with 
bone,  the  latter  structure  is  usually  seen  lying  bare  at  the  bottom 
of  the  wound,  denuded  of  its  periosteum,  and  the  cancelli  filled 
with  sloughy  foetid  medulla,  or  pus. 

The  duration  of  a  case  of  pyaemia  is  very  variable.  Acute  cases 
usually  last  a  little  over  a  week,  whilst  the  subacute  forms  may 
run  on  for  three  or  four  weeks,  and  chronic  cases  continue  for 
months,  and  not  unfrequently  end  in  complete  recovery. 

Post-mortem  Appearances.  —  1.  The  wound  is  unhealthy,  the 
surface  being  grey,  dry,  or  sloughy ;  if  bone  is  implicated,  as  in 
an  amputation  or  excision,  evidence  of  inflammatory  mischief, 
either  of  the  periosteum  or  medulla,  is  present.  2.  The  veins 
leading  from  the  wound  may  be  in  a  healthy  condition,  but  are 
more  commonly  in  a  state  of  septic  phlebitis  ;  the  coats  are 
thickened,  and  the  lumen  is  filled  with  soft,  disintegrating  clot, 
which  extends  for  a  considerable  distance;  the  tissues  surrounding 
the  vein  are  also  involved  in  the  suppurative  process.   3.  Secondary 


io6  A  MANUAL  OF  SURGERY 


abscesses  are  found  in  various  parts  of  the  body,  most  frequently 
in  the  lungs,  and  their  different  stages  can  be  clearly  demonstrated 
from  the  embolic  colonies  of  micrococci,  through  the  stage  of 
haemorrhagic  infarction  to  the  complete  abscess.  The  contained 
pus  may  be  of  the  normal  type,  or  thin  and  oily ;  it  is  always, 
however,  swarming  with  cocci.  4.  The  general  signs  common  to 
all  cases  of  septic  poisoning  (p.  7)  will  also  be  manifest. 

The  Diagnosis  of  pyaemia  should  not  be  difficult  in  the  majority 
of  cases  ;  but  when  it  originates  without  any  obvious  external 
wound,  as  in  a  deep-seated  abscess,  or  if  the  importance  of  some 
local  lesion  has  not  been  appreciated,  the  initial  symptoms  may  be 
mistaken  for  those  of  acute  rheumatism  or  ague. 

The  Prognosis  depends  upon  the  inherent  vitality  of  the  patient 
and  the  virulence  of  the  disease.  In  acute  cases  it  is  extremely 
grave,  whilst  in  the  chronic  type  recovery  is  not  only  possible,  but 
probable,  if  the  local  abscesses  are  favourably  situated. 

In  the  Treatment  of  acute  pyaemia  the  surgeon  is  acting  at  a 
considerable  disadvantage,  in  that  the  disease  is  only  recognisable 
when  it  has  obtained  some  hold  upon  the  patient,  since  the  recur- 
rent rigors,  by  which  it  is  known,  are  usually  the  evidence  of  a 
grave  general  infection  of  the  blood. 

Local  Treatment  is  most  important,  and  since  the  disease  is  in 
the  majority  of  cases  due  to  the  detachment  of  infected  emboli 
from  a  vein,  the  ideal  surgical  practice  consists  in  preventing,  if 
possible,  the  further  contamination  of  the  general  blood-stream. 
This  can  sometimes  be  accomplished,  in  the  case  of  a  limb,  by 
amputation  well  above  the  local  lesion  ;  or  if  the  medullary  cavity 
of  a  bone  is  the  source  of  trouble,  it  may  be  possible  to  scrape  out 
the  gangrenous  and  offensive  medullary  tissue,  and  disinfect  the 
cavity  with  pure  carbolic  acid  ;  or  if  it  is  due  to  a  wound  in  the 
soft  parts,  it  may  be  feasible  to  dissect  out  the  implicated  vein  and 
surrounding  tissues,  or  at  any  rate  to  remove  the  disintegrating 
clot  after  placing  a  ligature  upon  the  vessel  between  the  thrombus 
and  the  heart.  A  typical  illustration  of  such  treatment  is  that 
adopted  for  septic  thrombosis  of  the  lateral  sinus  complicating 
disease  of  the  middle  ear,  where,  after  tying  the  internal  jugular  in 
the  neck,  the  sinus  is  exposed  by  the  trephine,  opened,  and  all  the 
septic  clot  removed,  partly  from  above,  partly  from  below.  Ad- 
mirable results  have  been  thereby  obtained.  The  abscesses  must  be 
dealt  with,  where  practicable,  by  opening  them  early  and  washing 
them  out ;  such  wounds  often  heal  well,  and  joints  which  have 
been  distended  with  pus  may  recover  with  free  mobility.  Occa- 
sionally, however,  although  rigid  asepsis  has  been  maintained,  the 
suppuration  continues,  and  even  sloughing  of  the  abscess  wall  may 
follow.  If  the  general  condition  can  be  improved,  a  barrier  of 
granulation  tissue  will  form  in  time,  and  repair  be  established. 

Constitutional  Treatment  consists  in  supporting  the  patient's 
strength  by  nourishing  diet  and  stimulants,  and  in  taking  precau- 


INFECTIVE  DISEASES  io? 

tions  to  avoid  bedsores  or  any  local  injury.  Salicylate  of  quinine 
may  be  administered,  though  its  value  is  doubtful.  The  antistrep- 
tococcic serum  may  also  be  utilized,  and  it  may  do  good  in  cases 
which  have  not  progressed  too  far. 

Tetanus. 

Tetanus  is  a  local  infective  disease,  due  to  the  Bacillus  tetani, 
and  the  characteristic  symptoms  are  of  a  toxaemic  nature. 

Predisposing  Causes. — 1.  Climatic  Influences. — It  is  most  com- 
monly seen  in  the  tropics,  where  it  may  be  almost  epidemic, 
probably  owing  to  the  heat  favouring  the  development  and 
virulence  of  the  organisms  in  the  soil ;  hot  seasons  assist  its 
activity,  and  particularly  when  hot  days  are  followed  by  cold 
nights. 

2.  Personal  Proclivity. — It  was  formerly  considered  that  negroes, 
horses,  and  stable  attendants  were  specially  liable  to  this  disease, 
owing  to  some  peculiar  idiosyncrasy  ;  but  with  the  recent  addi- 
tions to  our  knowledge  as  to  the  habitat  of  the  Bacillus  tetani,  it 
is  extremely  doubtful  whether  such  an  idea  can  be  maintained. 
The  organism  is  a  facultative  saprophyte — i.e.,  is  capable  of  con- 
tinuing its  development  apart  from  the  body — and  is  almost 
constantly  found  in  garden  soil,  dust,  or  dirt  of  any  kind. 
Those,  therefore,  who  are  likely  to  be  much  brought  in  contact 
with  the  ground,  e.g.,  negroes,  horses,  and  agricultural  labourers, 
are  liable  to  develop  the  disease,  owing  to  their  more  constant 
exposure  to  infection. 

3.  Bad  Hygiene  is  a  most  important  predisposing  condition. 
Every  hygienic  error  favours  its  appearance,  but  especially  the 
overcrowding  of  sick  and  wounded  people  into  a  limited  space, 
and  especially  if  full  antisepsis  is  impossible. 

Exciting  Causes. — 1.  The  existence  of  a  wound.  It  may  follow 
a  lesion  which  causes  no  breach  of  surface,  such  as  a  blow  with 
the  fist,  or  a  bruise,  but  in  the  great  majority  of  cases  there  is  a 
definite  solution  of  continuity  of  the  skin.  Any  region  of  the  body 
may  be  thus  affected,  and  it  is  rare  for  tetanus  to  occur  in  any  but 
septic  wounds ;  where  asepsis  has  been  fully  maintained  the 
development  of  tetanus  is  almost  unknown.  Punctured  or 
lacerated  wounds  of  the  sole  of  the  foot,  perhaps  due  to  a  dirty  or 
rusty  nail,  are  as  likely  to  be  associated  with  tetanus  as  any. 

2.  Infection  with  the  Bacillus  tetani.  The  first  clue  to  the 
infective  nature  of  this  disease  was  obtained  from  the  observation 
that,  if  portions  of  soil  or  garden  mould  were  placed  under  the 
skin  of  animals,  they  died  in  a  short  time  with  tetanic  symptoms, 
and  in  the  pus  and  walls  of  the  resulting  abscess  characteristic 
bacilli  were  observed.  Experimenting  in  the  same  way,  it  has 
been  found  that  the  bacilli  or  their  spores  are  very  widely  dis- 
seminated, and,  indeed,  are   present  in  almost  every  sample  of 


[o8  A  MANUAL  OF  SURGERY 


garden  or  field  soil ;  they  have  been  found  in  the  grime  on  a 
working  man's  hand,  and  on  dirty  surgical  instruments.  Great 
difficulty  was  experienced  in  isolating  and  getting  pure  cultures 
of  the  bacillus,  but  at  last  Nicolaier  and  Kitasato  succeeded,  by 
heating  the  pus  from  an  infected  wound  to  a  temperature  of 
80°  C.  for  an  hour,  thereby  destroying  all  the  pyogenic  and  septic 
microbes.  It  develops  in  the  body  as  long,  delicate  threads  consist- 
ing of  and  breaking  up  into  separate  bacilli ;  in  artificial  cultures 
spores  form,  but  only  at  one  end,  causing  such  an  appearance 
that  the  microbe  is  known  as  the  'drumstick'  bacillus  (Fig.  12). 
These  organisms  are  anaerobic,  i.e.,  flourish  apart  from  oxygen, 
and,  indeed,  are  best  cultivated  on  nutrient  gelatine  at  blood-heat 
in  an  atmosphere  of  hydrogen.  They  are  not  endowed  with  high 
vitality,  and  hence  do  not  invade  living  tissues  unless  these  have 
been  previously  bruised  or  damaged  by  the  presence  of  septic 
inflammation.  They  grow  in  the  neighbourhood  and  near  the 
surface  of  septic  wounds,  the  septic  organisms  absorbing  all  the 
oxygen    present,   and   so    originating    the    anaerobic    conditions 


ta 


*4f* 

C\ 

Fig.  12. — Bacilli   of   Tetanus  from  Artificial  Culture,  showing  the 
Spores  located  at  the  Ends  of  the   Rods   ('Drumstick'  Bacilli). 

(TlLLMANNS.) 

necessary  for  their  development.  The  mode  of  action  of  the 
bacillus  consists  in  a  local  infection  with  general  toxaemia  ;  that  is 
to  say,  by  its  local  development  in  a  wound  certain  substances 
are  produced  which,  when  absorbed,  act  on  the  spinal  marrow 
and  brain,  producing  toxic  effects  very  similar  to  those  of 
strychnine.  The  actual  tetano-toxin  appears  to  have  the  nature 
of  a  ferment,  its  virulence  being  readily  destroyed  by  exposure 
to  a  somewhat  low  temperature,  e.g.,  one  of  68°  C.,  for  about  five 
minutes.  It  is  not  influenced  by  drying,  and  its  activity  is  such 
that  it  is  stated  to  be  nearly  400  times  as  poisonous  as  strychnine. 
As  to  the  post-mortem  Anatomical  Changes,  but  little  need- be 
said,  since  they  are  not  specially  characteristic.  The  muscles 
are  often  pale,  or  show  evidences  of  rupture  and  extravasation 
of  blood.  The  peripheral  nerves  extending  from  the  wound  are 
red  and  congested  for  some  distance,  but  this  is  probably  only  due 
to   septic    inflammation.      The   nerve  centres  frequently  present 


INFECTIVE  DISEASES  ion 


areas  of  softening,  and  perivascular  cellular  exudation,  with  some 
hyperaemia. 

A  few  observations  are  on  record  in  which  the  bacilli  have  been 
noticed  on  the  pia  mater  and  arachnoid  of  the  human  spinal  cord, 
and  others  claim  to  have  transmitted  the  disease  experimentally 
by  inoculation  of  the  subdural  space  with  an  emulsion  of  the  spinal 
cord  or  medulla.  If  these  facts  be  true,  they  indicate  that  we 
have  still  much  to  learn  as  to  the  nature  of  the  disease. 

Clinical  History.  —  Acute  Tetanus  usually  manifests  itself  in 
this  country  two  or  three  weeks  after  infection  (but  sometimes 
abroad  as  early  as  a  few  hours  or  days)  by  a  difficulty  in  opening 
the  mouth,  associated  with  a  cramp-like  pain  in  the  muscles  of 
mastication  and  of  the  neck.  This  soon  becomes  so  marked  that 
it  may  be  difficult  even  to  insert  a  paper-knife  between  the  teeth 
{trismus,  or  lock-jaw),  causing  great  difficulty  in  the  administration 
of  food  ;  to  it  is  added  a  fixed  and  rigid  condition  of  the  muscles  of 
the  back  of  the  neck  and  of  the  face,  the  latter  producing  a  curious 
grin-like  appearance  (risus  sardonicus),  whilst  dysphagia  soon  follows 
from  spasm  of  the  pharyngeal  muscles.  A  considerable  degree  of 
fever  is  often  manifested,  but  in  some  cases  an  apyrexial  course  is 
maintained  until  nearly  the  end.  The  spasms  soon  extend  to  the 
trunk  and  extremities,  accompanied  by  cramp-like  pains,  and  when 
fully  established  they  may  be  excessively  painful  and  violent,  and 
the  remissions  between  them  but  partial.  Fortunately  the  disease 
usually  involves  the  respiratory  muscles  late  in  the  attack.  The 
spasms  can  be  excited  by  any  form  of  stimulus,  such  as  the 
slamming  of  a  door,  a  draught  of  cold  air,  or  some  voluntary 
movement,  and  are  always  of  a  tonic  {i.e.,  continuous)  character. 
The  body  is  contorted  in  various  directions,  and  respiration  much 
impeded  by  the  fixation  of  the  thorax.  Occasionally  the  body  is 
arched  backwards  {opisthotonos)  by  the  contraction  of  the  muscles 
of  the  back,  the  recti  abdominis  being  firm  and  tense — '  as  hard 
as  boards '  ;  sometimes  it  is  doubled  forwards  {emprosthotonos), 
and  in  rare  cases  laterally  {pleurosthotonos).  The  muscles  may 
contract  so  violently  as  to  be  ruptured,  whilst  teeth  have  been 
broken  and  the  tongue  has '  been  almost  bitten  off.  The  in- 
tellectual faculties  usually  remain  clear  to  the  end,  which  is 
generally  due  to  exhaustion  from  a  repetition  of  the  convulsions, 
or  more  rarely  to  asphyxia  induced  by  a  prolonged  fixation  of  the 
respiratory  muscles.  Before  death  the  temperature  sometimes 
runs  up  to  1080,  or  even,  in  one  case,  to  1120  F.,  and  it  often 
continues  to  rise  for  a  degree  or  two  after  death  ;  such  hyper- 
pyrexia is  mainly  due  to  the  continuous  muscular  contractions. 
The  surface  of  the  body  is  bathed  in  sweat,  and  the  urine  occasion- 
ally albuminous.  Death  may  occur  in  twenty-four  hours  from  the 
onset  of  the  disease,  or  not  for  four  or  five  days. 

Chronic  Tetanus  usually  begins  later  after  infection,  is  less 
severe  in  its  symptoms,  and  more  likely  to  be  recovered  from. 


A   MANUAL  OF  SURGERY 


The  course  is  usually  afebrile,  and  the  spasmodic  contractions 
may  be  limited  to  the  wounded  part  of  the  body  whence  the 
infection  has  arisen,  or  may  be  general.  A  special  variety  of  this 
is  known  as  cephalo -tetanus,  or  T.  paralyticus  (German,  kopf -tetanus). 
It  follows  injuries  within  the  area  of  distribution  of  the  cranial 
nerves,  and  especially  those  about  the  supra-orbital  margin,  and 
is  characterized  by  the  association  of  trismus  with  facial  paralysis, 
although  spasms,  both  tonic  and  clonic,  occur  in  other  parts  of 
the  body.  Spasm  of  the  muscles  of  deglutition  and  attacks  of 
maniacal  frenzy  are  sometimes  present,  and  hence  the  name 
T.  hydrophobicus  which  has  been  applied  to  it.  The  paralysis  is 
supposed  to  be  due  to  an  ascending  neuritis  of  the  facial  nerve, 
which  becomes  compressed  in  the  aqueductus  Fallopii.  The 
condition  is  uncommon,  and  the  prognosis  not  quite  so  grave  as 
in  the  acute  cases. 

The  Diagnosis  of  tetanus  is  rarely  difficult.  In  the  early  stages 
it  must  be  distinguished  from  simple  trismus  arising  from  dental 
irritation,  or  from  inflammatory  ankylosis  of  the  temporo-maxillary 
joint.  This  may  be  readily  accomplished  by  noting  that  there  is 
also  present  in  tetanus  rigidity  of  the  neck  muscles.  In  the  later 
stages  strychnine  poisoning  leads  to  a  very  similar  group  of  symptoms, 
but  is  recognised  from  it  by  the  contractions  being  more  sudden 
and  violent,  the  relaxation  of  the  muscles  between  the  spasms 
complete,  so  that  the  mouth  can  readily  be  opened,  whilst  the 
hands  are  involved  in  the  contractions,  a  rare  sign  in  tetanus,  and 
the  muscles  of  mastication  often  escape. 

No  difficulty  should  be  experienced  in  distinguishing  tetanus 
from  hydrophobia,  owing  to  the  very  different  nature  of  the  con- 
vulsions in  the  latter  case — i.e.,  clonic  and  not  tonic  ;  moreover, 
they  affect  the  muscles  of  respiration  and  deglutition,  whilst  the 
history  of  the  case,  the  early  hallucinations,  and  the  absence  of 
tonic  muscular  contractions,  are  also  characteristic  features. 

The  Prognosis  is  unfavourable  in  any  case,  but  the  so-called 
idiopathic  variety  is  less  fatal  than  the  traumatic.  The  longer 
the  case  lasts,  and  the  lower  the  temperature,  the  more  likely  is 
the  patient  to  recover,  whilst  an  acute  onset,  hyperpyrexia,  sleep- 
lessness, delirium,  and  strabismus  are  bad  signs.  The  length  of 
the  incubation  period  is  also  a  most  important  factor,  since  it  has 
been  shown  tha.t  if  it  is  under  ten  days,  only  4  per  cent,  recover  ; 
whilst  if  it  lasts  for  eleven  to  fifteen  days,  27  per  cent,  of  cures 
may  be  expected,  and  if  the  outbreak  is  delayed  for  fifteen  to 
twenty  days,  45  per  cent,  of  the  patients  live. 

Treatment. — Careful  antisepsis  applied  to  wounds  is  the  surest 
means  of  preventing  its  occurrence,  and  the  worse  the  sanitary 
conditions  in  which  patients  are  found,  and  the  more  ragged  the 
wound,  the  stricter  should  be  the  measures  employed. 

If  the  originating  sore  is  accessible,  it  should  be  freely  excised 
and  the  wound  cauterized,  or  the  limb  may  be  amputated  ;  but 


INFECTIVE  DISEASES 


even  then  the  tetanic  convulsions  may  remain  for  a  time,  or  even 
prove  fatal,  from  the  amount  of  poison  already  in  the  system. 

In  addition  to  these  local  measures,  the  specific  tetanus  anti- 
toxin (prepared  by  drying  the  blood  serum  of  an  immunized 
animal)  should  be  injected.  At  present  the  results  of  this 
treatment  have  proved  disappointing,  since  few  cases  of  acute 
tetanus  have  been  saved  by  it,  and  the  effect  even  in  the  more 
chronic  cases  is  not  at  all  certain.  The  explanation  of  this  lies 
probably  in  the  fact  that  the  serum  is  in  reality  an  immunizing 
agent  (i.e.,  one  which  prevents  the  development  of  the  organisms), 
and  is  not  capable  of  dealing  with  the  toxic  bodies  already  acting 
on  the  nerve  centres ;  so  that  if  a  certain  dose  of  the  tetano-toxin 
has  once  been  absorbed,  it  will  produce  its  normal  effects,  even 
though  the  antitoxin  prevents  any  further  development  of  the 
organisms.  The  treatment  should  always  commence  with  a  large 
dose,  and  smaller  amounts  should  then  be  administered  once  or 
twice  a  day,  varying  with  the  severity  of  the  symptoms.  If  the 
fluid  antitoxic  serum  is  used,  20  to  30  c.c.  may  be  given  as  the 
initial  injection,  followed  by  doses  of  10  to  15  c.c.  twice  a  day. 
This  is  introduced  into  the  subcutaneous  tissues  of  the  abdomen 
and  back,  or  in  somewhat  smaller  doses  into  the  veins,  and  causes 
but  little  inconvenience.  If  Tizzoni's  dried  antitoxic  serum  is 
employed,  2  to  4  grammes,  dissolved  in  distilled  water,  may  be 
given  to  start  with,  and  1  to  2  grammes  for  subsequent  doses. 

During  the  last  few  years  it  has  been  shown  by  Roux  and 
Borrel  that  the  toxins  are  so  closely  attached  to  the  nerve-cells 
that  it  is  almost  hopeless  to  expect  even  an  intravenous  injection 
of  antitoxin  to  do  much  good,  and  hence  it  has  been  proposed  to 
introduce  it  into  the  substance  of  the  brain,  enabling  it  thus  to 
reach  and  act  on  the  nerve  centres  more  rapidly.  The  object  to 
be  gained  is  to  immunize  the  medullary  centres  and  prevent  any 
further  development  of  the  toxin  in  the  body ;  what  is  there 
already  must  be  allowed  to  work  itself  off.  The  injection  is  made 
through  the  dura  mater  into  the  posterior  portion  of  the  second 
frontal  convolution  on  each  side  ;  2*5  c.c.  of  the  dried  serum 
dissolved  in  5  c.c.  of  sterilized  water  are  injected  very  slowly,  and 
this  may  be  repeated  several  times,  if  an  interval  of  a  few  days  be 
allowed  to  elapse  between  each  injection.  The  point  selected  is 
placed  midway  between  the  external  angular  process  of  the  frontal 
bone  and  the  centre  point  of  the  line  between  the  root  of  the 
nose  and  the  external  occipital  protuberance.  A  small  trephine 
may  be  applied  here,  or  simply  a  hole  drilled  through  the  skull 
sufficient  to  allow  of  the  introduction  of  a  syringe,  which  is  pushed 
about  two  inches  deep  into  the  brain.  Of  course,  the  strictest 
asepsis  is  essential.  Probably  it  will  be  found  wise  to  restrict  this 
plan  to  the  treatment  of  the  worst  cases,  and  it  must  be  augmented 
by  subcutaneous  injections  and  the  other  subsidiary  measures  to 
be  now  noted, 


A   MANUAL  OF  SURGERY 


The  patient  should  be  kept  absolutely  quiet  in  a  darkened 
room,  and  free  from  all  sources  of  irritation.  Food  should  be 
nutritious,  fluid,  and  unstimulating  ;  it  has  been  suggested  to  feed 
the  patient  twice  a  day  by  a  stomach-pump  under  chloroform. 
When  the  trismus  is  very  marked,  he  may  be  fed  through  a  soft 
rubber  catheter  passed  into  the  pharynx  through  the^nose,  unless 
there  is  a  sufficient  gap  between  the  teeth  to  admit  of  its  entrance. 
Opium,  chloral  hydrate,  bromide  of  potash,  physostigma,  and 
curare,  have  been  vaunted  as  beneficial  drugs,  but  probably  cases 
which  have  recovered  after  their  exhibition  would  have  done  so 
without.  Chloroform  should  be  administered  to  control  the 
spasms. 

Hydrophobia. 

Hydrophobia  is  an  acute  general  infective  disease,  transmitted  from  animals 
to  men,  especially  from  rabid  dogs,  wolves,  etc.  It  consists  in  an  affection  of 
the  central  nervous  system,  and  one  of  its  most  marked  features  is  the  long  and 
variable  incubation  period.  It  never  originates  idiopathically  either  in  animals 
or  man,  and  although  the  actual  virus  has  not  yet  been  isolated,  there  can  be 
no  doubt  that  it  is  a  micro-organism.  Infection  usually  follows  a  bite  ;  but  if 
the  teeth  pass  first  through  a  garment,  the  virus  may  be  wiped  off,  and  the 
individual  may  escape.  It  has  also  been  proved  that  if  an  infected  animal 
merely  licks  an  abraded  surface  the  disease  may  be  transmitted,  even  when  the 
animal  has  not  at  the  time  shown  any  of  the  more  typical  signs  of  rabies. 

In  the  Dog,  rabies  manifests  itself  three  to  five  weeks  after  infection,  but  the 
period  varies  considerably ;  the  original  wound  usually  heals  perfectly,  or 
there  may  be  some  inflammatory  thickening  about  it.  Two  chief  varieties 
have  been  described — the  raging  or  maniacal,  and  the  quiet  or  dumb.  Rabies 
with  frenzy  commences  with  a  stage  of  depression,  which  is  manifested  by 
snappishness  and  irritability,  especially  towards  other  animals,  by  restlessness, 
and  by  the  dog  moping  in  dark  corners,  with  a  depraved  appetite,  eating  any 
kind  of  rubbish  or  dirt,  and  even  its  own  excreta.  This  period  lasts  for  two  or 
three  days,  and  is  perhaps  the  most  dangerous,  since  there  is  nothing  very 
suggestive  about  the  symptoms.  It  is  followed  by  a  period  of  frenzy  and 
maniacal  fury,  and  this  in  turn  is  succeeded  by  a  stage  of  paralysis,  going  on 
to  death.  During  the  whole  attack  the  mouth  is  filled  with  ropy  saliva,  which 
the  animal  vainly  tries  to  scratch  away ;  the  bark  loses  its  ring  and  becomes 
hoarse,  and  as  the  disease  progresses  the  lower  jaw  becomes  paralyzed  ;  finally, 
after  partial  or  general  convulsions,  the  animal  dies  five  or  six  days  from  the 
onset.  In  the  melancholic  or  dumb  form  the  animal  succumbs  more  rapidly, 
passing  through  the  same  stages  as  the  above,  with  the  exception  of  the 
maniacal  period.     The  disease  lasts  then  but  two  or  three  days. 

In  Man  the  incubation  period  is  most  variable,  lasting  from  days  to  months 
or  years,  but  as  a  rule  it  does  not  exceed  six  weeks.  During  this  interval  the 
wound  heals,  although  the  scar  may  remain  tender  and  neuralgic.  The  disease 
is  ushered  in  by  a  vague  sense  of  terror,  with  illusions  of  the  senses  and  dis- 
turbance of  the  mind,  lasting  for  about  twenty-four  hours.  Restlessness, 
sleeplessness,  loss  of  appetite,  and  a  repugnance  to  fluids  follow,  with  perhaps 
some  slight  febrile  disturbance.  The  more  characteristic  symptoms  are 
inaugurated  by  a  convulsive  stiffness  of  the  tongue,  neck,  and  especially  of 
the  muscles  of  deglutition  and  respiration,  which  becomes  more  marked  if  any 
attempt  is  made  to  swallow.  These  convulsions  are  clonic  in  character,  and 
thus  differ  from  those  of  tetanus;  they  become  more  and  more  generalized, 
being  brought  on  after  a  time  by  almost  any  afferent  impulse,  however  slight 
— such  as  a  blast  of  cold  air,  a  flash  of  light,  a  sudden  noise,  especially  such  as 
is  caused  by  the  movements  of  fluids ;  swallowing  is  quite  impracticable.     The 


Infective  diseases  113 

mouth  is  usually  filled  with  ropy  mucus,  which  is  very  difficult  to  remove. 
The  respirations  became  catchy,  and  a  hiccoughing  noise  may  be  produced  by 
the  spasm  of  the  diaphragm,  which  is  sometimes  thought  to  resemble  the 
barking  of  a  dog.  Finally,  the  convulsions  may  entirely  cease,  and  the  patient 
dies,  retaining  his  consciousness  to  the  end,  the  fatal  issue  being  due  to  the 
destructive  changes  taking  place  in  the  medulla,  or  to  exhaustion  ;  it  may, 
however,  occur  earlier,  from  spasm  of  the  glottis.  The  disease  lasts  about  a 
week,  but  may  be  more  rapid,  killing  even  in  two  days. 

The  Post-mortem  Changes  are  mainly  negative.  Evidences  of  acute  inflam- 
mation of  the  lower  part  of  the  medulla,  including  the  centres  for  the  gth, 
10th,  and  nth  nerves,  are  observed  on  microscopic  examination,  the  vessels 
being  thrombosed,  and  the  connective  tissue  infiltrated  with  leucocytes.  The 
nerve  fibres  and  ganglion  cells  may  also  be  found  degenerated.  The  salivary 
glands  are  always  somewhat  enlarged. 

Preventive  Measures  should  be  adopted  immediately  in  all  cases  of  bites  from 
dogs  which  are  either  rabid  or  may  possibly  become  so.  The  circulation  in 
the  limb  should  be  arrested  by  a  string  or  bandage,  bleeding  encouraged,  and 
some  powerful  caustic,  e.g.,  pure  carbolic  acid,  applied  as  soon  as  possible.  A 
free  excision  of  the  part  is,  however,  preferable. 

Pasteur's  Preventive  Treatment. — A  few  years  back  M.  Pasteur  discovered 
the  fact  that  the  injection  of  an  attenuated  virus  in  increasing  doses,  and 
in  gradually  increasing  strength,  protects  an  animal  or  individual  from  the 
disease,  and  mirabile  dictu !  will  even  catch  up  the  poison  already  inoculated, 
and  save  the  patient  from  its  subsequent  development,  if  too  long  a  start 
has  not  been  given.  The  method  employed  is  as  follows :  A  virus  of  constant 
and  maximum  intensity  is  first  obtained  by  passing  the  poison  from  a  dog 
through  a  series  of  rabbits,  until  the  disease  appears  with  regularity  on  the 
seventh  day,  all  parts  of  the  cord  being  then  equally  virulent.  The  material 
inoculated  is  obtained  by  mashing  up  a  portion  of  the  spinal  cord  or  medulla 
of  the  diseased  dog  in  sterilized  broth,  and  injecting  it  with  a  hypodermic 
syringe  beneath  the  arachnoid  after  trephining.  All  that  is  now  needed  is  to 
take  a  series  of  these  virulent  cords,  and  dry  them  by  hanging  in  a  glass  bell- 
jar  with  some  caustic  potash  at  the  bottom  for  variable  periods,  the  virus 
being  thus  weakened  in  its  intensity,  until  at  the  end  of  fourteen  days  it  is 
completely  destroyed.  Individuals  are  inoculated  with  portions  of  such  cords, 
pounded  up  in  sterilized  broth,  beginning  with  the  weakest,  and  gradually 
increasing  the  strength  of  the  injection,  until  a  preparation  of  a  cord  which  has 
merely  hung  one  day  is  used.  This  method  of  treatment  was  introduced  in 
1885,  and  the  results  hitherto  obtained  have  been  such  as  to  indicate  that  we 
have  here  a  most  potent  preventive  agent  against  hydrophobia,  granted  that 
the  disease  has  not  been  allowed  too  long  a  start.  When  the  disease  has 
attacked  an  individual,  only  palliative  treatment  can  be  adopted.  Every 
source  of  irritation  and  disturbance  must  be  removed,  and  the  patient  kept 
absolutely  quiet.  With  a  view  to  diminish  the  spasms,  chloral  may  be 
administered  internally,  or  chloroform  inhaled,  or  cocaine  sprayed  on  the 
fauces.  All  the  nourishment  that  the  patient  can  possibly  take  should  be 
administered,  with  the  addition  of  stimulants. 

Anthrax. 

This  disease  results  from  infection  with  the  Bacillus  anthracis,  which  produces 
in  sheep  and  cattle  the  so-called  'splenic  fever.'  In  man,  if  the  microbe  is 
inoculated  through  the  skin,  it  produces  a  form  of  carbuncle  known  as  a 
'  malignant  pustule,'  although  occasionally  a  more  diffuse  condition  termed 
'  anthrax  oedema  '  arises  from  local  infection  ;  whilst  if  the  virus  is  absorbed  by 
the  lungs  or  intestinal  canal,  it  originates  a  general  inflammatory  disorder, 
known  as  '  woolsorters'  disease,'  or  anthracsemia 

The   Bacillus   anthracis  (Fig.   13)   is   one   of   the   largest  of  the  pathogenic 


H4 


A   MANUAL  OF  SURGERY 


organisms,  measuring  5  t0  20  /<  in  length,  and  1  to  150^  in  breadth.  It  is 
found  in  the  blood  of  diseased  animals  in  the  form  of  rods  or  threads,  composed 
of  a  variable  number  of  individual  elements  (from  two  to  ten).  It  is  aerobic, 
immobile,  grows  best  at  about  blood-heat,  and  liquefies  gelatine.  Well-marked 
spores  are  formed  within  the  bacillus  when  cultivated  artificially  and  in  the 
presence  of  oxygen ;  but  spore  formation  has  not  been  observed  in  the  living 
tissues.  The  bacilli  are  readily  killed  by  boiling  for  a  few  seconds,  whilst  the 
decomposition  of  the  carcase  in  which  they  are  present  causes  their  death  in 
about  a  week.  The  spores,  however,  are  very  resistant ;  for  whilst  a  1  per 
cent,  solution  of  carbolic  acid  kills  the  bacilli  in  two  minutes,  the  spores  remain 
alive  after  a  week's  immersion.  Moreover,  alcohol  and  even  a  5  per  cent, 
solution  of  carbolic  acid  have  no  effect  on  them.  If  a  mouse  is  inoculated,  say, 
at  the  root  of  the  tail  with  a  needle  the  point  of  which  has  been  dipped  in  the 
blood  of  an  animal  which  died  of  splenic  fever,  it  succumbs  in  less  than 
twenty-four  hours,  and  bacilli  are  found  in  nearly  every  organ  of  the  body 

Some  animals  are  immune  against  the  attacks  of  anthrax,  especially  the  dog 
and  rat ;  and  one  of  Pasteur's  most  useful  discoveries  was  that  of  artificially 
providing  immunity  for  cattle  and  sheep  by  inoculating  them  with  an  at- 


FlG 


13. — Bacillus  Anthracis,  from 
Splenic  Pulp  of  Infected 
Animal,  x  1,200.  (Crookshank's 
'  Textbook  of  Bacteriology.') 


Fig.  14. — l;acillus  Anthracis  in 
the  Substance  of  the  Kidney, 
to  show  how  the  Tissues 
become  Infiltrated  by  it. 
x  600.  (Crookshank's  '  Text- 
book of  Bacteriology.'} 


tenuated  virus,  obtained  by  exposing  a  cultivation  for  some  time  to  a  high 
temperature. 

Symptoms. — Infection  with  this  organism  usually  occurs  an;ongst  graziers 
who  tend  the  living  animal,  or  butchers  who  deal  with  the  carcase  ;  it  is  also 
met  with  amongst  workers  in  hides  or  wool. 

Malignant  Pustule  commences  as  an  angry  red  pimple  at  the  site  of  inocula- 
tion, which  rapidly  spreads,  with  much  infiltration  of  the  base,  whilst  the 
centre  becomes  covered  with  vesicles,  the  serum  within  which  contains  the 
typical  bacilli.  _  This  stage  is  associated  with  no  pain,  but  only  with  great 
itching  and  irritation.  As  the  pustule  extends,  the  central  part  becomes  grey, 
and  finally  black,  constituting  an  eschar  or  slough,  whilst  around  it  upon  an 
area  of  deep  brawny  congestion  and  oedema  is  a  narrow  ring  of  vesicles.  The 
process  gradually  becomes  more  marked  locally,  whilst  the  lymphatic  glands 
and  vessels  are  also  enlarged  and  involved  in  the  disease.  Generally,  there  is 
a  certain  amount  of  fever  and  malaise,  which  does  not  become  pronounced 
until  about  the  fourth  or  fifth  day.  The  temperature  then  rises  to  1020  or 
1030  F.,  the  pulse  becomes  rapid  and  irregular,  and  gastric  irritability,  vomit- 
ing, flatulence,  more  marked.     Should  the  disease  progress  unchecked,  the 


INFECTIVE  DISEASES  n5 

respirations  become  shallow  and  embarrassed,  whilst  signs  of  grave  con- 
stitutional mischief,  such  as  delirium  or  coma,  manifest  themselves,  and  the 
unfortunate  individual  rapidly  succumbs,  generally  in  less  than  a  week  from 
the  onset,  but  sometimes  in  thirty  to  forty  hours.  More  commonly  the  case 
runs  a  more  favourable  course,  limiting  itself  to  the  local  manifestations, 
which  gradually  clear  up,  the  slough  separating  and  the  oedema  disappearing. 
Of  course,  should  there  be  more  than  one  focus  of  mischief,  the  prognosis  is 
much  worse. 

Anthrax  oedema  runs  a  rapidly  fatal  course  ;  it  is  usually  seen  about  the  face 
and  eyelids,  the  skin  becoming  red  and  brawny,  as  in  erysipelas,  and  after  a 
time  covered  with  vesicles,  whilst  finally  gangrenous  patches  appear.  The 
lymphatic  trunks  and  glands  are  also  involved. 

Woolsorters'  Disease  (or  anthracaemia)  is  the  term  applied  to  the  general 
condition  resulting  from  the  development  of  these  bacilli  in  the  body  without 
any  external  lesion.  The  virus  gains  access  to  the  system  either  by  swallowing 
or  inhaling  the  dried  spores.  If  they  enter  the  respiratory  tract,  the  patient 
complains  of  fever  and  malaise  for  a  few  days,  followed  by  the  development  of 
a  sero-fibrinous  pleuro-pneumonia,  the  exudation  containing  large  numbers  of 
bacilli.  This  runs  a  rapid  course,  with  high  fever,  great  dyspnoea,  impairment 
of  the  circulation,  and  finally  collapse  in  the  great  majority  of  the  cases.  If  the 
bacilli  enter  the  stomach,  they  are  usually  destroyed  by  the  acid  chyme  ;  but 
should  any  of  them  or  their  spores  reach  the  intestine,  the  alkaline  contents 
form  a  suitable  breeding-ground,  and  the  walls  of  the  gut  are  soon  attacked 
and  the  disease  becomes  general.  Colic,  ciamps,  vomiting,  and  blood-stained 
diarrhoea  are  the  most  marked  features  in  such  a  case.  The  intestinal  type 
appears  to  be  not  quite  so  virulent  and  fatal  as  the  pulmonary,  but  is  decidedly 
worse  than  the  cutaneous. 

Treatment. — In  the  cutaneous  affection,  excision  of  the  necrotic  patch,  and 
of  all  the  infiltrated  tissues  around,  and  the  application  of  the  actual  cautery 
or  of  pure  carbolic  acid,  are  usually  recommended,  though  some  who  have 
had  experience  of  the  affection  think  such  treatment  of  little  value.  Large 
doses  of  quinine  may  be  given,  but  for  the  general  disease  merely  symptomatic 
treatment  can  be  adopted.  De-emetised  ipecacuanha  has  been  much  recom- 
mended, both  as  a  local  application  after  excision,  and  also  internally  in  wool-  /. 
sorters'  disease. 

Gonorrhoea. 

Gonorrhoea  is  an  infective  process  due  to  the  action  of  a  specific 
micro-organism,  the  Gonococcus  (Plate  I.,  Fig.  6),  and  charac- 
terized by  a  discharge  of  pus  from  the  urethra.  The  organism 
was  first  isolated  by  Neisser  in  1879,  and  is  found  with  or  without 
other  pyogenic  cocci  in  the  discharge,  most  commonly  in  the 
epithelial  cells  or  pus  corpuscles,  but  sometimes  apart  from  them. 
They  are  readily  demonstrated  by  staining  a  film  of  pus,  dried  on 
a  cover-slip,  with  methylene  blue  or  gentian  violet,  and  are  almost 
always  found  in  the  diplococcus  condition,  i.e.,  they  occur  in  pairs, 
held  together  possibly  by  some  slight  capsule;  but  often  a  con- 
siderable number,  even  up  to  twenty,  are  massed  in  a  clump. 
The  gonococcus  is  not  easily  cultivated,  except  in  acid  media  ; 
the  addition  of  an  alkali  checks  the  growth  and  renders  the 
organisms  less  virulent.  The  disease  has  been  transmitted  both 
to  animals  and  to  the  human  subject  by  inoculation  experiments 
with  a  pure  and  active  culture.  The  organisms  find  their  way 
into  the  male  urethra,  and  invade  the  epithelial  cells  of  the  mucous 
membrane,  within  which  they  may  often  be  seen  ;  they  determine 

8—2 


n6  A  MANUAL  OF  SURGERY 

an  acute  catarrhal  inflammation,  which  quickly  runs  on  to  sup- 
puration. One  great  characteristic  of  gonorrhoea  consists  in  the 
readiness  with  which  it  extends  from  one  part  to  another,  and  the 
ease  with  which  even  a  healthy  urethral  or  vulval  mucous  mem- 
brane becomes  affected  by  it,  simple  contact  sufficing  to  determine 
an  attack.  Hence,  although  the  symptoms  are  often  very  slight 
and  insignificant,  severe  complications  may  arise,  which  may  per- 
manently cripple  the  individual,  or  even  destroy  life,  especially  if 
other  pyogenic  organisms  are  present. 

The  Symptoms  of  Acute  Gonorrhoea  usually  commence  within 
a  few  days  of  the  infection,  varying  from  two  to  eight.  Most 
commonly  the  discharge  appears  about  the  third  or  fourth  day, 
being  preceded  by  itching  of  the  meatus  and  a  scalding  pain  on 
passing  urine.  The  lips  of  the  meatus  are  congested  and  swollen, 
and  the  discharge,  which  is  at  first  thin  and  mucoid,  soon  becomes 
thick,  abundant,  and  yellow  in  colour.  This  stage  lasts  for  a 
variable  time,  and  is  sometimes  associated  with  a  good  deal  of 
dragging  pain  in  the  back  and  loins,  together  with  some  constitu- 
tional disturbance  and  fever.  The  bowels  are  usually  constipated, 
and  the  appetite  impaired.  Occasionally  the  swelling  and  conges- 
tion of  the  mucous  membrane  are  so  great  as  to  lead  to  retention 
of  urine  or  haemorrhage  from  the  urethra.  The  first  attack  is 
always  more  serious  than  subsequent  ones,  although  it  is  more 
amenable  to  proper  treatment.  Gouty  and  rheumatic  people  are 
especially  difficult  to  treat,  and  often  suffer  from  relapses  after  the 
discharge  has  apparently  ceased,  and  it  is  said  that  fair  people 
suffer  more  than  those  who  are  dark. 

If  suitable  treatment  is  adopted,  the  discharge  entirely  ceases 
at  the  end  of  two  or  three  weeks  ;  but  if  neglected,  or  sometimes 
in  spite  of  treatment,  the  inflammation  spreads  backwards,  giving 
rise  to  what  is  sometimes  termed  a  Posterior  Urethritis,  since  it 
involves  that  portion  of  the  canal  which  lies  behind  the  deep 
constrictor.  It  usually  becomes  evident  about  the  end  of  the 
second  week,  and  is  characterized  by  frequent  and  painful  mic- 
turition, a  sense  of  pain  and  heaviness  in  the  perineum,  possibly  a 
little  blood  in  the  urine,  and  a  general  feeling  of  depression.  This 
extension  backwards  is  always  serious,  since  it  is  likely  to  precede 
complications  involving  the  prostate,  testis,  or  seminal  vesicles, 
whilst  it  is  an  extremely  common  cause  of  Chronic  Gonorrhoea  or 
Gleet.  A  more  or  less  abundant  discharge  continues  for  some 
time  without  any  other  troublesome  symptom  than  occasional 
scalding  on  passing  urine.  The  discharge  varies  in  consistency, 
but  is  often  thin  and  muco-purulent,  whilst  sometimes,  if  due  to 
chronic  prostatitis,  it  may  be  so  clear  and  transparent  that  it 
resembles  uncooked  white  of  egg.  The  causes  of  gleet  vary  in 
different  cases;  it  is  sometimes  due  to  an  ulcerated  or  granular  con- 
dition of  the  mucous  membrane,  the  discharge  then  being  yellow, 
whilst  in  others  it  arises  from  chronic  prostatitis,  a  condition  not 


INFECTIVE  DISEASES 


117 


uncommonly  associated  with  chronic  enlargement  of  the  vesiculae 
seminales.  The  latter  condition  may  be  recognised  on  rectal 
examination,  whilst,  when  the  prostrate  is  involved,  flocculi  of 
mucus  in  the  shape  of  worm-like  threads  may  be  detected  in  the 
urine.  A  patch  of  granular  urethritis  should  be  suspected  when 
one  portion  of  the  urethra  is  especially  tender  on  the  passage  of  a 
sound,  but  its  presence  can  only  be  recognised  with  certainty  by 
the  use  of  the  urethroscope. 

Every  purulent  discharge  is  not  necessarily  gonorrhceal,  since 
a  simple  urethritis  may  follow  connection  with  a  woman  who  is 
simply  suffering  from  leucorrhcea,  or  has  scarcely  recovered  from 
her  menstrual  period,  but  with  no  suspicion  of  a  venereal  taint. 
In  these  cases  infection  may  be  due  to  ordinary  pyogenic  cocci,  or 
possibly  to  the  Bac.  coli  communis,  which  is  known  to  be  not  an 
unfrequent  cause  of  vulvo-vaginitis.  A  diagnosis  of  simple 
urethritis  may  be  suggested  by  the  history,  but  only  a  micro- 
scopical examination  of  the  pus,  and  a  demonstration  of  the 
absence  of  gonococci,  can  establish  it  with  certainty.  At  the 
same  time  it  must  be  remembered  that  gonococci  are  capable  of 
remaining  in  a  latent  or  passive  state  for  a  very  long  time  in  the 
folds  or  crypts  of  a  mucous  membrane,  and  hence  it  is  quite 
possible  for  a  person  who  has  once  suffered  from  it  to  be  capable 
of  transmitting  the  disease,  although  there  may  be  no  evidence  of 
its  existence  at  the  time. 

In  the  Treatment  of  the  early  stages  of  acute  gonorrhoea  it  is 
essential  to  keep  the  urine  free  from  acidity  by  the  use  of  alkalies, 
to  maintain  a  free  action  of  the  bowels,  and  to  allay  the  irritability 
of  the  parts  by  sedatives,  such  as  tincture  of  henbane.  The  diet 
should  be  light  and  unstimulating,  and  all  alcoholic  drinks  pro- 
hibited, as  also  strong  tea  and  coffee,  whilst  the  patient  should  be 
recommended  to  take  plenty  of  bland  fluids,  such  as  barley  water, 
or  milk  and  soda-water.  The  scrotum  should  be  supported  in  a 
suspender,  and  the  patient  advised  against  taking  severe  or  pro- 
longed exercise.  No  local  treatment  is  necessary,  although  the 
use  of  hot  hip-baths  may  relieve  the  pain  and  irritation  ;  indeed, 
at  this  period  injections  are  harmful.  The  same  treatment  must 
be  adopted  as  long  as  the  discharge  is  copious,  and  the  scalding 
continues.  As  soon  as  these  symptoms  moderate,  oleo-balsams  in 
the  shape  of  oil  of  sandal- wood  (10  minims,  in  capsules,  three  to 
six  times  a  day),  copaiba  (10  minims,  in  capsules  or  mixture,  thrice 
daily),  or  cubebs  (^  to  1  drachm  doses,  wrapped  in  wafer-paper), 
may  be  advantageously  employed.  Both  cubebs  and  copaiba, 
especially  the  latter,  are  capable  of  producing  a  bright-red  erythe- 
matous rash  which  causes  much  irritation,  and  may  be  extensively 
diffused  over  the  body. 

The  value  of  injections  in  the  treatment  of  the  disease  has 
been  much  discussed,  and  is  a  point  on  which  difference  of 
opinion  exists.     Qn  the  whole,  we  are  inclined  fo  think  that  many 


US  A   MANUAL  OF  SURGERY 

of  the  less  severe  cases  of  acute  gonorrhoea  can  be  successfully 
treated  without  them,  and  that  they  should  never  be  employed  when 
any  local  irritation  or  scalding  is  present ;  but  where  the  discharge 
tends  to  persist,  or  the  urethra  has  been  thickened  by  previous 
attacks,  and  especially  in  gleet,  their  use  is  imperative.  To 
employ  them  with  advantage,  the  following  plan  should  be 
adopted : — The  urethra  is  first  washed  out,  so  as  to  remove  any 
discharge  from  it ;  for  this  purpose  the  normal  act  of  micturition 
answers  admirably,  so  that  the  injection  should  be  used  immedi- 
ately after  passing  water.  The  rounded  nozzle  of  a  small  glass 
syringe,  containing  about  half  an  ounce,  is  inserted  into  the  meatus, 
the  lips  of  which  are  compressed  over  it.  The  fluid  is  thrown 
into  the  urethra,  and  held  there  for  about  twenty  seconds  by  com- 
pressing the  orifice  with  the  finger  and  thumb,  as  the  syringe  is 
withdrawn  ;  then,  on  relaxing  the  pressure,  the  fluid  escapes. 
Other  forms  of  syringe,  on  the  principle  of  the  indiarubber  bottle, 
etc.,  are  recommended,  but  the  glass  is  unquestionably  the 
cleanest.  Of  the  many  different  injections  employed,  perhaps  the 
best  consists  of  a  mixture  of  tincture  of  catechu  (10  minims  to 
i  ounce  of  water)  and  sulphate  of  zinc  (2  grains  to  1  ounce),  or  of 
permanganate  of  zinc  (\  grain  to  1  ounce),  or  nitrate  of  silver 
(\  grain  to  1  ounce).  The  great  secret  consists  in  using  the  injec- 
tion four  or  five  times  a  day  at  first,  and  afterwards  night  and 
morning,  even  after  all  visible  signs  of  the  discharge  have  ceased. 
The  fluid  should  always  be  warmed  prior  to  use,  and  care  taken 
not  to  use  too  strong  a  solution. 

One  is  bound  to  admit,  however,  that  many  genito-urinary 
surgeons  hold  views  very  different  to  these,  and,  indeed,  main- 
tain that  gonorrhoea  can  be  aborted,  or,  at  any  rate,  rapidly 
brought  under  control  at  any  stage  by  large  injections  of  a 
weak  solution  of  permanganate  of  potash,  introduced  with  suffi- 
cient force  to  distend  the  urethra  in  all  its  parts  and  enter  the 
bladder  ;  all  the  crypts  and  lacunae  are  thus  reached  by  the  anti- 
septic. 

The  Treatment  of  Gleet  is  always  a  matter  of  difficulty.  The 
general  habits  of  the  patient  must  be  attended  to,  as  in  the  acute 
stage,  whilst  the  bowels  must  be  opened,  and  absolute  sexual 
continence  enjoined  to  prevent  the  spread  of  the  infection.  Large 
doses  of  the  liq.  ferri  perchlor.,  combined  with  a  sufficient  amount 
of  Epsom  salts  to  prevent  constipation,  may  be  given.  Local 
treatment  is  generally  necessary  in  the  shape  of  injections  as 
already  described,  and  the  passage  of  a  cold  solid  metal  bougie 
every  three  or  four  days  has  an  excellent  effect.  Methodical  dila- 
tation of  the  urethra  is  also  advised,  with  the  object  of  compressing 
all  the  crypts  and  lacunas,  and  removing  pent-up  secretion.  If 
granular  urethritis  is  present,  the  topical  application  of  nitrate  of 
silver  may  be  undertaken  through  a  urethroscope,  but  requires  the 
greatest  care,  for  fear  of  the  subsequent  formation  of  a  stricture  ; 


INFECTIVE  DISEASES  Ug 


chronic  prostatitis  and  vesiculitis  are  dealt  with  by  counter-irrita- 
tion applied  to  the  perineum,  or  possibly  by  sedatives,  such  as 
belladonna,  administered  in  the  form  of  suppositories. 

Complications  of  Gonorrhoea.  —  These  may  be  conveniently 
arranged  under  the  following  headings : 

I.  Complications  due  to  Direct  Extension. — In  the  male,  the 
following  may  be  described  : 

Balanitis  is  of  frequent  occurrence  in  patients  with  long  fore- 
skins. It  is  ordinarily  due  to  pyogenic  organisms,  and  not  to 
gonococci.  As  a  secondary  result,  inflammation  of  the  lymphatics 
of  the  penis  and  inguinal  bubo  may  follow. 

Lacunar  Abscess  arises  from  infection  of  one  or  more  of  the 
lacuna?  with  the  gonococcus  or  accompanying  pyogenic  organisms. 
A  tense  painful  swelling  forms  along  the  floor  of  the  urethra, 
which  may  project  into  the  passage  and  discharge  either  into  the 
urethra,  or  externally,  or  both  ;  in  the  latter  case  a  penile  fistula 
will  result.  The  abscess  should  be  opened  as  early  as  possible 
from  without,  so  as  to  prevent  the  latter  occurrence,  which  is 
often  very  difficult  to  treat.  If  a  fistula  forms  within  a  quarter  of 
an  inch  or  so  of  the  meatus — a  common  situation — it  seldom  heals 
of  itself,  but  may  in  some  cases  be  closed  by  an  application  of  the 
electric  cautery  or  a  weak  solution  of  nitrate  of  silver.  If,  how- 
ever, it  remains  intractable,  the  fistula  should  be  laid  open  into 
the  meatus.  When  it  occurs  in  the  body  of  the  penis,  a  plastic 
operation  is  usually  required  ;  it  consists  in  paring  the  edges  and 
dissecting  up  the  skin  on  either  side  so  as  to  bring  it  together  in 
the  median  line. 

Chordee  results  from  inflammatory  infiltration  of  the  corpus 
spongiosum  or  one  of  the  corpora  cavernosa,  so  that  when  the 
penis  becomes  erect,  it  is  bent  downwards  or  to  one  side,  owing 
to  incomplete  distension  of  the  infiltrated  tissue.  This  condition 
is  exceedingly  painful,  and  most  marked  at  night  when  the  patient 
becomes  warm  in  bed.  It  is  best  dealt  with  by  applying  cold  to 
the  part,  and  by  administering  bromide  of  potassium  or  opium  at 
bedtime. 

Inflammation  of  Cowper's  Glands  may  in  some  cases  give  rise  to 
deep  suppuration  in  the  perineum,  with  symptoms  very  similar  to 
those  of  acute  prostatitis.  It  is  dealt  with  in  the  same  way  as  the 
latter  complaint. 

Acute  and  Chronic  Prostatitis  (Chapter  XXXVII.). 

Acute  and  Chronic  Vesiculitis  (Chapter  XXXIX.). 

Epididymitis  arises  by  distension  along  the  vas,  and  will  be  fully 
described  at  Chapter  XXXIX.  It  rarely  commences  before  the 
third  week,  and  often  not  until  the  fifth  or  sixth,  being  perhaps 
caused  by  the  injudicious  use  of  injections,  or  by  a  blow  or 
squeeze,  especially  if  the  scrotum  is  lax  and  pendulous. 

Acute  Cystitis  (Chapter  XXXVII.). 

In  the  female  many  complications  arise  by  direct  extension  of 


A  MANUAL  OF  SURGERY 


the  gonorrhoeal  inflammation  along  the  urinary  and  genital  tracts. 
The  primary  affection  is  most  commonly  a  vulvovaginitis,  and  this 
may  spread  to  the  lining  membrane  of  the  uterus,  or  even  to  that 
of  the  Fallopian  tubes  (salpingitis),  whilst  ovaritis  and  pelvic 
peritonitis  also  occur. 

II.  Complications  arising  from  Direct  Transmission  of  the  Virus. 
—  Gonorrhoeal  Proctitis  sometimes  results  in  the  female  from  infec- 
tion by  the  discharge  which  escapes  from  the  vulva,  whilst  in  both 
sexes  it  may  be  due  to  unnatural  practices.  Considerable  tenesmus 
is  produced,  accompanied  by  a  thick  muco-purulent  discharge. 
It  is  treated  by  injecting  lotions  of  acetate  of  lead  and  opium,  or 
of  boric  acid. 

Gonorrhoeal  Rhinitis  has  also  been  seen  in  a  few  cases.  It  leads 
to  an  abundant  discharge  of  pus,  and  should  be  treated  by  warm, 
soothing  injections,  followed  after  a  time  by  dilute  astringents. 

Gonorrhoeal  Conjunctivitis  occurs  either  in  adults,  when  it  is 
unilateral  to  start  with,  or  in  infants  when  it  is  bilateral,  and 
due  to  infection  during  transit  through  the  maternal  passages 
(ophthalmia  neonatorum).  It  is  a  remarkable  fact  that,  although 
gonorrhoea  is  so  very  prevalent,  such  a  small  proportion  of  the 
patients  suffer  from  conjunctival  infection  ;  it  would  appear,  there- 
fore, that  not  only  must  there  be  direct  contact  with  the  gonorrhoeal 
poison,  but  in  addition  the  mucous  membrane  must  be  in  a  recep- 
tive condition.  In  the  adult  variety  it  is  ushered  in  by  redness  and 
irritability  of  the  eye,  followed  quickly  by  a  discharge  which  is  at 
first  mucous,  but  soon  becomes  purulent.  The  eyelids  are  red 
and  swollen,  the  conjunctiva  is  thickened  and  spongy  (chemosis), 
and  the  discharge  liable  to  accumulate  within  the  conjunctival 
sac.  If  allowed  to  progress  unchecked,  the  cornea  may  be  injured 
by  the  inflammatory  process,  ulceration,  or  even  necrosis,  ensuing, 
and  possibly  general  panophthalmitis.  The  first  detail  in  the 
Treatment  consists  in  protecting  the  opposite  eye  by  means  of 
what  is  known  as  Buller's  shield ;  a  watch-glass  is  fixed  in  a 
piece  of  mackintosh  over  the  eye,  and  kept  in  position  by  plaster. 
The  affected  conjunctiva  must  be  unremittingly  attended  to  night 
and  day,  so  as  to  prevent  accumulation  of  discharge ;  it  is  fre- 
quently irrigated  with  warm  boric  acid  lotion,  and  every  four 
hours  the  membrane  is  carefully  washed,  dried,  and  swabbed  over 
with  a  solution  of  nitrate  of  silver  (5  grains  to  1  ounce).  Between 
the  applications  lint  wrung  out  of  iced  boric  acid  lotion  is  kept 
over  the  eye.  This  plan  of  treatment  is  continued  until  the  sup- 
puration ceases,  and  then  the  silver  salt  is  omitted,  and  simple 
astringents,  such  as  chloride  or  sulphate  of  zinc,  substituted. 

In  infants  the  disease  often  runs  a  rapid  and  severe  course,  and 
is  very  likely  to  lead  to  ulceration  or  sloughing  of  the  cornea,  a 
complication  not  uncommonly  followed  by  escape  of  the  lens 
and  blindness.  Crede's  preventive  treatment  should  always  be 
adopted  for  new-born  children,  viz.,  washing  out  the  conjunctival 


INFECTIVE  DISEASES 


sac  with  a  weak  solution  of  nitrate  of  silver  or  corrosive  subli- 
mate soon  after  birth.  When  suppuration  occurs,  the  treat- 
ment to  be  adopted  is  practically  identical  with  that  detailed 
above,  except  that  it  is  useless  to  attempt  to  limit  the  trouble 
to  one  eye. 

III.  Complications  resulting  from  General  Absorption. — Gonor- 
rhoea!. Sclerotitis,  or  inflammation  of  the  deep  subconjunctival 
fibrous  tissue,  is  a  rare  affection,  arising  quite  independently  of 
the  disease  just  described.  It  is  characterized  by  marked  sub- 
conjunctival redness,  the  globe  of  the  eye  becoming  distinctly 
tender.  Local  applications  of  atropine  are  required,  and,  if  need 
be,  leeches  to  the  temples. 

Gonorrheal  Affections  of  Joints  are  not  uncommon  sequelae, 
arising  usually  in  the  subacute  stage  of  the  disease.  They  occur 
either  in  the  form  of  a  synovitis  with  effusion,  or  as  an  arthritis, 
which  may  or  may  not  suppurate,  but  usually  ends  in  ankylosis. 
The  former  is  probably  due  to  the  embolic  transmission  of  gono- 
cocci  alone,  whilst  in  the  latter  pyogenic  organisms  are  also  con- 
veyed to  the  articulation.  For  symptoms  and  treatment,  see 
Chapter  XX. 

Any  muscular,  tendinous,  ligamentous,  or  aponeurotic  tissues 
may  become  inflamed  and  painful  during  the  course  of  an  attack 
of  gonorrhoea.  Special  mention  must  be  made  of  the  involvement 
of  the  ligaments  supporting  the  arch  of  the  foot,  since,  if  the 
cause  is  not  recognised  and  the  patient  is  still  allowed  to  walk, 
the  arch  of  the  foot  may  be  lost,  and  a  permanent  flat  foot 
result. 

Secondary  abscesses,  similar  to  those  of  pyaemia,  are  sometimes 
developed  in  cases  of  gonorrhoea,  probably  resulting  from  the 
diffusion  of  pyogenic  organisms,  and  even  general  infection  of  a 
septicaemic  nature  has  been  described,  leading  to  a  fatal  issue. 

YVe  now  come  to  a  group  of  diseases  which  have  been  classified 
by  Virchow  under  the  term  Infective  Granulomata.  They  are  all 
characterized  by  the  formation  of  growths  more  or  less  resembling 
granulation  tissue,  which  either  persist  or  undergo  various  de- 
generative changes.  They  are  all  infective  in  nature,  and  most 
of  them  chronic  in  their  progress,  although  acute  manifestations 
are  occasionally  met  with.  Five  conditions  are  included  under 
this  heading,  viz. :  Syphilis,  Tuberculosis,  Glanders,  Leprosy, 
and  Actinomycosis. 

Syphilis. 

Syphilis  is  an  infective  disease,  resulting  from  inoculation 
with  some  specific  virus,  which  has  not  yet  been  identified  with 
certainty.  Ltistgarten  demonstrated  an  organism  in  the  initial 
lesion  which  was  supposed  to  be  the  bacillus  of  syphilis,  but  it 


A  MANUAL  OF  SURGERY 


was  probably  nothing  more  than  the  bacillus  always  present  in 
smegma.  The  inability  to  transmit  the  disease  to  animals  is  one 
of  the  great  difficulties  in  the  way  of  a  complete  bacteriological 
examination. 

Syphilis  is  characterized  by  the  appearance  of  a  primary  sore, 
usually  known  as  a  hard  chancre,  which  is  followed  in  the  course 
of  a  few  weeks  by  evidences  of  general  infection,  referred  mainly 
to  the  skin  and  mucous  membranes,  comprising  the  secondary 
stage.  After  a  variable  time,  known  as  the  intermediate  period, 
during  which  symptoms  may  be  absent,  tertiary  manifestations 
may  show  themselves  in  any  and  every  part  of  the  body. 

Mode  of  Infection. — Acquired  syphilis  is  almost  always  due  to 
infection  of  the  genital  organs  arising  from  impure  connection. 
Occasionally  cases  are  met  with  in  which  the  disease  is  transmitted 
by  other  means  (syphilis  insontium),  and  then  the  primary  lesion 
is  often  located  on  some  other  part  of  the  body  (extragenital 
chancres) ;  thus,  a  hard  chancre  may  be  found  on  the  lips,  as  a 
result  of  drinking  out  of  the  same  glass  or  smoking  the  same  pipe 
as  a  syphilitic  patient,  or  may  even  be  acquired  by  kissing.  The 
disease  is  not  always  equally  infectious ;  in  the  primary  stage  the 
discharge  derived  from  the  chancre  will  alone  convey  the  con- 
tagion ;  in  the  secondary  period  the  virus  is  found  in  the  blood 
of  the  individual,  and  hence  all  pathological  exudations,  as  also 
the  blood  itself,  may  transmit  the  disease.  Pure  secretions, 
e.g.,  milk  or  urine,  are  free  from  infection,  although  if  mixed  with 
a  serous  exudation  from  abraded  surfaces,  as  so  frequently  occurs 
in  the  case  of  the  saliva,  they  at  once  become  infective.  The 
semen  is  probably  an  exception  to  the  above  rule,  since,  although 
the  maternal  passages  may  entirely  escape,  the  ovum  becomes 
diseased.  It  is  usually  held  that  in  the  tertiary  stage  the  patient 
is  no  longer  capable  of  transmitting  the  affection. 

The  syphilitic  virus  is  exceedingly  resistant  to  the  action  of 
antiseptics,  and  hence  the  risk  of  infection  is  very  great,  even 
though  prompt  measures  are  taken  to  destroy  it.  Thus,  many 
cases  are  on  record  in  which  an  abraded  surface  was  brought  into 
contact  with  a  syphilitic  poison,  and,  although  cauterized  with 
fuming  nitric  acid  within  a  few  hours,  the  disease  ran  its  ordinary 
course.  In  one  case,  however,  under  our  observation,  in  which 
a  student's  finger  was  accidentally  pricked  with  a  bent  broad 
needle,  which  a  moment  before  had  been  inserted  into  the  anterior 
chamber  of  a  syphilitic  patient  suffering  from  a  secondary  sup- 
purative iritis,  nitric  acid  was  applied  within  a  quarter  of  an  hour, 
and  although  a  suspicious  indurated  spot  formed  six  weeks  later 
at  the  site  of  injury,  no  other  evidences  of  syphilis  have  been 
observed,  in  spite  of  the  fact  that  the  individual  had  not  previously 
suffered  from  the  disease,  and  took  no  mercury. 

One  attack  of  syphilis  usually  confers  immunity  on  the  patient 
from  further  outbreaks  of  the  disease,  even  if  exposed  to  infection. 


INFECTIVE  DISEASES 


This  protection  is,  however,  not  always  permanent,  since  well- 
authenticated  cases  have  been  observed  of  second  attacks  of 
syphilis,  in  which  the  primary  lesion  was  followed  by  distinct 
signs  of  general  infection. 

Course  of  the  Case. — The  stage  of  Incubation  lasts  for  a  variable 
period,  extending  from  two  to  six  weeks  ;  as  a  rule,  however, 
evidences  of  induration  of  the  sore  can  be  detected  about  the 
third  week.  It  is  probable  that  long  ere  this  the  virus  has 
entered  the  circulation,  and  hence  removal  or  destruction  of  the 
local  lesion  has  not  the  slightest  influence  upon  the  progress  of 
the  case,  unless  it  can  be  undertaken  immediately  after  infection. 
During  this  period  nothing  unusual  is  noted  at  the  site  of  inocula- 
tion, if  the  infection  is  purely  syphilitic,  and  the  local  sore  merely 
a  slight  abrasion  ;  it  may  even  heal  completely  in  the  course  of 
a  few  days,  and  nothing  further  is  noticed  until  the  typical  in- 
duration manifests  itself.  Not  unfrequently,  however,  pyogenic 
infection  occurs  or  a  soft  chancre  is  also  present ;  in  the  latter 
case  the  lesion  does  not  heal  in  a  typical  manner,  and  the  base  of 
the  ulcerated  surface  becomes  indurated  after  a  time. 

I.  The  Primary  Stage  of  syphilis  is  characterized  by  the  develop- 
ment of  a  typical  primary  sore,  associated  with  enlargement  of 
the  neighbouring  lymphatic  glands.  It  is  usually  situated  on  the 
base  of  the  prepuce,  close  to  the  corona  glandis,  or  on  the  fraenum ; 
in  the  female  the  inner  aspects  of  the  labia  majorae  or  nymphae 
are  the  most  common  sites. 

The  primary  sore  does  not  invariably  present  the  same 
appearance,  although  it  is  always  characterized  by  a  certain 
amount  of  infiltration  and  induration.  Should  the  superficial 
abrasion  have  healed,  a  localized  growth  of  almost  cartilaginous 
hardness  forms  in  the  cicatrix,  closely  adherent  to  and  invading 
the  cutis  ;  but  if  a  soft  sore  has  first  developed,  the  surface 
remains  ulcerated  more  or  less  deeply,  though  the  base  becomes 
indurated.  The  following  are  the  chief  forms  in  which  the 
chancre  manifests  itself,  (a)  The  desquamating  papule  is  a  slightly 
elevated  spot,  which  is  extremely  irritable,  of  a  dusky  colour, 
and  free  from  ulceration.  It  is  usually  small,  but  hard,  and  its 
surface  covered  with  epithelial  scales.  If  exposed  to  friction,  or 
to  the  irritation  of  retained  discharges,  ulceration  is  very  likely  to 
take  place,  and  an  ordinary  Hunterian  chancre  will  then  form. 
Unless  this  occurs,  it  may  run  its  course  unobserved,  and  thus  a 
patient  becomes  syphilitic  without  being  able  to  trace  the  time  or 
source  of  infection,  (b)  The  indurated,  hard,  or  Hunterian  chancre 
is  that  most  commonly  seen  ;  it  results  from  the  irritation  of  a 
papule,  or  is  developed  in  association  with  a  soft  sore.  It  consists 
of  a  distinctly  localized  infiltration  and  induration  of  the  sub- 
mucous or  subcutaneous  tissues,  giving  rise  to  a  lump  which  feels 
like  a  pellet  of  cartilage  ;  or  the  induration  may  be  more  exten- 
sively  diffused   through   the   surrounding  structures.      In    some 


124 


A  MANUAL  OF  SURGERY 


cases  there  may  be  but  little  elevation  of  the  growth,  and  the  sur- 
face is  free  from  ulceration,  constituting  the  variety  known  as  the 
'  parchment  induration '  of  Ricord,  and  not  unfrequently  seen  on 
the  glans  penis.  Where,  however,  the  prepuce  or  body  of  the  penis 
is  involved,  greater  induration  takes  place,  owing  to  the  laxity  of 
the  connective  tissue.  When  affecting  the  base  of  the  prepuce, 
the  induration  tends  to  spread  transversely,  producing  a  collar- 
like mass,  which  on  retraction  of  the  part  rolls  back  en  bloc  in  a 
very  characteristic  manner.  Examined  microscopically,  the  new 
formation  consists  merely  of  a  mass  of  round  and  spindle  cells 
packed  closely  together,  with  a  certain  amount  of  intercellular 
fibrous  tissue  ;  giant  cells  are  sometimes  seen.  The  blood-supply 
of  the  part  is  scanty,  a  fact  which  explains  the  readiness  with 
which  ulceration  occurs.  Several  chancres  may  be  seen  on  the 
same  individual  if  the  infection  occurs  at  one  time,  and  it  is 
possible  that  a  patient  could  be  infected  at  two  different  periods 
if  only  a  short  interval  elapsed  between  the  inoculations  ;  but 
the  disease  is  not  generally  auto-inoculable,  and  when  once  a 
hard  chancre  has  developed  on  the  under  surface  of  the  prepuce, 
the  glans  does  not  become  infected  from  contact.  Multiple 
chancres  are  always  of  small  size,  and  the  induration  is  less 
marked  than  usual. 

A  Urethral  Chancre  is  usually  situated  just  within  the  lips  of 
the  meatus,  constituting  a  sore  with  an  indurated  base.  It  may 
be  felt  as  a  hard  nodule  on  grasping  the  urethra  between  the 
fingers,  and  gives  rise  to  a  thin  serous  discharge,  often  blood- 
stained. The  orifice  itself  is  sometimes  the  site  of  a  chancre,  and 
the  induration  may  completely  encircle  it.  This  condition  is 
very  apt  to  be  followed  by  a  stricture. 

Extragenital  Chancres  are  often  observed,  perhaps  most  com- 
monly on  the  lips,  finger,  and  nipple ;  but,  of  course,  any  part 
of  the  body  may  become  affected.  They  are  usually  characterized 
by  a  greater  amount  of  infiltration  and  less  distinct  and  definite 
induration  than  in  the  forms  met  with  on  the  genital  organs ; 
hence  the  swelling  is  more  prominent  and  vascular,  and  if  ulcera- 
tion occurs  there  is  a  greater  amount  of  discharge,  which  forms  a 
thick  scab  over  the  surface.  The  neighbouring  lymphatic  glands 
are  enlarged,  and  sometimes  surrounded  by  infiltrated  tissue. 
This  condition  has  often  been  mistaken  for  epithelioma,  from 
which,  however,  it  can  be  distinguished  by  the  age  of  the  patient, 
the  character  of  the  sore,  its  rapid  development,  and  the  simul- 
taneous enlargement  of  the  glands.  The  course  of  the  case  is 
generally  more  severe  than  when  the  primary  lesion  is  in  the 
usual  situation,  a  fact  possibly  explained  by  the  disease  remaining 
unrecognised  till  secondary  symptoms  appear. 

In  surgeons  or  accoucheurs  infection  may  occur  on  the  fingers, 
usually  starting  by  the  side  of  the  nail.  It  gives  rise  to  an 
indolent  sore,  which  becomes  infiltrated  and  ulcerates,  tending  to 


INFECTIVE  DISEASES 


spread  under  the  matrix  and  along  the  semilunar  fold.  There  is 
a  good  deal  of  discharge  and  pain,  and  the  terminal  phalanx 
becomes  swollen  and  bulbous.  The  epicondyloid  and  axillary 
glands  are  enlarged  as  the  case  progresses,  and  the  condition  has 
more  than  once  been  mistaken  for  malignant  disease. 

Phagedena  is  a  form  of  spreading  ulceration,  rarely  met  with  at  the  present 
time,  except  in  connection  with  venereal  disease,  and,  according  to  most 
authorities,  seldom  apart  from  syphilis.  It  always  attacks  unhealthy  and 
debilitated  individuals,  especially  men  with  phimosis.  The  discharge,  which 
is  abundant  and  sometimes  offensive,  is  retained  under  the  long  foreskin,  and 
this,  together  with  the  end  of  the  organ,  becomes  red,  swollen,  and  infiltrated. 
On  dividing  or  retracting  the  foreskin,  the  affected  surface  is  found  to  be 
sloughy,  and  the  ulceration,  unless  checked  by  treatment,  rapidly  spreads, 
and  may  destroy  glans  and  prepuce,  and  even  attack  the  body  of  the  penis. 
A  similar  condition  is  occasionally  seen  in  connection  with  an  inguinal  bubo, 
and  then  the  integrity  of  the  femoral  vessels  is  threatened. 

The  Treatment  consists  in  the  relief  of  all  tension  by  division  of  the  foreskin 
if  that  structure  has  not  been  already  destroyed,  followed  by  prolonged  im- 
mersion of  the  patient  in  a  hot  hip-bath,  in  order  that  the  toxins  may  be  so 
diluted  as  to  prevent  any  extension  of  the  ulceration,  and  thus  facilitate  the 
natural  processes  of  repair.  If  the  patient  cannot  be  kept  for  twelve  or  twenty- 
four  hours  in  a  warm  bath,  it  will  suffice  to  immerse  him  in  warm  water 
for  two  or  three  hours  every  day.  In  the  intervals  the  wound  should  be 
dressed  with  iodoform,  and  covered  with  lint  dipped  in  lotio  nigra.  Under  such 
circumstances,  the  surface  of  the  sore  quickly  cleans,  and  becomes  covered 
with  healthy  granulations.  The  later  treatment  is  conducted  as  for  primary 
syphilis,  although  the  depressed  condition  of  the  general  health  may  necessitate 
the  administration  of  tonics  and  even  a  visit  to  the  seaside.  Should  treatment 
by  immersion  in  hot  water  be  for  any  reason  impracticable,  the  old-fashioned 
plan  must  be  resorted  to,  viz.,  scraping  the  sore,  and  freely  cauterizing  the 
base  with  pure  carbolic  or  fuming  nitric  acid.  Possibly,  where  there  is  much 
slough,  this  may  advantageously  precede  immersion  in  a  bath. 

The  Lymphatic  Glands  which  receive  lymph  from  the  region 
in  which  the  sore  is  situated  become  characteristically  enlarged. 
They  move  freely  under  the  skin  and  feel  hard,  like  bullets, 
pellets  of  cartilage,  or  almonds  (hence  the  term  '  amygdaloid  ' 
which  has  often  been  applied  to  them) ;  they  are  usually  quite 
painless,  and  there  is  no  tendency  for  them  to  suppurate  if  the 
infection  is  purely  syphilitic  ;  but  if  the  original  sore  is  septic,  or 
also  inoculated  with  the  virus  of  a  soft  chancre,  an  abscess  often 
follows,  one  or  more  of  the  inguinal  glands  breaking  down,  and 
causing  a  painful,  red,  and  brawny  infiltration  of  the  superjacent 
integument.  After  a  time  the  skin  gives  way,  and  is  often  found 
extensively  undermined. 

Occasionally  the  lymphatic  vessels  extending  from  the  sore  to 
the  glands  become  the  seat  of  a  chronic  lymphangitis,  and  may 
be  felt  as  hard  cords  beneath  the  skin.  The  dorsal  lymphatic  of 
the  penis  is  frequently  blocked  in  this  way,  and  gives  rise  to  solid 
or  lymphatic  oedema  of  the  prepuce  and  glans.  Should  the 
chancre  suppurate,  an  abscess  may  form  in  the  course  of  the 
lymphatics. 

The  Diagnosis  of  a  syphilitic  from  a  soft  sore  is  not  always  easy. 


12b  A  MANUAL  OF  SURGERY 

Of  course,  where  there  is  no  ulceration,  .and  the  typical  induration 
of  the  base  can  be  felt,  no  doubt  need  arise.  But  when  the 
primary  sore  is  septic,  and  an  excavated  ulcer  is  present,  sur- 
rounded by  infiltrated  and  hyperaemic  tissues,  it  is  difficult  to  be 
certain  as  to  the  nature  of  the  case.  The  inguinal  glands  are 
enlarged  in  both  varieties,  and  the  fact  that  suppuration  occurs 
proves  nothing.  Even  the  existence  of  a  '  satellite '  chancre  from 
auto-inoculation  only  demonstrates  the  presence  of  a  soft  chancre; 
it  does  not  prove  the  absence  of  syphilis.  (See  also  on  '  Soft 
Chancre,'  Chapter  XXXVIII. ).  In  such  cases  it  is  often  neces- 
sary to  wait  for  the  development  of  secondary  symptoms  before  a 
decided  opinion  can  be  given. 

The  Duration  of  the  primary  sore  varies  in  different  cases,  and 
depends  in  great  measure  on  whether  treatment  is  commenced 
early  or  late.  If  the  case  comes  under  observation  during  the  first 
six  weeks,  and  a  mercurial  course  is  at  once  started,  the  chancre 
heals,  and  the  induration  usually  disappears  in  from  six  to  eight 
weeks.  The  glands  in  the  groin,  however,  remain  enlarged  for 
some  time.  The  longer  the  case  is  left  untreated,  the  more  slowly 
does  the  hardness  disappear.  If  no  mercury  is  administered  at 
all,  the  induration  may  last  for  twelve  months  or  more,  and  then 
slowly  passes  off,  although  it  may  run  a  much  shorter  course. 
From  an  uncomplicated  syphilitic  sore  but  little  scar  results, 
although  a  well-marked  cicatrix  may  follow  a  soft  or  septic 
chancre. 

Re-induration  of  the  cicatrix  sometimes  occurs  from  too  early 
a  cessation  of  the  mercurial  course,  or  from  some  localized  irrita- 
tion, or  from  a  fresh  exposure  to  infection.  It  is  occasionally  due 
to  a  tertiary  or  gummatous  development,  and  will  then  be  free 
from  lymphatic  complications. 

II.  Secondary  Syphilis. — In  the  secondary  stage,  the  virus  is 
diffused  generally  throughout  the  body  by  means  of  the  blood, 
which  is  itself  infective.  A  certain  amount  of  constitutional 
disturbance  may  exist,  the  patient  feeling  '  seedy  '  and  out  of 
sorts,  whilst  in  some  cases  distinct  febrile  phenomena  and  head- 
ache have  been  noted.  Well-marked  anaemia  is  often  present, 
and  on  examination  the  red  corpuscles  are  found  to  be  deficient 
in  number,  and  defective  in  the  amount  of  haemoglobin  contained 
within  them.  The  chief  secondary  manifestations  consist  in  the 
appearance  of  various  forms  of  rash  on  the  skin  and  mucous 
membranes,  associated  with  a  general  enlargement  of  the  lym- 
phatic glands,  sore  throat,  mucous  tubercles  and  condylomata, 
loss  of  hair,  and  other  less  common  phenomena,  and  these  usually 
show  themselves  in  from  seven  to  nine  weeks  from  the  time  of 
inoculation,  although  they  may  be  delayed  to  a  much  later  date. 
Their  intensity  also  varies  considerably,  the  phenomena  being 
sometimes  scarcely  evident,  and  at  others  very  marked.  They 
are  also  influenced  greatly  by  the  period  at  which  the  administra- 


INFECTIVE  DISEASES  127 


tion  of  mercury  commences ;  the  earlier  the  drug  is  given,  the 
less  obvious  are  the  secondary  phenomena. 

The  Cutaneous  Eruptions  of  secondary  syphilis  are  chiefly 
characterized  by  the  fact  that,  although  any  form  of  rash  may  be 
simulated,  no  specially  distinctive  variety  is  originated.  More- 
over, in  the  same  individual  the  eruption  is  not  always  of  the 
same  character  throughout,  several  distinct  types  developing  in 
separate  parts  of  the  body  (polymorphism).  The  rash  is  usually 
more  or  less  symmetrical,  the  colour  in  the  early  stages  being  a 
dusky  red,  resembling  that  of  raw  ham,  whilst  later  on  it  becomes 
of  a  more  coppery  hue  ;  occasionally,  however,  it  may  be  a  bright 
rosy  red.  Syphilitic  rashes  do  not  completely  fade  on  pressure, 
but  leave  a  brown  stain,  and  give  rise  to  but  little  irritation  or 
itching ;  they  always  tend  to  progress  from  the  simpler  types, 
due  to  hyperaemia,  to  the  more  serious,  in  which  infiltration  and 
overgrowth  are  evident. 

In  the  simplest  form,  merely  a  hyperaemia  is  present,  some- 
times appearing  as  a  dusky  mottling  of  the  skin  (roseolous 
syphilide),  which  quickly  fades,  or  may  persist  whilst  other 
types  are  developing.  If  distinct  papillae  become  infiltrated  and 
hyperaemic,  a  papular  syphilide  is  said  to  be  present ;  such  may 
become  either  vesicular  or  pustular,  constituting  the  vesicular  or 
pustular  syphilides  ;  the  latter  change  is  uncommon,  and  only 
appears  in  bad  cases  or  in  debilitated  patients.  Another  form  of 
eruption  is  the  squamous  syphilide,  characterized  by  patches  of 
hyperaemia  and  infiltration,  combined  with  superficial  desquama- 
tion. It  is  usually  bilateral,  and,  unlike  simple  psoriasis,  affects 
the  flexor  rather  than  the  extensor  surfaces.  In  the  later  stages, 
distinct  nodules  or  tubercles  are  produced  in  the  skin,  which  may 
even  run  on  to  ulceration  (tubercular  syphilide). 

As  to  the  situation  of  the  rash,  the  roseola  is  usually  limited  to 
the  abdomen,  whilst  the  other  forms  are  often  widely  scattered 
over  the  trunk  and  extremities,  involving,  however,  the  flexor 
more  than  the  extensor  surfaces  of  the  limbs.  A  somewhat 
characteristic  phenomenon  is  the  appearance  of  a  papular  rash  on 
the  forehead,  sometimes  known  as  the  corona  Veneris. 

The  Mucous  Membranes  may  be  affected  in  much  the  same  way 
as  the  skin.  The  fauces  become  red  and  congested,  the  hyper- 
aemic area  being  abruptly  limited,  and  semicircular  in  outline  ; 
symmetrical  ulceration  usually  follows,  originating  near  the 
anterior  pillars  of  the  fauces,  and  spreading  thence  to  the  tonsils 
and  along  the  soft  palate  to  the  uvula.  These  ulcers  are  shallow, 
have  sharply-cut  edges,  and  often  present  a  characteristic  greyish 
appearance,  constituting  what  is  known  as  a  '  snail-track  '  ulcer. 
The  secondary  sore  throat  rarely  results  in  extensive  loss  of 
substance,  and  hence  pharyngeal  stenosis  is  not  common  at  this 
period  of  the  disease.  Smoking  undoubtedly  aggravates  these 
conditions.     Concurrently  with  these  manifestations  in  the  fauces 


128  A  MANUAL  OF  SURGERY 

a  number  of  bare  patches  from  loss  of  epithelium  may  be  seen 
on  the  dorsum  of  the  tongue,  or  several  small  superficial,  but 
very  painful,  ulcers  may  develop  on  the  inside  of  the  cheeks  or 
lips. 

Mucous  tubercles  and  condylomata  are  somewhat  similar  affec- 
tions, though  more  pronounced,  arising  in  the  secondary  stage  in 
connection  with  mucous  membranes  and  those  parts  of  the  skin 
which  are  soft  and  moist.  Mucous  Tubercles  consist  of  slightly- 
raised  patches  of  enlarged  and  infiltrated  papillae,  white  in  appear- 
ance from  the  superficial  epithelium  becoming  sodden,  and  often 
progressing  to  actual  ulceration.  Examined  microscopically,  the 
papillae  are  found  to  be  definitely  enlarged,  and  the  epithelium 
heaped  up  over  them.  They  are  most  commonly  observed  at  the 
corners  of  the  mouth,  on  the  inner  aspect  of  the  cheeks,  the  side 
of  the  tongue  (often  due  there  to  the  irritation  of  rough  teeth), 
or  the  margin  of  the  anus ;  in  the  last-named  situation  they  are 
usually  symmetrical,  one  side  being  infected  from  the  other.  They 
are  also  not  at  all  uncommon  between  the  toes,  and  the  ulcers 
caused  thereby  become  exceedingly  offensive  from  septic  con- 
tamination. Condylomata  are  similarly  the  result  of  overgrowth 
of  the  papillae,  differing  from  mucous  tubercles  merely  in  the  extent 
to  which  this  has  been  carried.  They  consist  of  definite  wart- 
like masses,  which  may  attain  a  great  size,  constituting  a  cauli- 
flower-like growth.  They  are  most  commonly  seen  about  the 
anus  or  vulva,  in  the  former  situation  being  often  mistaken  by 
the  patient  for  piles ;  they  give  rise  to  an  abundant,  highly  infec- 
tive discharge.  A  similar  condition  is  sometimes  met  with  on  the 
dorsum  of  the  tongue,  and  is  then  known  as  '  Hutchinson's  wart.' 

The  Lymphatic  Glands  are  usually  enlarged  throughout  the 
body  during  this  period  of  the  disease,  being  felt  as  round,  hard 
swellings  beneath  the  skin.  The  extent  of  the  glandular  com- 
plication is  possibly  a  measure  of  the  degree  of  virulence  of  the 
affection.  The  condition  of  the  nuchal  and  epicondyloid  glands 
should  always  be  ascertained  in  suspicious  cases,  since,  if  no 
obvious  local  cause  exists  for  their  enlargement,  syphilis  is  very 
probably  present. 

Syphilitic  Alopecia. — The  hair  becomes  dull  and  lustreless,  and 
either  comes  out  in  patches  from  the  scalp,  eyebrows,  beard,  etc., 
or  there  is  a  general  '  thinning.'  The  follicles,  however,  are  not 
destroyed,  and  after  a  time  the  hair  will  grow  again  as  before. 

Later  secondary  manifestations  consist  of  flying  pains  in  the 
bones  (osteocopic),  iritis,  and  various  nervous  lesions,  whilst 
periosteal  nodes  may  form  on  the  tibiae  and  other  bones,  or  a 
symmetrical  chronic  effusion  develop  within  the  synovial  mem- 
brane of  joints. 

Syphilitic  Iritis  is  characterized  by  pain  in  the  eye,  generally 
referred  to  the  supra-orbital  nerve,  together  with  some  interference 
with  vision,  and  possibly  a  little  lachrymation  and  photophobia. 


INFECTIVE  DISEASES  129 


On  examination  a  bright-red  circular  zone  immediately  surrounds 
the  cornea,  resulting  from  hyperaemia  of  the  ciliary  vessels.  The 
iris  is  lustreless,  and  its  definition  somewhat  blurred.  Its  colour 
is  changed,  a  blue  iris  becoming  greenish-yellow  from  the  presence 
of  lymph.  The  pupil  is  diminished  in  size,  and  perhaps  irregular  ; 
its  movements  are  always  considerably  hampered,  and  sometimes 
entirely  prevented  by  the  formation  of  adhesions  either  to  the 
back  of  the  cornea  (anterior  synechiae)  or  to  the  lens  capsule 
(posterior  synechiae).  Occasionally  small  yellowish  nodules  are 
seen  on  its  surface,  consisting  of  plastic  lymph. 

The  Duration  of  the  secondary  stage  varies  considerably  in 
different  cases,  and  is  largely  influenced  by  the  character  of  the 
treatment  and  the  period  at  which  it  is  commenced.  The  sooner 
the  patient  is  brought  judiciously  under  the  influence  of  mercury, 
the  less  severe  the  secondary  phenomena,  whilst  cases  in  which 
treatment  has  been  delayed  are  likely  to  be  much  more  trouble- 
some. Hence  the  disease  is  often  of  an  aggravated  type  when 
following  extragenital  chancres,  as  also  in  women,  by  whom  the 
primary  lesion  often  passes  unnoticed  and  untreated.  When 
treatment  is  commenced  within-  four  or  five  weeks  of  infection, 
the  secondary  stage  is  slight,  and  all  traces  of  its  existence  may 
pass  off  in  two  months  or  less  ;  if  mercury  is  not  administered  until 
the  cutaneous  eruption  has  appeared,  this  stage  is  likely  to  last 
longer.  The  condition  of  the  patient's  health  is  an  important 
factor,  as  also  the  previous  habits,  particularly  as  to  temperance, 
since  syphilis  always  follows  a  more  aggravated  course  in  the 
weakly  and  the  dissipated.  Even  under  the  best  circumstances, 
the  patient  is  liable  to  outbreaks  of  the  affection  within  the  first 
twelve  months.  Relapses  are  by  no  means  uncommon,  being 
usually  due  to  intermissions  in  the  treatment.  The  rash  which 
appears  under  these  circumstances  is  often  of  a  more  charac- 
teristic type,  the  papules  being  grouped  into  rounded  or  corymbose 
figures. 

III.  The  Intermediate  or  late  Secondary  Stage  comprises  a 
group  of  symptoms  which  form  a  link  between  those  already 
described  and  the  tertiary  phenomena;  and  indeed  no  distinct 
limits  to  this  period  can  be  defined,  nor  need  it  appear  at  all  if 
the  patient's  general  health  is  good,  and  the  treatment  has  been 
carried  out  regularly.  Some  of  the  secondary  manifestations, 
especially  those  of  the  bones  and  joints,  may  persist  through  this 
period,  whilst  even  if  they  have  disappeared,  the  patient  is  liable 
to  suffer  from  '  reminders '  in  the  shape  of  various  cutaneous 
affections,  and  perhaps  epididymitis.  Deep  lesions  of  the  eye 
(choroido-retinitis),  and  of  the  central  nervous  system  (syphilitic 
monoplegia),  are  not  uncommon,  the  latter  usually  arising  from 
anaemia  of  the  cerebral  centres  due  to  a  syphilitic  endarteritis 
(p.  254).  The  principal  cutaneous  affection  is  the  so-called 
syphilitic  psoriasis,  most  frequently  seen  on  the  palms  and  soles. 

9 


»3° 


A  MANUAL  OF  SURGERY 


A  squamous  syphilide  is  often  observed  in  the  secondary  stage, 
but  is  then  symmetrical  and  readily  influenced  by  mercury.  In 
this  intermediate  period,  the  lesion  may  be  bilateral  or  limited  to 
one  side,  according  to  whether  it  appears  early  or  late.  In  the 
former  there  is  a  considerable  tendency  to  proliferation  of  the 
epithelium,  together  with  deep  cracks  and  fissures;  in  the  latter 
there  is  less  epithelial  overgrowth,  but  the  edges  are  often  dis- 
tinctly serpiginous  in  outline,  and  there  is  an  infiltrated  border. 

Rupia  and  Ecthyma  are  both  met  with  in  this  stage  of  the 
disease.  They  are  characterized  by  an  infiltration  of  the  skin, 
which  progresses  to  ulceration.  In  rupia  the  discharge  forms  a 
distinct  scab  on  the  surface,  which  increases  in  thickness  by  the 


Fig  15. 


-Rupia  of  Face.     (From  Wax  Model  in  Museum  of  Royal 
College  of  Surgeons.) 


deposit  of  successive  layers  one  under  the  other,  each  being 
somewhat  larger  than  the  one  which  precedes  it ;  hence  a  scab 
shaped  like  a  limpet-shell  is  produced,  resting  on  an  inflamed  and 
hyperaemic  base  (Fig.  15)  ;  any  part  of  the  body  may  be  affected 
in  this  way.  In  ecthyma  no  scab  forms  over  the  ulcerated  surface, 
or,  if  formed,  it  readily  comes  away,  leaving  exposed  a  hollow 
punched-out  sore,  surrounded  by  an  area  of  vivid  congestion. 
Under  appropriate  treatment  these  conditions  disappear,  but  leave 
depressed,  whitish  cicatrices,  often  surrounded  by  pigmentation. 

A  somewhat  unusual  intermediate  manifestation  is  a  subacute 
symmetrical  epididymitis,  in  which  the  cord  also  becomes 
thickened,  enlarged,  and  tender. 


INFECTIVE  DISEASES  131 

IV.  Tertiary  Syphilis. — -The  phenomena  occurring  in  this  stage 
may  appear  within  six  months  of  infection,  or  not  for  twenty 
or  thirty  years.  They  are  mainly  characterized  by  infiltration 
and  overgrowth  of  the  connective  tissues  of  the  body.  Such 
may  occur  in  one  or  many  places,  and  may  be  diffuse  or  localized. 
In  the  former  case  the  organ  or  part  affected  becomes  enlarged, 
hard,  and  sclerosed,  and  unless  the  condition  is  treated  promptly, 
the  normal  tissue  of  the  part  may  entirely  disappear,  being 
replaced  by  fibro-cicatricial  tissue.  If,  however,  the  process  is 
localized,  a  Gumma  is  formed. 

Any  tissue  in  the  body  may  be  the  seat  of  a  gummatous 
deposit,  which  apparently  arises  without  any  definite  cause, 
although  occasionally  its  onset  may  be  determined  by  an  injury. 
The  involved  area  becomes  occupied  by  a  round-celled  infiltra- 
tion, the  cells  being  derived  partly  from  proliferation  of  the 
connective  tissue,  and  partly  from  leucocytes.  This  gradually 
increases  in  amount,  the  normal  tissue  of  the  part  disappear- 
ing before  it.  Very  few  vessels  penetrate  into  the  mass  thus 
formed,  which  otherwise  somewhat  resembles  granulation  tissue. 
As  the  process  extends  peripherally,  the  older  portion  is  trans- 
formed into  cicatricial  tissue,  and,  finally,  owing  mainly  to  the 
compression  of  the  vessels  by  its  contraction,  and  partly  to  a 
concurrent  syphilitic  affection  of  the  tunica  intima  of  the  nutrient 
arteries  (p. 254),  the  blood-supply  of  the  centre  of  the  gumma 
fails,  and  the  tissue  dies.  In  this  stage  a  gumma  consists  of 
a  central,  whitish-yellow  slough,  devoid  of  vessels,  formed  by 
the  oldest  portions  of  the  growth  in  a  condition  of  fatty  degenera- 
tion and  necrosis ;  surrounding  this  is  a  zone  of  loose  vascular 
fibro-cicatricial  tissue,  whilst  the  periphery  of  the  tumour  is  con- 
stituted by  a  round-celled  hyperaemic  infiltration  of  the  normal 
tissues  of  the  part.  Under  appropriate  treatment,  the  whole  of 
this  new  formation  may  disappear,  being  replaced  by  a  fibrous 
cicatrix ;  but  not  unfrequently  the  central  portion  breaks  down 
into  a  gummy,  semi-purulent  fluid,  which  finds  its  way  to  the 
surface  and  is  discharged.  Where  the  necrotic  mass  is  large, 
a  portion  of  it  may  remain  adherent  to  the  surrounding  tissues 
after  ulceration  has  taken  place,  looking  somewhat  like  a  piece  of 
wet  wash-leather.  Under  exceptional  circumstances  the  central 
slough  may  become  encysted  by  the  formation  of  a  fibrous  capsule, 
and  calcification  of  the  centre  may  even  occur ;  this  is  stated  to 
be  most  frequently  found  in  the  brain,  testis,  and  liver. 

Clinically,  the  appearances  vary  according  to  whether  the 
gumma  is  cutaneous  or  subcutaneous. 

Cutaneous  gummata  (Fig.  16)  are  very  frequently  observed  in 
tertiary  syphilis,  especially  in  the  earlier  stages.  They  occur  as 
dusky-red  nodules  of  firm  consistency,  and  but  slightly  painful. 
Many  such  growths  are  often  grouped  together  in  one  region,  and 
when  ulceration  has  occurred,  they  produce  by  their  confluence 

9—2 


'32 


A  MANUAL  OF  SURGERY 


sores  with  a  rounded  or  serpiginous  outline.  Considerable 
destruction  of  tissue  follows,  but  they  are  readily  cured,  giving 
rise  to  depressed  white  cicatrices,  surrounded  by  pigmentation. 
Any  part  of  the  body  may  be  involved,  but  a  very  common  site 
is  about  or  just  below  the  knee,  on  the  outer,  rather  than  the 
inner,  aspect  of  the  leg. 

Occasionally  a  diffuse  infiltration  of  the  skin  is  met  with  in  this 
stage,  appearing  as  a  red  hyperaemic  area  with  a  rounded  or 
serpiginous  border,  and  not  at  all  unlike  lupus  in  appearance.  It 
is  readily  amenable  to  treatment,  and  runs  a  much  more  rapid 
course  than  lupus  ;  the  edge  is  usually  thickened  to  the  same 
extent  all  round,  and  there  is  but  little  tendency  to  the  formation 
of  outlying  nodules.     The  apple-jelly-like  granulations,  so  typical 


^ 

*»Mt~ - 

JjKM 

1  ■ 

■  .i^r- "  ijLi-c^. 

v,S(*f 

d^ 

^^B 

w 

Fig.  16. — Cutaneous   Gummata. 


of  lupus,  are  of  course  not  present.  A  cicatrix  is  usually  pro- 
duced, even  if  ulceration  has  not  taken  place. 

A  subcutaneous  gumma  develops  as  a  firm  nodule,  which  gradually 
increases  in  size,  and  sooner  or  later  travels  towards  the  surface ; 
the  centre  of  the  tumour  becomes  elastic  and  fluctuating  ;  a 
certain  amount  of  pain  and  tenderness  is  noticed,  and  when 
the  skin  is  affected,  it  becomes  dusky  and  even  oedematous. 
Ulceration  follows,  and  the  contents  of  the  gumma  thus  escape. 
The  sore  produced  is  deep,  the  edges  being  sharply  cut,  and 
perhaps  undermined  ;  the  base  of  the  ulcer  consists  of  granu- 
lation tissue,  although  it  is  sometimes  covered  by  the  charac- 
teristic slough. 

The  peculiar  features  of  tertiary  syphilis,  as  it  affects  special 
regions,  will  be  described  under  the  appropriate  headings :  vide 
syphilitic  diseases  of  arteries,  of  lymphatic  glands,  of  muscles, 


INFECTIVE  DISEASES 


of  bones,  of  joints,  of  the  lips,  of  the  pharynx,  of  the  tongue, 
of  the  larynx,  of  the  rectum,  of  the  testis.  The  symptoms  arising 
from  gumma  of  the  brain  will  be  alluded  to  at  Chapter XXIV 
but  the  general  relation  of  syphilis  to  the  nervous  system  has 
been  purposely  omitted,  since  it  belongs  rather  to  the  physician 
than  to  the  surgeon. 

The  Prognosis  of  syphilis  is  good  if  the  patient  comes  under 
treatment  at  a  sufficiently  early  stage,  and  if  he  has  no  idiosyn- 
crasy which  prevents  the  administration  of  mercury  or  iodide  of 
potassium.  In  persons  suffering  from  extragenital  chancres,  which 
are  not  recognised  till  late,  the  disease  often  runs  a  more  than 
usually  severe  course.  The  general  health  of  the  patient,  and 
perhaps  a  peculiar  predisposition,  may  influence  the  evolution  of 
the  case  considerably,  whilst  the  co-existence  of  tuberculous  disease 
may  render  the  prognosis  peculiarly  unfavourable,  especially  when 
the  disease  is  inherited.  The  character  of  the  rash,  and  the  extent 
of  the  general  glandular  enlargement  in  the  secondary  stage,  may 
perhaps  give  some  indication  of  the  gravity  of  the  case  ;  where  the 
eruption  is  but  slightly  marked,  the  other  symptoms  are  usually 
mild,  whilst  a  pustular  eruption  is  almost  always  of  grave  import. 
Death  is  rarely  produced  by  any  of  the  secondary  manifestations, 
but  may  occur  in  the  tertiary  stage,  when  important  viscera,  such 
as  the  brain,  spinal  cord,  liver,  etc.,  are  involved. 

As  to  the  Curability  of  syphilis,  the  general  opinion  held  at 
present  is  that,  if  the  disease  is  seen  early,  and  treated  satis- 
factorily, the  patient  will  in  all  probability  never  suffer  from  any 
further  manifestations  after  the  secondary  symptoms  have  dis- 
appeared. A  cure  can,  however,  never  be  definitely  promised, 
since,  should  the  general  health  of  the  patient  become  impaired, 
characteristic  syphilitic  phenomena  may  make  themselves  evident 
even  thirty  or  forty  years  after  the  primary  lesion.  There  is  also 
no  doubt  that  certain  cases  are  to  be  looked  on  as  absolutely 
incurable,  owing  probably  to  the  fact  that  they  were  not  brought 
under  treatment  until  tertiary  phenomena  were  present ;  such  are 
usually  seen  amongst  females. 

The  Treatment  of  syphilis  consists  in  the  administration  of 
mercury  during  the  primary  and  secondary  stages,  and  of  iodide 
of  potassium,  with  or  without  mercury,  in  the  late  secondary  and 
tertiary  periods. 

Many  different  methods  have  been  suggested  for  the  administra- 
tion of  mercury,  in  order  that  the  patient  may  derive  the  greatest 
amount  of  benefit  from  the  drug  with  the  minimum  of  incon- 
venience, (a)  It  is  usually  given  by  the  mouth,  either  in  the  form 
of  pills  composed  of  grey  powder  (grs.  i. — iii.,  t.d.s.),  or  of  the 
green  iodide  (gr.  ^ — i,  t.d.s.),  or  as  a  mixture  containing  a 
solution  of  corrosive  sublimate.  The  last  method  is  distinctly 
objectionable,  inasmuch  as  its  prolonged  use  in  sufficient  doses 
disturbs  the  digestion.     Grey  powder  is  perhaps  the  best  means 


i34  A   MANUAL  OF  SURGERY 

of  giving  the  drug ;  the  patient  should  commence  with  2  grains, 
given  three  times  a  day,  or  in  some  cases  ij  grains  four  times  a 
day,  combined  with  a  little  extract  of  opium  or  pulv.  ipecac,  co. 
if  there  is  any  tendency  to  diarrhoea ;  but  this  addition  is  not 
always  needed.  This  should  be  cautiously  continued  until  all 
prominent  signs  of  the  disease  have  disappeared,  and  then  the 
dose  is  gradually  reduced,  (b)  Inunction  of  the  mercurial  ointment 
is  also  frequently  adopted,  and  with  great  success,  inasmuch  as  it 
is  less  likely  to  cause  digestive  derangements.  If  the  ordinary 
officinal  ointment  is  employed,  a  portion  as  large  as  a  hazel-nut  is 
rubbed  into  the  groin  or  axilla  nightly,  the  part  being  washed  the 
following  morning,  and  not  used  again  for  this  purpose  for  three 
or  four  days  ;  if  the  ointment  is  made  up  with  lanoline,  a  some- 
what smaller  amount  is  required.  Possibly  this  is  one  of  the  best 
ways  of  bringing  a  patient  rapidly  under  the  influence  of  the  drug. 
(c)  Mercurial  vapour  baths  may  be  advantageously  employed  where 
the  cutaneous  eruption  is  very  extensive.  The  patient  sits  naked 
on  a  cane-seated  chair,  and  covered  with  a  blanket  or  specially 
constructed  cloak  reaching  from  the  neck  to  the  ground,  and  not 
touching  the  body  ;  20  or  30  grains  of  calomel  are  placed  on  a 
metal  plate  surrounded  by  a  trough  containing  about  1  ounce  of 
water.  The  water  is  boiled,  and  the  calomel  sublimed,  by  means 
of  a  spirit-lamp  placed  under  the  chair.  In  about  twenty  minutes 
all  the  calomel  will  be  volatilized,  and  deposited  in  part  upon  the 
skin  of  the  patient,  who  perspires  freely  during  the  process.  He 
then  gets  into  bed  between  warm  blankets,  without  wiping  the 
skin.  This  treatment  may  be  combined  with  medication  by  the 
mouth,  (d)  Mercury  is  sometimes  administered  by  subcutaneous 
injections,  in  the  form  of  the  perchloride,  |  grain  or  less  being 
injected  once  or  twice  a  week  into  the  substance  of  the  gluteus 
maximus.  A  little  thickening  of  the  site  of  injection  results,  but 
quickly  passes  away,  and  suppuration  scarcely  ever  follows. 

During  the  course  of  mercury,  the  patient's  general  health  and 
habits  must  be  carefully  regulated,  all  excesses  in  drink  and  diet 
being  forbidden,  and  strict  instructions  given  as  to  keeping  the 
teeth  and  gums  clean.  To  minimize  the  risk  of  throat  and  mouth 
trouble,  it  is  wise  to  stop  all  smoking  for  at  least  six  months. 
The  dose  required  varies  in  different  individuals,  being  increased 
in  robust  people,  and  diminished  in  those  who  are  weak  or  un- 
healthy. It  should  always  be  pushed  until  mild  physiological 
effects  are  produced  in  the  shape  of  slight  tenderness  of  the  gums, 
but  salivation  of  the  patient  is  undesirable.  Full  doses  are  usually 
required  for  four  or  five  months,  followed  by  a  milder  course, 
which  should  extend  till  the  end  of  the  first  year. 

Although  symptoms  of  excessive  mercurialism  are  generally 
induced  by  overdoses  of  the  drug,  yet  in  some  people  a  very 
small  dose  suffices  to  produce  severe  effects  ;  the  existence  of 
this  idiosyncrasy  must  not  be  forgotten,  and  large  doses  should 


INFECTIVE  DISEASES 


J35 


never  be  administered  without  first  ascertaining  whether  or  not 
the  patient  can  tolerate  them.  When  mercury  is  producing 
toxic  effects,  the  gums  become  soft  and  spongy,  and  bleed  readily 
on  pressure.  Salivation  follows,  and  even  acute  glossitis  may  be 
produced,  whilst  the  breath  is  always  exceedingly  offensive.  In 
worse  cases  the  teeth  become  loose,  and  even  necrosis  of  the 
alveoli  has  been  known.  Derangements  of  the  digestion,  in  the 
shape  of  colicky  pain  and  diarrhoea,  are  also  observed.  The 
treatment  of  this  condition  consists  in  suspending  the  administra- 
tion of  the  drug,  and  giving  a  sharp  saline  purge,  whilst  the 
spongy  state  of  the  gums  is  remedied  by  the  use  of  an  alum  or 
chlorate  of  potash  mouth-wash. 

Iodide  of  potassium  is  essential  in  the  treatment  of  the  tertiary 
and  intermediate  stages.  It  appears  probable  that  its  chief  action 
is  the  removal  of  gummatous  tissue,  but  that  it  has  no  other 
influence  upon  the  course  of  the  disease ;  in  order  to  prevent 
recurrence  of  the  trouble,  mercury  is  still  required.  The  dose  of 
iodide  should  not  exceed  5  grains  to  start  with,  and  is  gradually 
increased  until  in  some  cases  1  drachm  four  times  a  day  has  been 
reached.  A  feeling  of  depression  and  sinking  at  the  epigastrium 
is  often  produced,  but  may  be  alleviated  by  the  addition  to  the 
mixture  of  sal  volatile  (11\_.  xv.)  or  carbonate  of  ammonia,  as 
suggested  by  Sir  James  Paget.  Symptoms  of  coryza  may  follow, 
and  an  acneiform  eruption  over  the  shoulders  and  face,  which, 
however,  often  disappears  on  increasing  the  dose.  Sometimes  a 
vesicular,  or  even  bullous,  rash  is  caused  by  this  drug.  When 
large  doses  are  given,  bicarbonate  of  soda  or  potash  must  be 
combined  with  it,  in  order  to  prevent  its  decomposition  by  the 
gastric  juice,  and  plenty  of  water  should  always  be  taken  im- 
mediately afterwards  to  assist  in  its  dilution  and  facilitate  its 
absorption.  The  iodides  of  sodium  and  ammonium  are  some- 
times substituted  for  the  potassium  salt,  on  the  plea  that  they 
give  rise  to  less  depression. 

Other  drugs,  such  as  sarsaparilla  and  iron,  are  often  combined 
with  iodide  of  potassium  in  the  later  stages  of  the  disease,  and 
may  be  useful. 

The  Local  Treatment  of  syphilitic  sores  consists  mainly  in  the 
application  of  various  preparations  of  mercury.  The  primary 
chancre  is  usually  treated  with  lotio  nigra  on  lint,  iodoform  being 
sometimes  employed  if  septic  ulceration  is  present.  Mucous 
tubercles  in  the  neighbourhood  of  the  anus  or  vulva,  or  between 
the  toes,  are  best  dealt  with  by  keeping  them  scrupulously  clean 
and  dusting  them  over  with  powdered  calomel,  or  by  the  applica- 
tion of  calomel  ointment,  a  piece  of  lint  being  inserted  between 
opposing  surfaces  to  keep  them  from  rubbing  one  against  the 
other.  Secondary  ulceration  of  the  throat  does  not  usually  require 
local  treatment,  as  it  soon  disappears  under  the  influence  of 
mercury.     A  mercurial  gargle  may,  however,  be  employed,  or  in 


l3G  A   MANUAL  OF  SURGERY 

bad  cases  calomel  may  be  placed  on  a  hot  copper  coin,  and  its 
vapour  inhaled.  Superficial  gummatous  ulcers  are  treated  by  re- 
moving the  scabs,  and  applying  some  form  of  mercurial  oint- 
ment. A  determined  attempt  should  be  made  to  keep  deep  gum- 
matous ulcers  in  an  aseptic  condition,  since  the  advent  of  sepsis 
to  such  sores,  especially  if  they  are  connected  with  bones,  makes 
a  marked  difference  in  their  progress.  In  neglected  cases  the 
wound  may  become  exceedingly  foul,  and  in  chronic  cases  a 
hectic  temperature  and  even  amyloid  degeneration  of  the  viscera 
have  been  observed.  When  gummata  come  to  the  surface  and 
point,  they  should  be  opened  with  the  same  precautions  as  are 
adopted  in  the  case  of  an  abscess,  and  either  dressed  antisepti- 
cally,  or  their  cavity  stuffed  with  lint  or  gauze  soaked  in  lotio 
nigra. 

Inherited  or  Congenital  Syphilis. 

Syphilis  may  be  conveyed  to  the  ovum  either  by  direct  trans- 
mission from  the  father  or  mother  alone,  or  both  parents  may 
be  tainted  with  the  disease.  Occasionally  the  mother  acquires 
syphilis  during  pregnancy,  and  in  such  cases  the  foetus  also 
becomes  affected.  In  those  instances  where  the  ovum  is  infected 
from  the  father,  whilst  the  mother  has  escaped,  the  latter  becomes 
in  measure  protected,  so  that,  if  the  child  is  put  to  her  breast,  she 
does  not  contract  the  disease,  even  though  there  are  ulcerating 
lesions  on  the  child's  gum  and  lips  ;  healthy  wet-nurses  are 
invariably  infected  {Colics' s  Law).  Whether  the  immunity  is 
permanent  or  not  is  still  a  matter  of  uncertainty,  and  even  the 
inviolability  of  this  law  has  recently  been  called  in  question. 

The  length  of  time  during  which  the  patients  retain  the  power 
of  transmitting  the  disease  to  the  foetus  is  an  exceedingly  difficult 
point  to  determine,  and  one  which  is  constantly  coming  before 
the  practitioner,  who  is  asked  to  decide  at  what  period  it  is  safe 
for  a  syphilitic  patient  to  marry.  The  rule  of  practice  generally 
followed  is  that  no  one  suffering  from  syphilis  should  be  allowed 
to  marry  until  he  or  she  has  been  free  from  all  symptoms  for  at 
least  twelve  months,  and  even  then  it  is  advisable  that  a  mild 
course  of  mercury  should  be  given  for  about  three  months  shortly 
before  marriage. 

A  syphilitic  foetus  often  fails  to  arrive  at  maturity,  the  mother 
miscarrying  at  the  end  of  six  or  seven  months.  This  is  probably 
due  to  a  specific  affection  of  the  endometrium,  especially  involv- 
ing that  portion  of  the  decidua  which  enters  into  the  formation 
of  the  placenta.  The  circulation  and  nutrition  of  the  foetus  are 
thereby  impaired,  so  that  it  is  usually  born  not  only  dead,  but 
in  many  cases  macerated,  and  partially  decomposing.  This  may 
be  repeated  for  several  pregnancies,  and  then  a  living  child  is 
produced.     In  many  cases,   however,  a  living  child  is  born  at 


INFECTIVE  DISEASES 


'37 


full    time    at   the   end   of  the    first    pregnancy,    in    spite   of  the 
syphilitic  infection  of  the  parents. 

At  birth  the  child  often  appears  healthy  and  well  nourished, 
but  is  sometimes  small  and  imperfectly  developed.  The  first 
definite  symptoms  of  the  disease  manifest  themselves  at  a  variable 
period,  extending  from  three  weeks  to  three  months,  after  birth  ; 
the  child  becomes  thin  and  emaciated  ;  the  skin,  which  hangs  in 
wrinkles  over  the  body,  changes  to  a  dull  earthy  colour,  whilst 
the  features  looked  pinched  and  wizened,  like  those  of  an  old  man. 
Marked  anaemia  is  always  present,  and  tends  to  persist  for  a  con- 
siderable time.  Speaking  generally,  the  symptoms  of  inherited 
syphilis  are  similar  to  those  of  the  acquired  disease,  except  that 


Fig.  17. — Child  with  Inherited  Syphilis,  showing  Radiating  Scars 
round  the  Mouth.  (From  a  Photograph  kindly  lent  by  Dr. 
G.  F.  Still.) 


the  primary  lesion  is  absent.  Thus,  during  the  first  year  of  life 
the  child  develops  various  cutaneous  eruptions,  mucous  tubercles, 
and  superficial  ulcerations  of  the  mucous  membranes.  A  dusky 
red  roseola,  especially  about  the  nates  (napkin  area),  may  first  be 
noticed,  but  does  not  last  long.  This  is  usually  followed  by  the 
appearance  of  mucous  tubercles  at  the  angles  of  the  mouth,  in  the 
nose,  and  around  the  anus,  as  also  in  the  moist  folds  of  the  groin, 
and  between  the  scrotum  and  thigh.  The  sores  on  the  lips  are 
sometimes  very  marked,  giving  rise  to  ulcerated  surfaces,  which, 
by  their  subsequent  cicatrization,  leave  radiating  scars  (or 
rhagades),  especially  about  the  angles  of  the  mouth  (Fig.  17). 
Other  cutaneous  affections,  such  as  squamous  syphilides  of  the 


138 


A   MANUAL  OF  SURGERY 


soles  of  the  feet,  together  with  papular  syphilides  of  the  body,  and 
a  bullous  eruption  becoming  pustular  (pemphigus),  are  also 
observed,  the  last  mentioned,  however,  only  occurring  in  de- 
bilitated infants.  A  catarrhal  rhinitis  is  a  very  early  and  constant 
manifestation,  giving  rise  to  obstructed  nasal  respiration,  or 
snuffles.  This  affection  is  often  protracted,  going  on  to  ulceration 
and  destruction  of  the  nasal  bones  and  cartilages  ;  their  subsequent 
development  is  thus  prevented  or  impaired,  and  hence  the  bridge 
of  the  nose  remains  depressed  and  sunken,  even  when  adult  life  is 


Fig.  18. — Head  and  Face  of  a  Patient  with  Inherited  Syphilis,  showing 
Depressed  Bridge  of  Nose  and  Frontal  Bosses.  (From  a  Photo- 
graph.) 


reached  (Fig.  18).  Enlargement  of  the  spleen  and  liver  is  also 
common. 

Many  infants  during  the  first  year  of  life  die  from  malnutrition 
or  marasmus  ;  but  if  properly  treated  a  considerable  proportion 
regain  their  health  within  six  or  eight  months,  all  the  manifesta- 
tions described  above  disappearing,  although  their  scars  may 
remain.  The  child's  subsequent  development  is  frequently  im- 
paired, and  it  often  retains  an  almost  pathognomonic  facies. 

After  the  first  year,  any  of  the  tertiary  phenomena  which  appear 
in  acquired  syphilis  may  develop,  but,  in  addition  to  these,  peculiar 
manifestations  may  be  produced,  especially  affecting  the  teeth, 
bones,  and  cornea. 


INFECTIVE  DISEASES 


»39 


The  Teeth  in  inherited  syphilis  are  sometimes  very  char- 
acteristic. The  temporary  teeth  usually  appear  early,  are 
discoloured,  and  crumble  away.  The  permanent  teeth  are  often 
sound  and  healthy,  but  are  sometimes  deformed.  The  central 
incisors  of  the  upper  jaw  are  those  most  particularly  affected,  but 
the  upper  laterals  and  the  incisors  of  the  lower  jaw  may  also  be 
involved.  Instead  of  being  broader  at  the  crown  than  at  the  root, 
they  diminish  in  size  from  root  to  crown,  being  stunted,  and 
separated  from  one  another  by  interspaces.  The  angles  of  the 
crown  are  rounded  off,  and  a  distinct  notch,  forming  a  large 
segment  of  a  small  circle,  occupies  the  centre.  The  enamel  is 
often  imperfectly  developed,  and  hence  they  decay  early.  Occa- 
sionally they  may  be  shaped  like  a  screw-driver,  narrowing  from 
root  to  crown,  and  with  a  straight  free  border.  The  notched 
and  stunted  teeth  described  above  are  sometimes  known  as 
1  Hutchinson's  teeth,'  but  they  are  not  very  commonly  seen  at  the 
present  day. 

The  Bone  affections  observed  in  inherited  syphilis  will  be  de- 
scribed at  Chapter  XVIII. 

Interstitial  Keratitis,  or  diffuse  inflammation  of  the  cornea, 
usually  occurs  about  the  age  of  puberty,  or  earlier.  It  is  limited 
at  first  to  one  eye,  but  the  other  is  almost  certain  to  be  similarly 
affected  at  a  later  date.  It  commences  as  a  diffuse  haziness  of 
the  cornea,  which  looks  something  like  ground  glass,  associated 
with  hyperaemia  of  the  ciliary  region.  Red  areas,  or  '  salmon 
patches,'  may  be  produced  in  the  midst  of  the  opacity,  due  to  a 
new  formation  of  minute  vessels.  There  is  no  tendency  to  ulcera- 
tion, but  in  protracted  cases  the  anterior  part  of  the  eye  may  bulge 
forwards,  constituting  a  condition  known  as  '  anterior  staphyloma.' 
The  inflammation  may  spread  to  the  iris  and  ciliary  body.  With 
suitable  precautions  the  cases  usually  do  well,  although  treatment 
for  several  years  may  be  necessary. 

The  Treatment  of  inherited  syphilis  should  commence  as  soon 
as  definite  manifestations  of  the  disease  are  present.  The  general 
health  must  be  attended  to,  and  if  the  mother  is  unable  to  nurse 
the  child,  it  must  be  brought  up  by  hand  ;  on  no  account  must 
it  be  given  to  a  wet-nurse.  Mercury  is  best  administered  by 
anointing  the  under  surface  of  the  flannel  belly-band  with  mer- 
curial ointment,  or  the  same  preparation  may  be  rubbed  into  the 
soles  of  the  feet  every  night.  This  should  be  continued  until  all 
secondary  phenomena  have  disappeared,  and  advisably  until  the 
child  is  a  year  old.  Cod-liver  oil  may  also  be  ordered  with 
advantage  in  some  cases.  When  tertiary  symptoms  appear, 
iodide  of  potassium  and  mercury  may  be  given  in  a  mixture,  in 
suitable  doses. 

The  local  treatment  of  external  lesions  is  conducted  according 
to  the  rules  laid  down  for  the  acquired  type  of  the  disease. 


i4o  A   MANUAL  OF  SURGERY 


Tuberculosis. 

By  tuberculosis  is  meant  a  condition  resulting  from  the  develop- 
ment within  the  tissues  of  the  body  of  certain  definite  anatomical 
structures,  known  as  tubercles,  and  caused  by  the  growth  and 
activity  of  the  Bacillus  tuberculosis.  Before  the  fact  was  established 
that  such  lesions  were  due  to  a  micro-organism,  they  were  usually 
termed  strumous  or  scrofulous,  and  even  at  the  present  day  these 
two  names  are  occasionally  employed  to  indicate  that  condition 
of  constitutional  weakness  which  predisposes  to  the  appearance  of 
tuberculous  disease.  It  is  better,  however,  to  avoid  the  use  of 
such  misleading  terms. 

.^Etiology. —  i.  The  individual  is  often  predisposed  to  the  develop- 
ment of  this  disease  by  some  inherited  weakness,  as  indicated  by 
the  fact  that  parents,  relations,  or  ancestors  have  suffered  from 
some  similar  affection,  or  that  it  has  occurred  in  other  branches 
of  the  same  family.  It  is  becoming  doubtful,  however,  whether 
heredity  plays  such  an  important  part  as  was  formerly  attributed 
to  it,  and  whether  the  disease  is  not  much  more  commonly  due  to 
direct  infection.  Considerable  ingenuity  has  been  exercised  in 
describing  various  types  of  physiognomy  supposed  to  be  charac- 
teristic of  a  tuberculous  inheritance,  and  although  not  always 
present,  these  appearances  are  not  unfrequently  observed.  Two 
chief  varieties  are  described,  viz.,  the  sanguine  and  the  phlegmatic. 
In  the  former,  the  individual  is  slight  and  well  proportioned, 
possessing  a  thin,  delicate  skin,  often  freckled,  and  so  transparent 
that  the  subcutaneous  veins  are  readily  seen.  The  hair  is  fine 
and  auburn-coloured,  or  even  reddish,  the  conjunctivae  are  thin 
and  pearly,  the  eyelashes  well  developed,  and  the  fingers  long 
and  tapering.  Such  children  are  usually  excitable  and  precocious 
in  their  habits,  and  possess  taking  manners.  The  phlegmatic  type 
is  characterized  by  a  short,  stunted  stature,  with  somewhat  coarse 
features,  and  strong  though  somewhat  short  limbs.  The  skin  is 
coarse  and  muddy-looking,  the  lips  thick,  the  hair  rough  and 
brown.  In  children  of  either  type  there  is  a  considerable  tendency 
to  the  development  of  eczema,  inflammation  of  the  mucous  mem- 
branes, and  a  subacute  enlargement  of  the  lymphatic  glands,  all 
of  which  are  simple  in  nature,  but  may  constitute  a  suitable  nidus 
for  the  development  of  tubercle,  especially  if  the  child  is  run  down 
by  some  preceding  illness,  such  as  measles  or  scarlet  fever.  They 
also  suffer  frequently  from  cracked  lips,  and  as  a  result  of  the 
irritation  caused  thereby  considerable  infiltration  and  thickening 
may  follow.  Although  tuberculous  disease  is  most  frequently 
seen  in  young  people  or  children,  no  age  is  exempt  from  its 
attacks,  even  elderly  persons  being  affected  by  what  is  known 
as  '  senile  tuberculosis.'  These  senile  manifestations  differ  in  no 
way  from  those  met  with  in  the  young. 


INFECTIVE  DISEASES 


141 


2.  Unhealthy  surroundings  and  bad  hygiene  certainly  predispose  to 
its  development  ;  hence  it  is  seen,  perhaps,  in  its  severest  forms 
amongst  the  poor,  although  it  is  only  too  common  amongst  the 
rich,  arising  usually  from  improper  feeding  and  want  of  fresh  air 
in  the  case  of  children,  and  not  unfrequently  from  faulty  hygiene 
or  carelessness,  especially  as  to  judicious  clothing,  in  adults. 

3.  A  local  nidus  suitable  for  the  development  of  the  micro- 
organism usually  exists,  although  tuberculous  infection  occasion- 
ally follows  wounds  and  punctures  in  previously  healthy  parts. 
Thus,  as  already  mentioned,  lymphatic  glands  in  a  condition 
of  chronic  enlargement  and  hyperemia  form  a  suitable  breeding- 
ground  for  the  bacillus,  as  also  bones  and  joints  which  are  in  a 
state  of  congestion  as  a  result  of  slight  and  often  overlooked 
injuries. 

4.  The  ultimate  exciting  cause  of  tuberculosis  is  the  develop- 


Fig.  19. 


-Bacillus  Tuberculosis  in   and  around  Giant  Cell. 
shank's  'Textbook  of  Bacteriology.') 


(Crook- 


ment  within  the  tissues  of  the  Bacillus  tuberculosis  (Fig.  19).  This 
organism,  which  was  originally  isolated  by  Koch,  is  always  present, 
though  not  always  recognisable,  in  the  products  of  the  disease. 
It  exists  in  the  form  of  fine  straight  rods,  the  individual  bacilli 
being  2  [x  to  5  \i  in  length,  and  "i  /x  to  3  //.  in  breadth.  They  are 
always  cultivated  artificially  with  difficulty,  growing  best  on 
glycerine  agar-agar,  and  only  slowly  on  coagulated  blood  serum 
at  the  temperature  of  the  body.  The  colonies  produced  consist 
of  yellowish -white  or  greyish  scales,  more  or  less  cheesy  in 
appearance.  The  organism  gains  admission  to  the  system  either 
through  some  abrasion  of  the  skin,  or  by  the  digestive  tract  with 
some  article  of  food,  especially  milk,  or  by  inhalation,  its  presence 
in  the  dust  of  rooms  occupied  by  phthisical  individuals  having 
been  frequently  demonstrated,  and  being  due  to  the  dessication  of 
the  sputum. 

The   infective   nature    of    the   disease    has    been    abundantly 


i42  A   MANUAL  OF  SURGERY 


demonstrated  by  clinical  and  experimental  work  during  the  last 
few  years.  Thus,  it  can  be  readily  transmitted  by  inoculation  to 
animals,  especially  to  rabbits  and  guinea-pigs,  the  anterior  chamber 
of  the  eye  of  the  rabbit  being  a  very  favourite  spot,  owing  to  the 
fact  that  the  growth  of  the  characteristic  neoplasm  can  be  readily 
watched,  and  that  spontaneous  tuberculosis  never  occurs  in  this 
region.  Transmission  of  the  disease  to  the  human  subject  has 
frequently  occurred  from  direct  inoculation  through  a  puncture  or 
abrasion  of  the  skin,  as  in  the  case  of  surgeons  whose  fingers  have 
been  wounded  whilst  operating  on  tuberculous  cases.  The  risk 
of  living  with  phthisical  patients,  or  of  occupying  their  rooms 
without  previous  thorough  disinfection,  is  also  fully  admitted  at 
the  present  day. 

Pathological  Anatomy. — The  tuberculous  process  consists  in  the 
development  of  the  so-called  grey  or  miliary  tubercles,  which  run 
together,  and  produce  larger  masses,  and  these  undergo  secondary 
changes,  whilst  the  tissues  invaded  become  inflamed  and  gradually 
disappear,  being  replaced  by  pulpy  granulation  tissue,  in  the  midst 
of  which  the  tuberculous  foci  can  be  seen. 

Miliary  tubercles  can  be  recognised  by  the  naked  eye  as  greyish, 
semi-translucent  nodules,  rarely  exceeding  a  millet-seed  in  size. 
The  process  which  leads  to  their  formation  almost  always  com- 
mences in  or  around  the  small  vessels,  and  can  perhaps  be  best 
studied  in  the  pia  mater.  The  bacilli  are  presumably  brought  to 
some  area  of  lowered  vitality,  settling  in  the  tunica  intima.  This 
leads  to  an  overgrowth  of  the  endothelial  elements — i.e.,  to  an 
endarteritis,  which  may  spread  for  some  distance — and  this  in 
turn  is  followed  by  a  proliferation  and  infiltration  of  the  surround- 
ing connective  tissues,  resulting  in  the  obliteration  of  the  affected 
vessel,  and  the  formation  of  the  characteristic  tuberculous  nodule. 
In  the  earlier  stages  all  that  is  seen  is  an  ill-defined  mass  of  con- 
nective-tissue cells,  distinctly  nucleated,  and  aggregated  around  a 
bloodvessel,  thus  giving  rise  to  no  very  characteristic  appearances. 
The  structure  of  a  fully-developed  tubercle  (Plate  III.,  Fig.  i)  is  as 
follows :  In  the  centre  lies  a  giant  cell,  containing  a  large  number 
of  nuclei,  which  are  often  arranged  around  its  periphery,  or  grouped 
together  at  one  or  other  pole.  Delicate  processes  extend  from  the 
giant  cell,  and  form  a  fine  network,  in  the  meshes  of  which  are 
situated  the  cells  of  the  surrounding  zone.  These  are  rather 
larger  than  ordinary  leucocytes,  with  a  granular  protoplasm  and  a 
clearly-defined  oval  nucleus.  They  are  known  as  epithelioid  cells, 
although  they  are  derived  from  the  neighbouring  connective 
tissues,  and  are,  in  fact,  identical  with  fibroblasts.  Around  them 
are  collected  a  large  number  of  smaller  cells,  probably  leucocytes, 
and  these  merge  into  the  surrounding  structures,  which  are 
gradually  changed  into  granulation  or  fibro-cicatricial  tissue.  •  In 
many  cases  the  giant  cell  is  absent,  and,  indeed,  it  must  in  no  way 
be  looked  upon  as  a  characteristic  feature  of  tubercle,  since  such 


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INFECTIVE  DISEASES  143 


cells  are  often  met  with  in  syphilis  and  other  conditions  where 
active  tissue  changes  are  taking  place.  Its  origin  is  a  little 
doubtful,  but  it  is  probably  derived  from  an  enlargement  of  one 
connective-tissue  corpuscle,  or  by  the  union  of  several  such  cells. 
No  vessels  are  present  in  the  tuberculous  neoplasm,  and  as  a  result 
degenerative  changes  are  certain  to  follow.  Not  unfrequently  a 
number  of  these  tubercles  develop  close  together,  and  under  these 
circumstances  the  intervening  structures  disappear,  being  re- 
placed by  granulation  tissue,  which  may  in  part  become  further 
transformed  into  cicatricial  tissue.  By  the  use  of  appropriate 
staining  reagents  it  can  be  demonstrated  that  bacilli  are  present 
in  the  giant  cell,  and  sometimes  in  the  zone  of  epithelioid  cells 
surrounding  it  (Fig.  19),  but  as  soon  as  degenerative  changes 
commence,  the  organisms  can  no  longer  be  recognised. 

If  the  disease  progresses,  caseation  always  ensues,  owing 
partly  to  the  defective  nutrition  of  the  neoplasm,  partly  to  the 
specific  action  of  the  bacillus  or  its  products.  Not  only  does 
the  centre  of  the  miliary  tubercle  undergo  this  change,  but  also 
the  granulation  tissue  around  or  between  the  separate  nodules. 
A  caseating  focus  of  yellow  or  crude  tubercle,  as  it  used  to  be 
termed,  consists  of  a  degenerating  centre  surrounded  by  a  zone  of 
granulation  or  fibro-cicatricial  tissue,  in  which  are  scattered 
miliary  tubercles,  and  which  in  turn  gradually  runs  into  normal 
tissue  (Plate  III.,  Fig.  2). 

The  ultimate  result  of  this  process  depends  to  a  large  extent  on 
the  general  health  of  the  individual  and  the  treatment  which  is 
adopted. 

1.  If  the  parts  are  kept  at  rest,  and  free  from  external  irrita- 
tion, and  if  the  constitutional  weakness  is  combated  by  suitable 
measures,  the  destructive  process  may  come  to  an  end.  In 
such  a  case  the  peripheral  layer  of  granulations  is  converted  into 
dense  fibro-cicatricial  tissue,  which  forms  a  sort  of  capsule,  and 
checks  the  advance  of  the  disease.  The  caseous  material  is  either 
removed  by  an  invasion  of  leucocytes,  or  becomes  calcified,  usually 
leaving  a  firm  fibrous  nodule,  perhaps  interspersed  with  calcareous 
particles.  Possibly  some  of  the  tuberculous  material  persists  in  a 
latent  state  in  this  mass,  like  an  '  extinct  volcano,'  ready  to  be 
lighted  up  into  activity  if  the  opportunity  is  given.  In  less 
advanced  cases  the  diseased  tissue  may  be  so  completely  removed 
as  to  leave  scarcely  any  trace  of  its  existence  behind. 

2.  The  caseous  material  is  often  transformed  into  a  yellowish 
fluid,  usually  known  as  pus,  by  a  process  of  emulsification,  due  to 
the  absorption  of  fluid  from  the  hyperaemic  tissues  around,  and 
resulting  either  from  mechanical  causes,  or  more  probably  from 
the  activity  of  the  tuberculous  organisms,  or  possibly  from  infec- 
tion with  ordinary  pyogenic  or  septic  bacteria.  In  such  cases  a 
chronic  or  subacute  tuberculous  abscess  results,  the  structure  and 
characters  of  which  have  been  already  described  (p.  50). 


i44  A   MANUAL  OF  SURGERY 


One  of  the  chief  features  of  tuberculous  disease  is  its  great 
tendency  to  diffusion.  This  may  occur  (a)  locally,  by  direct  con- 
tinuity of  tissue,  or  by  extension  along  neighbouring  lymphatics  or 
bloodvessels ;  or  (b)  distant  viscera  or  organs  may  become  infected, 
probably  through  dissemination  by  the  bloodvessels.  Thus 
phthisis  is  a  not  uncommon  sequence  of  a  similar  affection  of 
bones,  joints,  or  lymphatic  glands,  whilst  meningeal  tuberculosis 
is  more  frequently  associated  with  tuberculous  affections  of  the 
genital  organs,  (c)  Moreover,  any  tuberculous  lesion  may  lead  to 
acute  general  tuberculosis,  in  which  the  disease  is  scattered  widely 
throughout  the  body,  giving  rise  to  rapid  emaciation,  high  fever 
of  an  intermittent  type,  and  usually  severe  diarrhoea,  dyspnoea, 
and  delirium  or  coma,  death  ensuing  in  a  few  weeks. 

Treatment. — It  must  be  fully  recognised  that  tuberculosis  is  an 
infectious,  and  therefore,  to  a  large  extent,  a  preventable  disease, 
and  it  is  the  duty  of  all  medical  practitioners  to  do  everything  in 
their  power  to  limit  its  ravages.  We  cannot  here  enter  into  this 
subject,  but  would  merely  mention  the  dangers  to  the  general 
public  arising  from  the  distribution  of  milk  obtained  from  tuber- 
culous cows,  and  from  the  indiscriminate  expectoration  of  tuber- 
culous sputum. 

Curative  treatment  is  based  on  the  assumption  that  natural 
processes  of  repair  have  a  considerable  influence  upon  the  course 
of  the  disease.  When  Koch  first  discovered  the  bacillus,  a  great 
impetus  was  given  to  surgical  treatment,  and  some  authorities 
went  so  far  as  to  maintain  that  it  was  as  necessary  to  extirpate 
every  particle  of  diseased  tissue  as  in  a  case  of  cancer.  The 
pendulum  has  now  slowly  swung  back,  and  we  are  more  and 
more  endeavouring  to  promote  healthy  repair  of  the  lesions  by 
constitutional  measures.  The  value  of  an  abundance  of  fresh  air 
is  fully  admitted,  and  many  sanatoria  for  the  open-air  treatment  of 
phthisis  and  other  tuberculous  lesions  are  being  built  or  planned. 
In  this  country  residence  by  the  seaside,  especially  in  such  bracing 
places  as  Margate,  or,  if  that  be  too  cold,  Ramsgate,  Bournemouth, 
or  Ventnor,  is  usually  recommended.  At  the  same  time,  plenty 
of  good  food,  such  as  milk  and  eggs,  must  be  taken.  Local  foci 
should  be  kept  at  rest,  and,  if  the  disease  is  external,  elevation 
and  steady  pressure  (as  by  Scott's  dressing)  are  desirable  acces- 
sories. On  the  other  hand,  if  a  tuberculous  lesion  is  sufficiently 
localized  and  suitably  situated,  as  when  it  occurs  in  the  lymphatic 
glands  of  the  neck,  total  excision  is  the  ideal  treatment,  although 
one  has  sometimes  to  be  satisfied  with  scraping.  In  this  process 
the  possibility  of  disseminating  the  disease  by  too  vigorous 
manipulations  must  not  be  overlooked.  Any  open  tuberculous 
sores  should  be  well  scraped,  and  the  surface  then  swabbed  over 
with  liquefied  carbolic  acid,  and  dressed  with  gauze  soaked  in  an 
iodoform  emulsion. 


INFECTIVE  DISEASES  145 

The  manifestations  of  tubercle  as  it  affects  special  organs  are 
dealt  with  elsewhere  under  the  appropriate  headings  (see  diseases 
of  skin,  bones,  joints,  lymphatic  glands,  kidney,  testis,  etc.). 

Glanders. 

Glanders  is  primarily  a  disease  of  the  horse,  ass,  or  mule,  which  is  trans- 
mitted to  men  by  direct  inoculation,  and  hence  is  usually  seen  only  in  stable 
attendants  and  those  brought  in  contact  with  such  animals.  It  is  charac- 
terized by  the  development  of  inflammatory  swellings  under  the  mucous 
membrane  of  the  respiratory  tract,  which  break  down  and  ulcerate,  and  by 
the  formation  of  similar  growths,  embolic  in  origin,  in  the  lungs  and  other 
viscera,  which  go  on  to  abscess  formation. 

There  is  now  no  doubt  that  the  disease  is  due  to  a  definite  micro-organism, 
the  Bacillus  mallei,  which  was  isolated  about  1882  by  Schutz  and  Loffler,  and 
has  since  been  cultivated  outside  the  body  ;  the  experimental  evidence  as  to  its 
being  the  cause  of  the  malady  is  quite  complete. 

In  Horses  and  other  animals,  glanders  manifests  itself  by  a  formation  of 
larger  or  smaller  rounded  swellings  in  the  mucous  membrane  of  the  nose, 
which  break  down  and  ulcerate,  giving  rise  to  a  thin,  sero-purulent  discharge, 
and  perhaps  destruction  of  the  bones  and  cartilages.  The  lymphatic  glands, 
especially  those  under  the  jaw,  early  become  enlarged,  constituting  the  '  farcy 
buds'  of  farriers,  and  by  their  ulceration  may  leave  ragged,  foul  sores.  The 
lymphatic  trunks  to  and  from  the  glands  are  involved  ('  corded  veins  '),  whilst 
the  lungs  and  internal  viscera  may  also  be  infected,  and  undergo  destructive 
changes,  usually  ending  in  suppuration.  The  disease  is  often  chronic,  lasting 
perhaps  for  years  ;  any  undue  strain  put  upon  the  animal  may  lead  to  an  acute 
outbreak,  which  is  fatal  in  six  to  twelve  days. 

In  Man,  glanders  generally  starts  about  the  hands  and  face,  but  occasionally 
in  the  nasal  mucous  membrane.  In  acute  cases  the  incubation  period  lasts  from 
three  to  five  days,  and  is  succeeded  by  the  occurrence  of  malaise  and  febrile 
disturbance,  followed  by  severe  pains  in  the  bones  and  joints.  The  site  of 
inoculation  becomes  swollen  and  angry,  whilst  the  lymphatics  leading  from 
this  to  the  nearest  glands  are  enlarged  and  inflamed.  An  eruption  of  papules, 
which  somewhat  resemble  those  of  small-pox,  occurs  around  the  primary 
lesion,  on  the  face,  and  in  other  parts  of  the  body  ;  but  each  papule,  as  also 
the  primary  lesion,  breaks  down  and  goes  on  to  the  formation  of  an  ecthy- 
matous-looking  ulcer.  It  is  not  an  uncommon  feature  of  these  sores,  when 
placed  over  a  bony  surface,  to  involve  the  periosteum  and  lay  bare  the  sub- 
jacent bone.  Similar  changes  occur  in  the  viscera,  muscles,  and  joints,  and 
these  being  associated  with  high  fever  of  an  asthenic  type,  may  suggest  the 
existence  of  pyaemia.     In  such  cases  death  may  ensue  in  seven  to  ten  days. 

In  Chronic  Glanders  simikr  symptoms  are  met  with,  but  the  course  is 
slower ;  there  is  little  or  no  fever ;  the  disease  is  less  extensive,  and  inter- 
missions are  not  uncommon.  Total  recovery  is  stated  to  occur  in  50  per  cent, 
of  the  cases.  It  may  affect  the  nasal  mucosa,  leading  to  chronic  ulceration, 
but  more  commonly  it  appears  in  the  shape  of  chronic  abscesses,  which  often 
extend  deeply,  even  down  to  the  bones  and  are  very  difficult  to  deal  with.  In 
one  case  the  disease  gradually  spread  down  along  the  peronei  muscles,  and  in 
spite  of  repeated  scrapings  and  the  application  of  pure  carbolic  acid,  the 
process  was  only  arrested  at  the  point  where  the  peroneus  longus  disappears 
into  the  foot. 

It  is  important  to  determine  the  Diagnosis  as  early  as  possible,  in  order  to 
undertake  energetic  local  treatment.  The  local  lesions  are  distinguished  from 
small-pox  by  the  presence  of  the  characteristic  bacilli  in  the  discharge,  by  the 
fact  that  they  more  extensively  involve  the  subcutaneous  tissues,  and  by  the 
absence  of  umbilication.  Chronic  cases  resemble  syphilis  and  tuberculosis,  but 
the  history  of  exposure  to  infection  from  animals  suffering  from  the  disease  is 
most  important,  as  also  the  result  of  cultivations  made  from  the  discharge. 

10 


146 


A  MANUAL  OF  SURGERY 


When  the  bacilli  are  grown  on  potatoes,  a  colony  of  a  yellowish,  honey-like 
character  forms  in  two  or  three  days,  which  gradually  turns  to  a  chocolate- 
brown  colour.  Inoculation  of  the  peritoneal  cavity  of  a  guinea-pig  with  some 
of  the  secretion  leads  to  acute  orchitis  in  two  or  three  days,  the  testicles  being 
enlarged  and  the  skin  over  them  reddened ;  the  affection  usually  runs  on  to 
suppuration.  Mallein,  a  sterilized  culture  of  the  organisms,  may  also  be  used 
for  diagnostic  purposes,  an  injection  of  a  minute  dose  causing  a  sharp  febrile 
reaction  if  glanders  is  present. 

Treatment  in  acute  cases  can  be  of  use  only  when  undertaken  early,  and 
before  general  infection  has  ensued.  The  local  foci  should  be  thoroughly 
extirpated,  either  by  the  knife,  or  by  scraping  and  applying  some  active 
cauterizing  agent.  The  same  treatment  must  be  adopted  in  chronic  cases, 
and  may  then  need  frequent  repetition. 


Leprosy. 

Leprosy  (syn.  :  lepra,  or  elephantiasis  Gracomm)  is  a  general  infective  disease 
due  to  the  Bacillus  lepra;,  characterized  by  the  formation  of  granulation-like 
neoplasms,  which  arise  primarily  in  connection  with  the  skin  and  nerves. 

The  bacilli  of  leprosy  closely 
resemble  those  of  tubercle,  being 
4  to  6  /(  long  and  1  n  broad  (Fig.  20). 
They  are  stained  by  most  of  the 
ordinary  methods  of  demonstrating 
bacteria,  and  are  found  in  abund- 
ance in  the  tissues ;  but  the  disease 
has  not  yet  been  transmitted  to 
animals. 

Leprosy,  though  formerly  common 
in  this  country,  is  now  but  rarely 
seen,  and  has  then  been  imported. 
In  Iceland,  Norway,  Russia,  and  the 
East  it  is  still  frequently  met  with, 
although  the  compulsory  separation 
of  lepers  enforced  in  Norway  is 
much  diminishing  the  number  in 
that  country.  It  is  apparently  con- 
tagious, though  with  ordinary  care 
infection  may  be  avoided ;  but  in 
the  exhalations  and  secretions  bacilli 
are  abundant,  at  any  rate  in  the 
later  stages.  Opinions  differ  as  to  whether  or  not  it  is  transmitted  by 
heredity,  but  probably  this  is  not  the  case. 

Symptoms. — Two  cnief  varieties  of  leprosy  exist,  viz.,  the  tuberculated  and 
the  anaesthetic,  or  non-tuberculated  ;  but  the  two  are  often  associated. 

Tuberculated  or  Cutaneous  Leprosy  is  the  form  most  commonly  seen  in 
Europe.  Nothing  may  be  noticed  for  months  or  years  after  exposure  to  the 
contagion,  and  then,  after  a  period  of  malaise,  associated  with  dyspepsia, 
diarrhoea,  and  drowsiness,  a  distinct  febrile  attack  is  noted,  lasting  for  days 
or  weeks  ;  it  may  be  ushered  in  by  a  rigor,  and  the  temperature  is  usually  of 
a  remittent  type.  This  is  followed  by,  or  associated  with,  the  appearance 
of  shiny,  red,  hyperaemic  spots,  which  are  from  the  first  infiltrated,  slightly 
raised,  and  hyperaesthetic ;  they  are  usually  situated  on  the  forehead  or 
cheeks,  on  the  outer  side  of  the  thighs,  or  on  the  front  of  the  forearms.  They 
may  fade  away  and  disappear  entirely,  and  then  again  become  evident,  or 
fresh  patches  may  be  developed,  and  always  with  febrile  symptoms.  After  a 
variable  period,  '  tuberculation  '  ensues;  numbers  of  little  pink  nodules  form 
over  the  site  of  one  or  more  of  the  erythematous  patches,  and  these  gradually 


Fig.  20. — Leprosy  Bacilli  contained 
within  Epithelial  Cells. 


INFECTIVE  DISEASES  147 


increase  in  size  and  coalesce,  until  possibly  they  become  as  large  as  a  walnut 
or  hen's  egg,  and  are  then  of  a  brownish-yellow  colour.  _  Almost  any  part 
of  the  surface  of  the  body  may  be  invaded  in  this  manner,  but  the  face  is 
especially  prone  to  be  involved,  and  the  resulting  disfigurement  is  very 
marked,  a  curious  leonine  appearance  being  imparted  to  the  features.  The 
nodules  are  more  or  less  anaesthetic  from  the  pressure  of  the  infiltration  on 
the  nerves,  and  the  ultimate  result  of  the  process  may  vary  considerably  ; 
resolution  sometimes  occurs,  or  the  nodules  may  be  transformed  into  de- 
pressed and  pigmented  cicatrices,  or  ulceration  may  ensue.  Visceral  com- 
plications and  enlargement  of  the  lymphatic  glands  follow,  any  fresh  deposit 
being  associated  with  febrile  phenomena.  The  testes  atrophy,  and  sexual 
power  is  lost  in  both  sexes.  Death  is  usually  due  to  septic  phenomena, 
laryngeal  obstruction,  or  disease  of  the  lungs  or  kidneys  ;  but  the  patient  may 
live  for  many  years. 

The  nodules  consist  of  masses  of  granulation  tissue,  and  scattered  through 
them  are  numbers  of  large  cells,  containing  multitudes  of  bacilli  (Fig.  20). 
Considerable  difficulty  exists  in  cultivating  these  organisms,  but  Ducrey  has 
succeeded  by  using  an  alkaline  medium,  and  excluding  air 


Fig.   21  — Leprous  Hand.      (From  Wax  Model  in   Museum  of  Royal 
College  of  Surgeons.) 

Anaesthetic,  or  Non-tuberculated,  Leprosy  is  the  most  common  form  met 
with  in  hot  climates.  The  earliest  phenomena  consist  in  a  certain  amount  of 
malaise  without  appreciable  fever,  together  with  sharp  tingling  or  lancinating 
pains  and  tenderness  along  the  course  of  certain  peripheral  nerves.  The  ulnar, 
median,  peroneal,  and  saphenous  nerves  are  those  most  often  affected.  This 
is  followed  by  muscular  weakness,  running  on  finally  to  paralysis,  various 
modifications  of  sensation,  and  trophic  phenomena,  involving  at  first  only  the 
skin,  but  later  on  attacking  bones,  joints  and  muscles.  Circular  yellowish- 
white  patches  are  observed  in  the  skin,  spreading  peripherally,  and  tending  to 
run  together,  forming  large  irregular  ovals;  the  border  is  often  raised,  and 
hypersensitive,  but  the  central  portions  become  atrophic,  dry,  white,  and 
anaesthetic.  The  anaesthesia  gradually  spreads,  and  serious  lesions,  partly  due 
to  trauma,  partly  arising  from  trophic  changes,  result.  The  muscles  atrophy 
and  contract,  and  give  rise  to  deformity,  the  hands  sometimes  becoming 
markedly  '  clawed,'  as  in  ulnar  paralysis  (Fig.  21).  Interstitial  absorption  of 
the  bones  of  the  peripheral  portions  of  the  limbs  may  lead  the  fingers,  toes, 
and  other  portions  to  shrivel  and  disappear,  preceded  by  ankylosis  of  the 
joints.  The  affected  nerves  can  usually  be  felt  distinctly  enlarged  and  tender. 
Visceral  lesions  are  not  so  marked  in  this  as  in  the  other  form  of  the  disease, 
and  the  patient  may  retain  a  considerable  degree  of  health  and  strength, 
whilst  his  sexual  powers  are  not  much  interfered  with.  Finally  he  dies  from 
general  debility,  or  from  various  complications,  but  the  case  may  last  twenty 
or  more  years. 

IO — 2 


148  A  MANUAL  OF  SURGERY 

The  Treatment  is  still  very  unsatisfactory.  Chaulmoogra  oil,  administered 
both  internally  and  externally,  is  the  drug  most  frequently  depended  on,  but 
latterly  intra-muscular  injections  of  corrosive  sublimate  have  been  employed 
with  some  success. 

Actinomycosis. 

Actinomycosis  is  a  disease  mainly  of  cattle,  but  occasionally  seen  in  man, 
due  to  the  growth  of  the  ray  fungus  (streptothrix  actinomyces) . 

The  fungus  is  transmitted  to  animals  with  their  food,  having  been  found 
most  often  within  the  husk,  or  sheath,  of  barley.  It  usually  attacks  the  tongue 
or  jaw,  turning  these  into  hard  infiltrated  masses  (the  '  wooden  tongue '  or 
'  big  jaw  '  of  cattle),  in  which,  after  a  time,  suppuration  appears  at  many  foci, 
producing  multiple  abscesses,  which  discharge  externally,  and  leave  a  diffuse 
inflammatory  mass  riddled  with  sinuses.     The  pus  from  such  abscesses  is  of 


Fig.  22. — Actinomyces  in  Tissues.     (From  Crookshank's  '  Textbook  of 
Bacteriology.') 

the  usual  type,  but  in  addition  contains  firm  yellowish  gritty  bodies,  which 
can  be  isolated  by  the  fingers,  and  consist  of  masses  of  the  fungus,  perhaps 
undergoing  calcareous  changes.  On  microscopic  examination  of  these  collec- 
tions one  finds  in  the  interior  an  abundant  mycelial  development,  in  the 
centre  of  which  are  observed  numerous  small  rounded  bodies,  probably 
conidia.  The  fibres,  which  are  arranged  more  or  less  in  a  concentric  fashion, 
terminate  peripherally  in  a  layer  of  radiating,  club-shaped  bulbous  processes, 
arranged  in  a  more  or  less  symmetrical  fashion ;  these  enlargements  are  not 
spores,  as  was  originally  taught,  but  are  merely  due  to  a  hyaline  degeneration 
of  the  sheaths  of  the  filaments  (Fig.  22). 

In  Man  the  disease  occurs  much  more  commonly  than  was  expected  when 
attention  was  first  drawn  to  it,  and  is  probably  due  to  direct  inoculation  with 
the  fungus  from  chewing  or  eating  fresh  corn,  or  by  inhaling  the  spores  with 
dust  during  the  process  of  grinding  corn.  It  has  been  found  in  the  tongue 
and  maxilla,  causing  diffuse  induration  and  suppuration  ;  in  the  lungs,  giving 
rise  to  destructive  lesions  very  similar  to  those  of  tuberculosis,  and  perhaps 
ending  in   localized   empyemata;    in  various   parts  of  the  intestinal   canal, 


INFECTIVE  DISEASES 


149 


especially  about  the  caecum  ;  in  the  liver,  giving  rise  to  a  very  characteristic 
reticulated  swelling,  in  which  diffuse  suppuration  occurs  ;  and  in  the  skin. 
Wherever  situated,  the  same  pathological  phenomena  manifest  themselves, 
viz.,  either  the  formation  of  a  localized  tumour,  in  the  jaw  possibly  simulating 
an  epulis,  or  of  a  diffuse  infiltrating  mass,  in  which  abscesses  form  ;  great 
destruction  of  tissue  is  likely  to  result.  The  bones  are  affected  equally  with 
the  soft  parts,  and  may  become  carious.  In  itself  the  process  is  not  dangerous, 
but  may  become  so  by  involving  important  organs,  or  by  septic  contamina- 
tion. The  commonest  site  for  it  is  close  to  the  angle  of  the  jaw  (Fig.  23), 
constituting  a  cervico-facial  tumour,  the  appearance  of  which  is  tolerably 
characteristic.  At  first 
the  mass  has  a  smooth, 
regular,  and  even 
surface,  and  merges 
gradually  into  the 
surrounding  tissues ; 
the  skin  over  it  is 
usually  hyperaemic. 
As  time  passes,  little 
nodular  excrescences, 
with  a  peculiar  yel- 
lowish apex,  form 
here  and  there  on  the 
surface  of  the  tumour, 
and  these  finally 
soften,  point,  and 
burst,  giving  exit  to 
a  small  amount  of 
glutinous  pus,  in 
which  the  actinomy- 
cotic nodules  can  be 
demonstrated.  "When 
all  the  fungus  has 
been  discharged,  the 
abscess  contracts,  and 
the  wound  closes. 
The  cicatrization  in- 
duced by  the  constant 
repetition  of  this  pro- 
cess makes  the  surface 
of  the  mass  curiously 
nodular  and  puckered, 
and  this  condition,  when  present,  is  almost  pathognomonic.  Trismus  is  an 
exceedingly  constant  symptom  in  the  cervico-facial  form  of  the  disease, 
coming  on  early,  and  being  apparently  independent  of  the  size  of  the  mass 
or  its  involvement  of  nerves. 

The  Treatment  most  recently  advised  consists  in  the  administration  of  large 
doses  of  iodide  of  potassium  (grs.  20  or  30  three  times  a  day),  which  seems  to 
have  almost  as  great  an  influence  in  this  disease  as  in  syphilis.  This  alone 
may  suffice  when  there  is  no  open  wound ;  but  if  open  seres  are  present, 
surgical  measures  must  also  be  employed.  Extirpation  of  all  the  infiltrated 
tissue,  either  by  the  knife  or  by  vigorous  scraping,  should  be  undertaken,  and 
the  part  freely  cauterized  ;  in  fact,  it  must  be  treated  in  exactly  the  same 
way  as  a  diffuse  tubercular  mass.  This  can,  however,  only  be  very  partially 
carried  out  in  the  visceral  affections. 


Fig.  23. — Cervico-Facial  Actinomycosis.     (By  kind 
Permission  of  Mr.  Malcolm  Morris.) 


CHAPTER  VII. 

TUMOURS  AND  CYSTS. 

Although  the  term  'tumour'  is  often  used  for  any  abnormal 
swelling  which  may  be  met  with  in  the  body,  yet  for  scientific 
purposes  its  application  is  much  more  limited.  A  tumour  may  be 
defined  as  '  a  mass  of  new  formation  that  tends  to  grow  or  persist, 
without  fulfilling  any  physiological  function,  and  with  no  typical 
termination.'  The  fact  that  it  has  no  typical  termination  dis- 
tinguishes it  from  inflammatory  overgrowths,  which  always  lead 
sooner  or  later  to  the  formation  of  fibro-cicatricial  tissue,  or  some 
modification  of  it  ;  inflammatory  growths,  moreover,  may  dis- 
appear completely,  and  often  diminish  in  size  temporarily.  Pure 
hypertrophies  are  excluded  by  this  definition,  since  they  always 
depend  more  or  less  on  some  increased  physiological  function,  and 
are  composed  of  an  increased  development  of  normal  tissues,  as, 
for  instance,  the  blacksmith's  biceps.  Congenital  overgrowth  of 
a  limb  or  portion  of  a  limb  also  occurs,  and  is  known  as  'gigantism'; 
it  cannot  be  considered  a  tumour,  being  merely  an  exaggerated 
development  of  normal  tissues. 

As  to  the  Causes  of  tumours,  but  little  is  known.  Probably 
they  are  all  in  the  first  instance  local  developments,  and  may  be 
lighted  up  by  some  form  of  injury  or  irritation,  which  determines 
abnormal  development  of  some  of  the  tissues  of  the  part.  Thus, 
a  blow  on  the  breast  is  often  responsible  for  an  adenoma  ;  the 
irritation  caused  by  smoking  a  clay  pipe  may  produce  epithelioma 
of  the  lip,  and  many  other  illustrations  readily  suggest  themselves. 
Moreover,  even  if,  as  supposed  by  some  pathologists,  the  carcino- 
mata  and  sarcomata  result  from  infection,  it  is  probable  that  some 
local  irritation  or  breach  of  surface  is  needed  to  allow  entrance 
to,  or  determine  the  activity  of,  the  organisms.  The  hereditary 
nature  of  some  malignant  tumours  is  sometimes  thought  to  be 
evidence  of  a  constitutional  origin  ;  but  although  it  may  indicate 
a  predisposition  of  the  patient  to  their  development,  some  local 
condition  is  usually  found  to  determine  it.  Cohnheim  has  sug- 
gested that  tumours  may  be  due  to  excessive  growth  in  small 
portions  of  undeveloped  and  undifferentiated  embryonic  material, 


TUMOURS  AND  CYSTS  151 


or,  as  he  terms  them,  foetal  residues,  left  among  the  normal  tissues. 
These  remain  in  a  condition  of  suspended  activity,  until  some 
local  lesion  excites  their  development.  As  an  illustration  may  be 
mentioned  the  fact  that  many  branchial  cysts  do  not  appear  till 
adult  life  ;  evidently  the  embryonic  cells  were  present  from  birth, 
but  required  some  special  stimulus  to  call  them  into  activity.  It 
is  also  probable  that  the  presence  of  cartilage  in  many  tumours  of 
the  parotid  and  testis  may  be  explained  in  a  similar  way  ;  in  the 
former  case  it  is  due  to  the  inclusion  of  a  portion  of  Meckel's 
cartilage;  in  the  latter,  to  the  fact  that  the  testis  develops  in 
the  posterior  abdominal  wall  not  far  from  the  notochord,  and 
evidently  cartilaginous  cells  from  the  protoyertebrse  developed 
around  this  structure  become  included  within  it. 

Tumours  may  be  divided  into  two  great  classes  from  a  clinical 
standpoint,  viz.,  the  benign  and  the  malignant. 

Benign  or  Simple  Tumours  are  characterized  by  the  develop- 
ment being  strictly  local,  by  their  more  or  less  exact  limitation, 
being  frequently  encapsuled,  and  by  their  method  of  growth, 
which  results  from  a  proliferation  of  all  the  cells  constituting  their 
structure.  There  is  no  tendency  to  infiltrate  or  invade  surround- 
ing tissues,  which  are  merely  pushed  aside  and  compressed  ;  pain 
and  atrophy  are  sometimes  caused  by  this  pressure.  The  capsule 
is  formed  by  an  ensheathing  layer  of  fibro-cellular  tissue,  the 
outcome  of  the  chronic  irritation  and  inflammation  engendered 
by  the  growth  and  development  of  the  mass  ;  hence  enucleation 
is  easy,  and  recurrence  uncommon.  They  are  not  unfrequently 
multiple,  and  may  be  hereditary :  but  these  characters  are  no 
evidence  of  a  constitutional  taint. 

Malignant  Tumours,  unless  removed  by  operation,  are  almost 
invariably  fatal.  The  following  are  the  chief  characteristics  of 
malignancy  :  (1)  The  primary  growth  is  usually  single,  rarely 
multiple.  (2)  It  progresses  steadily  and  constantly,  but  with 
varying  rapidity  in  different  cases.  (3)  The  local  development  is 
characterized  by  an  infiltration  of  the  surrounding  tissues,  which 
are  gradually  replaced  by  the  tumour  substance.  A  capsule  is 
rarely  formed,  or,  if  at  all,  only  in  the  early  stages,  and  thus  the 
limits  of  the  growth  are  not  clearly  defined.  Moreover,  many 
varieties  spread  locally  along  the  efferent  lymphatics,  and  hence, 
although  the  growth  may  appear  to  have  been  completely 
removed,  recurrences  are  very  common,  owing  to  the  non-removal 
of  these  prolongations  (or,  as  they  are  termed  by  the  lay  public, 
'  roots ')  of  the  disease  into  apparently  normal  tissue.  If  a 
malignant  tumour,  with  all  its  ramifications,  is  completely 
removed,  it  does  not  recur.  The  impossibility  of  knowing 
whether  all  the  growth  has  been  removed,  or  how  far  it  has 
extended  into  the  surrounding  tissues,  is  responsible  for  the 
frequent  recurrences.  (4)  When  a  malignant  tumour  invades  the 
skin,  it  usually  leads  to  ulceration,  and  then  not  uncommonly  a 


i52  A  MANUAL  OF  SURGERY 

foul  fungating  mass  results  (the  fungus  hamatodes  of  the  older 
pathologists).  (5)  Secondary  deposits  are  often  found  in  neigh- 
bouring lymphatic  glands  or  distant  viscera.  (6)  An  apyrexial 
cachexia  develops  in  the  later  stages,  partly  due  to  the  pain,  partly 
to  the  pressure  of  the  growth  on  important  structures,  and  in  part 
to  the  absorption  of  toxic  products  from  the  tumour.  The  patient 
is  thin  and  emaciated,  the  face  drawn  and  with  an  expression  of 
pain  on  it ;  the  appetite  is  impaired,  and  the  skin  often  sallow  and 
earthy-looking.  (7)  Finally,  death  ends  the  scene,  after  a  longer 
or  shorter  period  of  suffering. 

The  degree  of  malignancy  varies  with  different  tumours.  In 
some  the  local  phenomena  predominate,  whilst  in  others  the 
constitutional  symptoms  are  the  more  important.  Thus,  rodent 
ulcer  is  slow  in  its  progress,  and  produces  no  visceral  deposits  ;  it 
destroys  life  merely  by  implication  of  vital  parts.  Melanotic 
sarcoma,  on  the  other  hand,  may  produce  only  a  small  primary 
growth,  but  the  most  extensively  diffused  secondary  deposits  may 
form  in  the  viscera.  The  sarcomata  are  very  frequently  dissemi- 
nated by  the  blood-stream,  and  hence  secondary  growths  are  not 
common  in  the  lymphatic  glands,  whilst  the  carcinomata  spread 
by  means  of  the  lymphatics.  Even  among  the  latter  consider- 
able differences  are  met  with ;  thus,  in  glandular  cancer  secondary 
growths  occur  both  in  the  lymphatics  and  the  viscera ;  whilst  in 
squamous  epithelioma  neighbouring  lymphatics  are  affected,  but 
the  viscera  generally  escape.  The  term  semi-malignant  is  some- 
times applied  to  those  growths  which  are  on  the  borderland 
between  the  malignant  and  benign. 

The  Classification  of  Tumours  is  conducted  along  lines  partly 
anatomical,  partly  embryological,  and  on  these  grounds  the 
following  groups  are  described  : 

I.  Tumours  derived  from  mesoblastic  tissue,  constituting  what 
is  known  as  the  Connective  Tissue  Group  : 

(1)  Embryonic  connective  tissue  tumours  : 

(a)  Myxoma  (mucoid  tumour). 

(b)  Sarcoma. 

(2)  Fully-developed  connective  tissue  tumours  : 

(a)  Lipoma  (fatty  tumour). 

(b)  Fibroma  (fibrous  tumour). 

(c)  Chondroma  (cartilaginous  tumour). 
id)  Osteoma  (bony  tumour). 

(e)  Myoma  (muscle  tumour). 

(/     Neuroma  (tumour  in  connection  with  nerves). 
(g)   Angioma  (tumour  composed  of  bloodvessels). 
(h)  Odontoma  (tumour  connected  with  the  teeth). 
(i)   Lymphadenoma,  or  lymphangioma  (tumours  of 
lymphatic  origin). 


TUMOURS  A±JD  CYSTS  153 

II.  Tumours  derived  from  epiblastic  or  hypobiastic  structures, 
or  Epithelial  Tumours  : 

(ij   Innocent  varieties : 

(a)  Papilloma  (wart-like  growth). 

(b)  Adenoma  (glandular  new  formation). 
(2)   Malignant  growths,  or  the  carcinomata : 

(a)  Epithelioma  (cancer  of  skin  or  mucous  mem- 

brane). 

(b)  Rodent  ulcer  (cancer  of  sebaceous  glands). 

(c)  Columnar  carcinoma  (cancer  arising  from  tubular 

glands,   e.g.,    Lieberkiihn's   follicles,   or   from 
ducts  lined  with  columnar  epithelium). 

(d)  Acinous    carcinoma   (cancer   arising   in    glands 

with  spheroidal  epithelium). 

L  The  Connective  Tissue  Group  of  Tumours  :  (r)  Tumours 
composed  of  Embryonic  Connective  Tissue. 

Myxoma. — A    myxoma  is  a  tumour  consisting   of  connective 
tissue  cells,  surrounded  and   separated   from  each   other  by  an 


Fig.  24. — Myxomatous  Tissue,  showing  the  Stellate  Cells  with  their 
Branching  Processes  separated  by  Translucent  Intercellular 
Substance.     (Tillmanns.) 

intercellular  substance  of  a  mucoid  character  ;  a  similar  type  of 
material  occurs  normally  in  the  substance  of  the  umbilical  cord. 
The  cells  are  usually  polygonal  in  shape,  and  present  long  branched 
processes  which  interlace  with  those  from  adjacent  cells  (Fig.  24). 
The  intercellular  substance  is  homogeneous  and  translucent,  con- 
taining wandering  connective  tissue  corpuscles,  and  traversed  by 
bloodvessels ;  the  density  of  the  tumour  varies  inversely  with  the 
amount  of  intercellular  substance.  It  is  not  uncommon  for  this 
form  of  growth  to  be  associated  with  sarcoma,  and  hence  a 
thorough  and  early  removal  of  the  mass  is  always  advisable. 


154  A   MANUAL  OF  SURGERY 


Myxomata  occur  as  rounded  tumours,  perhaps  tabulated,  in  the 
neighbourhood  of  mucous  membranes — e.g.,  the  face,  intestine, 
and  bladder ;  they  also  grow  in  the  sheaths  of  nerves,  and  are  the 
commonest  form  of  simple  tumour  of  the  spinal  cord.  Mucous 
polypi  of  the  nose  were  formerly  considered  of  this  nature,  but  at 
the  present  time  rhinologists  look  on  them  as  merely  consisting  of 
cedematous  granulation  tissue. 

Sarcoma  (Greek,  <rap£,  flesh  =  a  flesh-like  tumour). — By  a  sar- 
coma is  meant  a  tumour  formed  from  some  kind  of  immature  or 
embryonic  connective  tissue  ;  that  is  to  say,  it  consists  of  cells  of 
varying  size  and  shape,  held  together  by  a  delicate  reticulum, 
which  penetrates  between  each  of  the  cellular  elements.  The 
structure  is,  thus,  not  unlike  that  of  inflammatory  new  formations, 
but  differs  from  it  in  that  there  is  a  considerable  tendency  to 
develop  into  higher  types  of  tissue,  such  as  bone,  cartilage,  etc., 
although  the  embryonic  character  of  the  growth  still  persists  at 
the  periphery.  From  carcinoma  it  is  recognised  by  the  fact  that 
in  all  except  the  alveolar  sarcomata  the  structure  is  more  or  less 
uniform,  and  the  cells  are  not  grouped  in  alveoli  separated  from 
one  another  by  stroma  ;  moreover,  there  is  no  intercellular  tissue 
between  the  epithelial  cells  of  a  cancer,  whereas,  with  suitable 
preparation,  it  can  always  be  demonstrated  between  the  cells  of  a 
sarcoma. 

A  sarcoma  always  arises  from  pre-existing  connective  tissue, 
and  hence  is  of  mesoblastic  origin  ;  occasionally  it  starts  from  the 
deeper  parts  of  the  skin,  but  even  here  it  is  probably  derived  from 
the  same  embryological  basis.  It  may  be  at  first  well  defined, 
and  even  in  some  cases  encapsuled  ;  but  many  forms  from  the 
first,  and  all  later  on,  infiltrate  the  surrounding  tissues,  replacing 
them  with  their  own  particular  structure,  a  process  which  can  be 
well  observed  in  sarcomata  of  muscles.  The  blood -supply  is  very 
abundant,  and,  indeed,  may  be  so  free  as  to  cause  the  tumour  to 
pulsate.  The  vessels  consist  of  spaces  or  clefts  within  the  tumour 
substance,  and  are  lined  merely  by  the  most  delicate  endothelium; 
the  arteries  and  veins  in  the  neighbourhood  are  much  dilated. 
Interstitial  haemorrhage  is  frequent,  owing  to  the  thinness  of  the 
vessel  walls,  and  cysts  may  in  this  way  be  produced.  Dissemina- 
tion is  usually  dependent  on  the  relation  of  the  tumour  to  the 
veins.  As  already  stated,  the  veins  communicate  with  spaces 
hollowed  out  of  the  tumour  substance ;  into  and  along  these 
the  sarcomatous  tissue  may  burrow,  until  the  apex  of  this  intra- 
vascular growth  projects  into  the  lumen  of  a  vessel  in  which  the 
blood  is  freely  circulating.  It  may  be  detached  by  some  slight 
mechanical  injury,  and  is  then  carried  away  as  a  malignant 
embolus ;  if  a  large  portion  is  set  free,  it  may  lodge  in  the  right 
side  of  the  heart,  or  in  the  lungs,  and  cause  a  fatal  result.  Smaller 
emboli  are  either  detained  in  the  lungs,  or  pass  through  into  the 


TUMOURS  AND  CYSTS 


l55 


general  circulation,  giving  rise  to  secondary  growths  wherever 
they  are  arrested  ;  it  is  quite  usual  for  general  visceral  implication 
to  be  secondary  to  the  pulmonary  growths.  Nothing  is  known  as 
to  the  existence  of  nerves  or  lymphatics  in  sarcomata ;  occasionally, 
however,  dissemination  by  way  of  the  lymphatic  glands  is  met 
with,  especially  in  melanotic  sarcoma,  lympho-sarcoma,  and 
sarcoma  of  the  tonsil,  testis,  and  thyroid  body.  Various  secondary 
changes  are  apt  to  occur,  e.g.,  fatty  degeneration,  mucoid  softening, 
and  haemorrhage,  whilst  calcification  is  not  uncommon. 

On  naked-eye  examination,  a  sarcoma  presents  a  more  or  less 
homogeneous  appearance,  the  colour  varying  with  the  amount  of 
the  blood-supply,  from  a  greyish-white  in  the  fibro-sarcomata  to 
a  deep   maroon    colour   in  the  myeloid.     On    scraping   the  cut 

surface,  juice,  like  that  from  a 
cancer,  is  never  obtained,  even 
when  the  tumour  has  been  re- 
moved from  the  body  for  some 
time,  and  thus  the  cohesion  of 
the  cells  impaired  ;  a  milky  sub- 
stance then  sometimes  appears, 
whilst  in  myeloid  sarcoma  a  slimy 
fluid  escapes,  but  it  in  no  way 
resembles   that    obtained    from    a 


v%- 


Fig.  25. — Small  Round -celled 
Sarcoma  infiltrating  Muscular 
Tissue.     (Tillmanns.) 


cancer. 

This  form  of  malignant  disease 
occurs  most  commonly  in  young 
and  middle-aged  people,  especially 
affecting  the  first  and  fourth  de- 
cades of  life  ;  it  may  also  be  con- 
genital. The  degree  of  malignancy  varies  considerably,  some 
forms  being  almost  benign,  or,  at  any  rate,  only  locally  malignant, 
whilst  others  are  exceedingly  virulent  in  nature. 

Sarcomata  are  divided  artificially  into  the  following  groups, 
depending  on  the  size,  shape,  arrangement,  and  character  of  the 
constituent  cells  :  (a)  The  round-celled  ;  (b)  the  spindle-celled  ; 
(c)  the  myeloid  ;   (d)  the  alveolar  ;  and  (e)  the  melanotic. 

(a)  Round-celled  Sarcomata  (Fig.  25)  consist  of  a  mass  of  round 
cells  containing  a  very  definite  circular  or  oval  nucleus  ;  the  inter- 
cellular substance  is  slight  in  amount,  and  often  homogeneous  in 
character.  The  mass  is  very  vascular,  and  may  even  pulsate ; 
it  is  soft,  like  granulation  tissue,  and  usually  grows  rapidly. 
Several  subdivisions  are  described :  (i.)  The  small  round-celled 
sarcoma  is  extremely  malignant,  infiltrating  surrounding  parts, 
and  early  giving  rise  to  secondary  deposits ;  lymphatic  glands 
are  not  unfrequently  affected  in  this  variety.  Any  part  of  the 
body  may  be  involved,  and  it  may  be  met  with  at  any  age. 
(ii.)  The  large  round-celled  sarcoma  is  made  up  of  larger  cells,  which 
contain  one  or  two  large  oval  nuclei  with  an  abundant  protoplasm 


'5* 


A  MANUAL  OF  SURGERY 


around.  A  well-marked  stroma  is  interspersed  between  the  cells, 
and  an  alveolar  arrangement  is  sometimes  present  ;  it  occurs  in 
the  same  position  as  the  former,  but  is  rather  less  malignant, 
(iii.)  Lymphosarcoma  is  very  similar  in  structure  ;  the  cells,  how- 
ever, are  small,  and  the  intercellular  substance  is  of  a  delicate 
reticular  nature,  corresponding  to  the  retiform  tissue  commonly 
met  with  in  lymphatic  glands.  Such  tumours  grow  rapidly,  and 
are  exceedingly  malignant ;  they  usually  start  in  lymphatic  glands, 
or  in  the  lymphoid  tissue  of  mucous  membranes,  and  are  dissemi- 
nated by  means  of  the  lymphatics.  For  the  clinical  characters  of 
these  tumours,  see  Chapter  XII.  (iv.)  Glioma  or  glio-sarcoma  is 
probably  a  variety  of  round-celled  sarcoma  which  develops  in 
connection  with  the  nervous  system  ;  but  there  is  some  doubt  as 


Fig.  26. — Spindle-celled  Sarcoma. 
The  individual  cells  have  been  separated,  and  the  characteristic  nuclei  can  be 


to  whether  it  should  be  considered  a  sarcoma  at  all.  It  consists 
of  round  cells  from  which  a  number  of  delicate  filamentous  pro- 
cesses are  furnished  ;  they  probably  originate  from  the  neuroglia, 
the  cells  of  which  they  much  resemble.  Gliomata  are  found  grow- 
ing from  the  retina  in  children,  forming  tumours  which,  situated 
at  first  within  the  eye,  sooner  or  later  invade  the  lymph  spaces 
surrounding  the  bloodvessels  in  the  orbit,  and  also  spread  back- 
wards along  the  optic  nerve  to  the  chiasma,  and  thence  downwards 
to  the  opposite  eye,  or  upwards  to  the  brain.  They  are  also 
found  as  primary  growths  in  the  cerebral  substance,  and  some- 
times in  the  spinal  cord.  They  have  no  general  malignancy,  but 
may  destroy  life  as  a  result  of  their  local  development. 

(b)  Spindle-celled  Sarcomata  (Fig.  26)  consist  of  large  or  small 
spindle  cells,  which  are  often  arranged  in  a  somewhat  fasciculated 
manner  with  a  greater  or  less  amount  of  intercellular  substance. 
When  consisting  of  small  cells,  the  tumour  grows  rapidly,  and  is 
firmer  and  less  succulent  than  the  round-celled  variety.  In 
some  cases  the  intercellular  substance  is  very  abundant,  and 
so  fibrillated  in  character  as  to  cause  the  tumour  to  be  known  as 


TUMOURS  AND  CYSTS 


157 


a  fibrosarcoma  (the  '  recurrent  fibroid '  of  Paget).  They  may 
originate  in  any  part  of  the  body,  but  more  especially  from 
aponeuroses,  fasciae,  tendons,  etc.,  constituting  localized  growths, 
which  are  at  first  tolerably  well  defined,  but  later  on  invade  and 
infiltrate  surrounding  parts.  When  growing  rapidly,  the  cells 
become  less  fusiform  in  shape,  and  may  even  approach  to  the 
round  cell  in  character,  after  passing  through  a  stage  known  as 
the  oval-  or  oat-shaped  sarcoma.  These  tumours,  consisting  of 
small  spindle  cells,  are  usually  very  malignant  in  character,  except 
when  of  the  fibro-sarcomatous  character,  and  then  the  tendency 
to  become  disseminated  is  less  marked,  although  there  is  usually 


w^ty 


Fig.  27.— Myeloid  Sarcoma,  showing  the  Multi-nucleated  Myeloid 
Cells  (Myeloplaxes)  lying  amongst  the  more  abundant  Spindle 
Cells.     (Green's  'Pathology.') 

a  considerable  risk  of  local  recurrence.  The  large  spindle-celled 
sarcomata  are  softer  and  of  a  deeper  colour  than  the  former.  They 
grow  from  the  fibrous  tissues,  and  not  uncommonly  from  the 
viscera.  The  congenital  sarcoma  of  the  kidney  is  of  this  nature, 
though  some  of  the  cells  become  transversely  striated,  looking 
like  muscle  fibres ;  such  tumours  are  sometimes  called  '  myo- 
sarcomata.' 

(c)  Myeloid  Sarcomata  (Fig.  27)  are  characterized  by  the  pres- 


158  A  MANUAL  OF  SURGERY 


ence  of  large  numbers  of  multi-nucleated  giant  cells  {myeloplaxes), 
imbedded  in  a  considerable  quantity  of  round  or  spindle  cells,  the 
intercellular  substance  being  usually  of  a  gelatinous  nature.  The 
myeloid  cells  vary  a  good  deal  in  size,  but  always  contain  a  large 
number  of  distinct  nuclei,  which  are  not  distributed  regularly  in 
the  periphery  of  the  cell,  as  in  the  case  of  the  giant  cells  of 
tubercle ;  they  may  be  regular  in  outline,  or  prolonged  into 
numerous  interlacing  processes,  although  these  latter  are  usually 
not  very  evident.  There  is  also  no  definite  arrangement  of  cells 
around  them  as  in  the  tubercular  giant-cell  systems.  These 
tumours  are  soft  in  consistency,  and  on  scraping  a  slimy  fluid  is 
obtained.  They  are  exceedingly  vascular,  and  may  pulsate. 
Haemorrhage  into  their  substance  is  common,  giving  rise  to  cysts, 
filled  with  serum  and  a  yellowish  fibrinous  clot  stained  with  the 
colouring  matter  of  the  blood.  When  fresh,  the  growing  edge  is 
of  a  dark  maroon  colour  on  section,  and  has  been  likened  to  the 
appearance  of  a  pomegranate  ;  when  preserved  in  spirit,  these 
tumours  are  always  of  a  characteristic  brown  colour,  owing  to  the 
formation  of  haematin.  They  are  the  least  malignant  of  all  the 
sarcomata,  but  rarely  or  never  giving  rise  to  secondary  deposits, 
either  in  the  lymphatic  glands  or  viscera.  Their  growth  is 
tolerably  rapid,  and  they  may  attain  enormous  dimensions.  Myeloid 
sarcoma  is  almost  invariably  found  growing  from  bones ;  for  the 
particular  sites,  symptoms  and  treatment,  see  Chapter  XVIII.  A 
certain  amount  of  doubt  exists  as  to  whether  these  tumours  should 
be  included  amongst  the  sarco-  ^_ 

mata,  since  their  clinical  history  fjg  ,/#*'§ 


and  progress  are  of  a  benign  ^   . ^ %  /;* U%? '  .§> U \ 

type,  and  the  term  'myeloma'  -^  S^.-.i'V'V/-- ;V "l>> ■   %  J/ 

has   been  suggested   for  them,  <§>  * ».^  J*^ ^vC*? -* .1 -«% ? -** 
as  indicating  in  measure  their  ';  % ! -."V  ^\^ '-        jf  1'i  f 

nature  and  structure.  &^i  i.   •,    .,   "  AA 


(d)  Alveolar  Sarcoma  (Fig.  28)  ,  *  i ";--  & |  'i;/^^%^y%^'"^\ » 
is  a  variety  in  which  the  cells  %.%s     ••'?/•>      ' .-s'.VjVJ^"}* 
are  grouped  together  in  alveoli, 
separated  by  a  distinct  fibrous 
stroma.      On    microscopic   ex-  •<-,'»'?;  *  ^Z"~k^*3^'S® 
amination  they  closely  resemble  ^  f  ®  <&"%f'f("!&*''    K 
cancer ;    but  on  carefully  pen-  "  ? 

cilling  a  section  with  a  camel's-  Fig.  28. — Alveolar  Sarcoma. 

hair    brush,    it   will    be    found  (Tillmanns.) 

that  the  stroma  sends   delicate  The  individual  cells  in  the  alveoli  are 

prolongations   between    each   of  here  apparently  lying  in  close  con- 

fY              11           t-u-                            <-  tact,  but  in  reality  there  is  a  certain 

the    cells.        I  his    variety     of  amount  of  intercellular  substance 

tumour  is  most  commonly  found  placed  between  each  of  them. 

growing  from  the  skin,  and  is 

occasionally  of  a  melanotic  nature,  and  always  very  malignant. 

(e)  Melanotic  Sarcoma  is  perhaps  the  most  virulent  of  all  this 


TUMOURS  AND  CYSTS  159 

group  of  tumours.  It  almost  invariably  originates  from  pigmented 
structures,  e.g.,  the  deeper  layers  of  the  skin  or  the  retina.  It  is, 
however,  sometimes  met  with  growing  from  the  mucous  mem- 
brane of  the  lips  and  gums.  It  consists  of  round  or  spindle  cells, 
often  arranged  in  alveoli,  whilst  in  other  cases  club-shaped  pro- 
cesses of  epithelium  may  penetrate  into  the  subjacent  tissues,  thus 
causing  it  to  resemble  epithelioma.  The  most  prominent  feature 
is  the  brown  colour,  owing  to  a  deposit  within  the  cells  of  granules 
of  melanin.  The  amount  of  this  pigmentation  varies  consider- 
ably, some  tumours  being  of  a  deep  brown  or  brownish-black 
colour,  and  then  consisting  of  flattened  plaques,  whilst  others 
are  of  a  papillomatous  nature,  and  show  but  slight  discoloration, 
especially  if  growing  rapidly.  The  tumour  soon  spreads  to  the 
nearest  lymphatic  glands,  and  secondary  deposits  in  the  viscera 
follow.  So  great  is  the  malignancy,  that,  according  to  Erichsen, 
if  the  primary  growth  has  attained  the  size  of  a  filbert,  local 
treatment  is  of  but  little  value.  The  original  tumour  is  often  not 
very  large,  and  the  secondary  deposits  are  similarly  characterized 
by  their  number  rather  than  by  their  size,  scarcely  an  organ  in 
the  body  being  free. 

Of  late  years  a  more  benign  type  of  melanosis  has  been  described,  and  is 
now  well  recognised  by  dermatologists.  It  usually  spreads  from  a  congenital 
mole  as  a  deeply  pigmented  patch,  which  may  extend  over  an  area  of  several 
square  inches,  and  presents  at  first  no  sign  of  induration  or  infiltration  ;  in  this 
stage  microscopic  examination  reveals  no  change  in  texture  except  pigmenta- 
tion of  the  deeper  layers  of  the  cutis  vera.  Sooner  or  later,  a  tumour  develops 
in  the  centre  of  this  patch,  and  may  be  either  a  sarcoma  or  a  cancer,  but  more 
frequently  the  former.  It  is  not  very  rapid  in  its  course,  but  if  left  alone  will 
finally  become  disseminated.  In  treating  this  type  of  melanosis,  it  is  essential 
to  remove  every  portion  of  pigmented  tissue  as  well  as  the  tumour. 

Some  degree  of  uncertainty  exists  as  to  the  position  which  should  be 
assigned  to  the  tumour  known  as  an  endothelioma ;  it  originates  in  mesoblastic 
tissues,  but  is  somewhat  similar  in  nature  to  the  cancers,  for  which,  indeed, 
it  has  often  been  mistaken.  It  arises  from  the  endothelial  cells  of  serous 
membranes,  lymphatics  or  bloodvessels,  and  usually  consists  of  columns  of 
cells  supported  by  a  fibro-cellular  stroma.  It  sometimes  originates  from  the 
pleura  or  cerebral  membranes,  but  may  also  be  observed  in  glandular  organs, 
such  as  the  breast,  parotid,  testis,  or  ovary.  On  serous  membranes  it  may 
give  rise  to  large  tumours,  from  which  secondary  deposits  in  glands  or  viscera 
are  after  a  time  developed,  but  the  rate  of  dissemination  is  not  great.  In 
glands  the  tumour  often  starts  as  a  more  or  less  cylindrical  proliferation  of 
the  endothelial  cells  of  the  arterioles  or  lymphatics  ;  this  gradually  extends 
along  the  vessel  and  usually  leads  to  its  obliteration,  whilst  either  the  cells  or 
the  surrounding  tissues  undergo  a  mucoid  or  hyaline  change;  this  arrange- 
ment in  cylinders  or  columns  led  to  the  name  cylindroma,  which  was  often 
applied  to  it.  The  tumour  runs  a  slowly  malignant  course,  comparable  to 
that  of  some  of  the  less  virulent  sarcomata,  and  its  nearest  homologue  is 
probably  an  angio-sarcoma. 

The  Treatment  of  sarcoma  consists  in  its  removal  as  early  and 
completely  as  possible.  This  may  be  a  simple  matter  in  cases 
where  the  tumour  is  encapsuled,  but  even  then  recurrence  is  very 


i6o 


A  MANUAL  OF  SURGERY 


likely  to  follow  unless  the  capsule  is  also  taken  away,  and  a 
considerable  margin  of  tissue  beyond  it.  Where,  however,  the 
growth  is  more  diffuse,  the  only  hope  lies  in  cutting  widely,  so  as 
to  get  beyond  its  furthest  limits  ;  the  prognosis  of  such  cases  is 
very  bad. 

In  hopelessly  inoperable  cases  somewhat  similar  measures  have 
been  employed  as  for  the  similar  stage  of  cancer  (vide  p.  145). 
Several  cures  have  now  been  recorded  from  the  use  of  Coley's 
fluid,  which  consists  of  a  sterilized  culture  of  the  Streptococcus 
erysipelatis  and  Micrococcus  prodigiosus  in  bouillon.  This  fluid  is 
intensely  toxic,  and  the  injections,  commencing  with  doses  of  half 
a  minim,  are  gradually  increased  up  to  7  or  8  minims ;  severe 
reaction  usually  follows,  and  the  surgeon  should  aim  at  obtaining 
two  or  three  such  effects  each  week.  The  fluid  is  introduced  partly 
into  the  abdominal  wall,  and  partly  into,  or  around,  the  tumour. 
In  favourable  cases  the  growth  gradually  dwindles.  The  spindle- 
celled  sarcomata  are  apparently  the  most  suitable  for  this  treat- 
ment, whilst  ossifying  and  melano- sarcomata  are  but  little,  if  at 
all,  affected. 


(2)  Tumours  consisting  of  Fully-developed  Connective  Tissue. 

Lipoma. — A   fatty   tumour  is   an  overgrowth  of  fibro-cellular 

On    microscopical    examination    it 


-- 


tissue,    infiltrated    with    fat. 
differs  in  no  respect  from 
ordinary    adipose    tissue, 
and  is  not  very  freely  sup- 
plied with  bloodvessels. 

When  localized  (Fig. 
29)  it  forms  a  tumour, 
soft  and  semi-fluctuating 
in  consistence,  rounded 
and  lobulated  in  outline, 
and  if  occurring  in  the 
subcutaneous  tissues,  the 
skin  becomes  dimpled  on 
moving  it  from  side  to 
side,  owing  to  the  fact 
that  fibrous  trabeculae 
pass  from  the  capsule  to 
the  skin.  The  growth  is 
usually  encapsuled  and 
freely  movable ;  but  if 
exposed  to  pressure  or 
friction,  as  when  situated 
on  a  man's  shoulder  and 

rubbed  by  the  braces,  it  becomes  firmly  adherent  to  surrounding 
structures.     Such  growths  are  either  single  or  multiple,  in  the 


Fig.  29. — Lipoma,  showing  Characteristic 

Lobulated  Outline.     (From  King's 

College  Museum.) 


TUMOURS  AND  CYSTS 


161 


latter  case  perhaps  occurring  in  hundreds,  and  are  most  com- 
monly found  about  the  trunk  or  the  upper  extremities.  It  has 
been  stated  that  lipomata  travel  from  one  point  of  the  body  to 
another  by  the  action  of  gravity,  but  it  is  somewhat  doubtful 
whether  this  ever  occurs.  Occasionally  subcutaneous  tumours 
become  pedunculated  and  pendulous. 

Deep  inter-muscular  lipomata  are  sometimes  met  with,  and  the 
diagnosis  may  then  be  uncertain,  since  their  mobility  and  lobulated 
outline  are  masked  by  the  superjacent  tissues  ;  they  have  even 
been  mistaken  for  sarcomatous  growths.  Still  more  difficult  of 
recognition  are  those 
known  as  parosteal  lipo- 
mata, growing  from  the 
outer  surface  of  the  peri- 
osteum. They  are  often 
congenital,  and  appear 
as  soft  swellings,  lying 
beneath  the  muscles  in 
close  proximity  to  a  bone 
and  suggesting  the 
presence  of  a  chronic 
abscess.  We  observed 
one  a  little  time  back- 
growing  just  above  the 
angle  of  the  jaw  beneath 
the  masseter. 

Pericranial  lipoma  is 
of  a  somewhat  similar 
nature.  It  is  usually 
congenital  in  origin,  and 
often  the  cranium  is  per- 
forated and  a  connec- 
tion established  with  the 
meninges.  An  angioma- 
tous element  is  some- 
times present  in  these 
growths. 

By  the  term  Diffuse  Lipoma  (Fig.  30)  is  meant  a  fatty  infiltra- 
tion of  the  subcutaneous  tissues  of  some  region  of  the  body, 
particularly  beneath  the  chin  and  at  the  back  of  the  neck,  and 
more  rarely  in  the  pubic  region.  These  growths  are  often 
multiple  and  almost  always  symmetrical.  They  usually  occur  in 
individuals  who  drink  freely  and  take  but  little  exercise.  Their 
size  diminishes  on  limiting  the  amount  of  alcohol  and  making  the 
patient  do  physical  work. 

Occasionally  the  connective-tissue  basis  of  a  lipoma  undergoes 
modifications  ;  e.g.,  it  may  become  increased  in  amount,  con- 
stituting a  Fibro-lipoma,  or  be  transformed  into  mucoid  tissue, 

11 


Fig.  30. — Diffuse  Lipoma. 


162  A  MANUAL  OF  SURGERY 

giving  rise  to  a  Myxo-lipoma ;  or,  again,  the  vessels  may  become 
dilated,  originating  a  Nsevo-lipoma ;  and  even  a  Sarco-lipoma  may 
develop. 

Localized  or  diffuse  overgrowths  are  often  met  with  in  the 
sub -peritoneal  fatty  tissue,  constituting  Subserous  Lipomata. 
They  occur  not  unfrequently  in  the  lower  part  of  the  abdomen, 
and  may  extend  into  the  inguinal  and  crural  canals,  forming 
the  so-called  fatty  tumour  in  these  parts.  By  their  traction  a 
process  of  peritoneum  may  eventually  be  drawn  down,  and  a  true 
hernia  produced.  A  similar  condition  occurs  in  the  anterior 
abdominal  wall,  small  pedunculated  masses  of  fat  projecting 
through  congenital  or  acquired  openings  in  the  linea  alba  or 
linea  semilunaris ;  these  are  sometimes  known  as  Fatty  Hernia 
of  the  Linea  Alba,  and  are  often  painful. 

Lipoma  Arborescens  is  the  term  applied  to  a  villous  outgrowth 
of  fatty  tissue,  met  with  in  the  interior  of  joints,  and  usually 
associated  with  osteo-arthritis.  There  is  often  a  considerable 
increase  in  the  amount  of  intra-articular  fluid,  and  the  condition 
has  then  been  designated  '  synovitis  lipomatosus.' 

The  Treatment  of  lipomata  consists  in  their  removal.  When 
they  are  loosely  encapsuled,  this  is  a  very  simple  matter,  all  that 
is  required  in  many  cases  being  to  squeeze  the  mass  forwards 
between  the  thumb  and  finger,  making  the  skin  tense  over  it,  and 
then  to  incise  the  capsule  freely,  when  the  tumour  almost  jumps 
out ;  but  if  there  are  many  adhesions  it  may  not  be  so  easy.  In 
the  diffuse  forms  dietetic  and  hygienic  measures  should  first  be 
tried.  Should  an  operation  be  required,  it  is  well  to  cut  through 
the  whole  thickness  of  the  tumour  at  once,  and  deal  with  each 
half  separately,  dissecting  it  away  from  its  deep  attachments. 

Fibromata  consist  of  overgrowths  of  fibrous  tissue ;  they  were 
formerly  divided  into  two  groups,  the  hard  and  the  soft,  and 
although  there  is  no  essential  difference  between  them,  it  is  a 
useful  clinical  distinction. 

The  Hard  Fibroma  is  composed  of  firm  dense  tissue,  which 
creaks  on  section  with  the  knife,  the  exposed  surface  showing 
numerous  trabecular  of  glistening  fibres,  similar  in  character  to 
those  met  with  in  a  tendon  (Fig.  31).  Microscopically,  interlacing 
fibrillae  are  seen,  which  are  sometimes  arranged  concentrically 
around  the  bloodvessels  ;  there  are  but  few  nucleated  cells  in  the 
more  slowly  growing  tumours.  The  vascular  supply  is  somewhat 
defective,  although  dilated  veins  are  often  present,  especially  in 
the  capsule,  and  sometimes  in  the  substance  of  the  mass  ;  these, 
if  opened  by  ulceration,  may  lead  to  profuse  haemorrhage.  Hard 
fibromata  are  met  with  in  the  form  of  epulis,  fibrous  polypus  of  the 
nose,  keloid,  and  not  uncommonly  in  connection  with  the  sheaths 
of  nerves. 

Soft   Fibromata  develop  as  localized  overgrowths  of  the  sub- 


TUMOURS  AND  CYSTS 


163 


cutaneous  fibro-cellular  tissue,  or  as  the  so-called  Molluscum 
fibrosum  of  the  skin.  In  the  latter  case  many  different  forms  of 
the  growth  are  met  with  ;  sometimes  a  development  of  small 
nodules  occurs,  scattered  widely  over  the  surface,  usually  pinkish, 
and  with  the  skin  over  them  somewhat  corrugated  ;  these  may  be 
associated  with  changes  in  the  underlying  nerves  (p.  168).  It  also 
exists  in  the  form  of  pendulous  folds,  perhaps  involving  a  large 
area  of  the  trunk  ;  the  so-called  pachydermatocele  of  the  scalp  is 
of  this  nature. 

Chondroma. — Cartilaginous   tumours    are    met    with    growing 
either  in  connection  with  bones  or  in  certain  soft  tissues.     They 


Fig.  31. — Section  of  Hard  Fibroma.     (Royal  College  of  Surgeons' 

Museum.) 


consist  of  hyaline  cartilage,  which,  instead  of  being  uniform  in 
texture  and  devoid  of  vessels  as  at  the  articular  ends  of  bones, 
occurs  in  the  form  of  pellets  or  nodules  of  varying  size,  held 
together  by  vascular  connective  tissue,  which  may  even  penetrate 
into  the  substance  of  the  cartilage.  The  cells  are  also  less  regular 
in  shape  than  is  the  case  with  normal  cartilage,  and  are  not 
arranged  according  to  any  definite  plan. 

Chondromata  are  liable  to  become  calcified,  and  even  ossified. 
When  large,  the  central  parts  may  undergo  a  mucoid  change, 
giving   rise   to   a   cavity   which,    if  sepsis  is  admitted,  becomes 

11 — 2 


164 


A  MANUAL  OF  SURGERY 


exceedingly  foul.     They   are   not  uncommonly   accompanied    in 
their  growth  by  sarcomatous  and  other  elements. 

When  growing  from  the  long  bones,  chondromata  usually  start 
from  beneath  the  periosteum,  and  are  independent  of  the  epiphy- 
seal cartilage,  although  it  has  been  suggested  by  Virchow  that 
they  may  originate  from  a  nodule  of  cartilage  which  has  been  dis- 
placed from  its  usual  situation  during  an  attack  of  rickets.  They 
constitute  firm  lobulated  encapsuled  tumours,  and  give  rise  to  no 
pain,  except  when  they  encroach  on  neighbouring  nerves.  They 
often  attain  a  great  size.  The  growth  may  extend  secondarily 
into  the  medullary  canal,  and  thus  cause  expansion  of  the  bone ;  or 
it  may  erode  the  compact  tissue,  and  lead  to  spontaneous  fracture. 
Amputation  of  the  limb  will  probably  be  necessary,  unless  the 
case  comes  under  observation  in  the  early  stages,  when  the  tumour 
can  be  gouged  or  scraped  away. 

Chondromata  also  originate  from  the  smaller  bones,  usually  from 
those  of  the  hand  (Fig.  32).  In  such  cases 
the  growth  commences  in  the  interior, 
close  to  the  epiphyseal  cartilage ;  several 
tumours  may  be  present  in  the  same  indi- 
vidual. The  bone  is  expanded  by  the 
growth,  and  the  parts  become  much  de- 
formed. Treatment  consists  in  incising 
the  capsule,  and  scooping  out  the  carti- 
laginous tissue,  a  proceeding  which  may 
result  in  defective  growth  and  subsequent 
deformity.  In  the  later  stages,  however, 
amputation  is  inevitable. 

Chondromata  are  also  found  in  the  soft 
parts,  especially  affecting  the  parotid  and 
submaxillary  glands,  and  the  testes.  In 
the  parotid  gland  they  are  usually  asso- 
ciated with  mucous  and  fibrous  tissue,  a 
few  glandular  elements  being  also  embedded  in  the  mass.  They 
develop  from  the  capsule  of  the  gland,  or  immediately  beneath  it, 
and  are  usually  simple  in  nature,  though  occasionally  they  become 
sarcomatous.  Submaxillary  chondroma  is  frequently  an  almost 
unmixed  cartilaginous  tumour. 

Overgrowths  of  cartilage,  known  as  Ecchondroses,  occur  around 
the  articular  cartilages  in  connection  with  osteo-arthritis ;  they 
also  arise  from  the  cartilages  and  septum  of  the  nose,  and  from 
the  laryngeal  cartilages.  Some  of  the  loose  bodies  which  form  in 
joints  are  of  a  similar  nature. 

Osteoma. — Bony  tumours  are  of  two  chief  forms  :  the  cancellous 
and  the  ivory. 

Cancellous  Osteomata  are  usually  met  with  growing  near  the 
articular  end  of  a  bone,  being  derived  originally  from  some  iso- 
lated portion  of  the  epiphyseal  cartilage,  which  has  perhaps  been 


Fig.    32. — Multim-e 

Chondromata  of 

the  Fingers. 


PLATE  IV 


Exostosis  of  the  Radius. 

This  growth  occurred  in  a  young  man  aged  twenty-three  years.  It  will  be  noticed 
that  it  has  caused  great  deformity  of  the  ulna,  and,  indeed,  apart  from  the  skia- 
gram, one  might  have  supposed  that  it  had  originated  from  that  bone. 

To  face  •/>.  165.] 


TUMOURS  AND  CYSTS  165 

separated  from  its  original  connection  after  an  attack  of  rickets. 
It  is  well  known  that  in  this  affection  irregular  outgrowths  from 
the  epiphyseal  cartilage  occur,  and  if  one  of  these  near  the  peri- 
phery of  the  bone  becomes  shut  off  from  its  epiphyseal  attachment, 
it  is  easy  to  understand  its  development  into  a  tumour,  which 
consists  of  cancellous  bone,  capped  by  a  layer  of  hyaline  cartilage, 
from  which  it  grows  (Fig.  33).  It  is  pedunculated  or  sessile,  and 
may  attain  to  a  large  size,  leading  to  considerable  deformity 
(Plate  IV.).  It  necessarily  develops  in  young  people,  and  may 
be  congenital.  As  the  individual  grows,  the  basis  of  attachment 
may  become  separated  from  the  epiphysis  to  an  extent  corre- 
sponding to  the  amount  of  growth  which  has  taken  place  at  that 
spot,  or  it  may  still  remain  attached  to  the  epiphyseal  line.     As  a 


Fig.  33. — Diagrammatic  Represen- 
tation of  Cancellous  Exostosis 
growing  from  the  lower  end 
of  the  Femur.  Fig.  34. — Subungual  Exostosis. 

_.  .    .,',     '.  .   ,  .  (Bland  Sutton.) 

Its  proximity  to  the  epiphyseal  car- 

tilage  is  indicated,  as  also  its  carti- 
laginous covering  and  the  bursa 
which  occasionally  lies  over  its 
summit. 

rule  its  growth  and  development  cease  at  maturity,  when  the 
cartilage  covering  it,  as  well  as  the  epiphyseal  cartilage,  ossifies. 
A  bursa  occasionally  forms  over  the  most  prominent  part  of  these 
tumours  as  a  result  of  friction  or  pressure,  giving  rise  to  the  con- 
dition known  as  Exostosis  Bursata  ;  this  cavity  may  communicate 
with  the  joint.  An  effusion  of  blood  or  serum  into  the  bursa  may 
be  the  first  evidence  of  the  existence  of  such  a  growth.  Multiple 
exostoses  are  not  unfrequently  met  with,  and  are  then  often 
hereditary.  The  most  common  situation  for  such  a  tumour  is 
the  inner  condyle  of  the  femur,  close  to  the  adductor  tubercle, 
but  they  are  not  rare  on  the  inner  aspect  of  the  mandible.  The 
Subungual  Exostosis  (Fig.  34)  develops  as  a  rounded,  cherry-like 
swelling  under  the  nail  of  the  great  toe.  It  is  very  painful,  and 
should  be  treated  by  removing  the  nail,  incising  the  tissues  over 


1 66 


A  MANUAL  OF  SURGERY 


it  down  to  the  bone,  and  clipping  it  away  with  cutting  pliers. 

Fig.  35  represents  a  skiagram  of  an  exostosis  growing  from  the 

proximal  phalanx  of  the  thumb. 

Ivory  Exostoses  develop  most  frequently  on  the  inner  or  outer 

aspect  of  the  cranial  bones,  especially  affecting  the  orbit,  external 

auditory   meatus,    antrum,  and   frontal    sinus    (Fig.   36).     They 

consist  of  masses  of  very  dense  compact  tissue,  covered  by 
periosteum,  from  which  they  grow.  They 
are  usually  lobulated,  and  when  situated 
in  the  frontal  sinus,  or  growing  from  the 
under  surface  of  the  skull,  may  give  rise 
to  serious  symptoms  from  irritation  or 
compression  of  the  brain  or  its  membranes. 
In  a  few  cases  necrosis  has  resulted,  and 
they  have  sloughed  out,  thus  bringing 
about  a  spontaneous  cure. 

Occasionally  diffuse  overgrowth  of  the 
bones  of  the  skull  (Hyperostoses)  are  met 
with,  affecting  either  the  calvarium  alone, 
being  then  probably  syphilitic  in  nature,  or 
the  facial  and  cranial  bones,  as  in  leontiasis 
ossea.  New  formation  of  bone  sometimes 
occurs  in  the  substance  of  tendons  which 
are  exposed  to  irritation  or  excessive 
action,  e.g.,  the  tendon  of  the  adductor 
longus  in  riders,  producing  what  is  known 
as  '  the  rider's  bone,'  but  this  is  inflam- 
matory in  origin. 

The  Treatment  of  osteomata  consists  in 
their  removal  where  possible.  This  may 
be  tolerably  simple  in  the  case  of  the 
cancellous  osteomata  of  the  limbs,  but  is 

sometimes  a  most  formidable  proceeding  when  dealing  with  sessile 

compact  exostoses  of  the  calvarium. 

Myoma.— Myomata  almost  always  consist  of  unstriped  muscle 
fibres  (Leiomyoma  or  fibromyoma),  forming  rounded  and  often  en- 
capsuled  tumours,  the  cells  of  which  are  long  and  fusiform,  and 
contain  a  rod-like  nucleus.  Bundles  of  these  cells  are  grouped 
together  into  fasciculi,  which  are  arranged  more  or  less  regularly. 
The  tumours  themselves  are  not  very  vascular,  but  vessels  of 
considerable  size  are  found  in  the  capsule.  It  is  often  difficult  to 
distinguish  these  tumours  microscopically  from  fibromata  on  the 
one  hand,  and  from  fibro-sarcomata  on  the  other.  From  the 
former  they  are  known  by  the  fact  that  individual  cells  can  be 
recognised,  and  by  the  absence  of  wavy  tendinous  fibrillae ;  from 
the  latter  the  distinction  depends  on  the  facts  that  other  types  of 
tissue  may  occur  in  the  sarcoma,  and  that  the  growing  edge  is 


Fig.  35. — Skiagram  of 
Exostosis  growing 
from  the  Base  of 
Proximal  Phalanx 
of  Thumb,  showing 
Open  Cancellous 
Texture  and  Origin 
near  the  Epiphy- 
seal Cartilage. 


TUMOURS  AND  CYSTS 


167 


usually  more  or  less  embryonic  in  character,  whilst  a  myoma 
is  of  the  same  structure  throughout.  Again,  in  a  myoma  the 
bloodvessels  have  distinct  and  definite  walls,  and  in  a  sarcoma 
they  are  simply  clefts  or  passages  in  the  tumour  substance. 

Myomata  are  met  with  in  the  uterus  and  prostate,  and  occasion- 
ally in  the  walls  of  the  alimentary  canal  and  in  the  ovary. 
Secondary  changes  sometimes  occur,  e.g.,  mucoid  softening,  as  in 
fibro-cystic   disease   of  the   uterus,  calcification,  ulceration  with 


Fig.  36 — Ivory  Exostosis  growing  from  Frontal  Sinus,  and  encroach- 
ing both  on  the  Orbit  and  the  Cranial  Cavity.     (Bland  Sutton.) 

(From  specimen  in  the  College  of  Surgeons'  Museum.) 

profuse  haemorrhage,  and  possibly  consequent  septic  inflammation, 
whilst  malignant  disease  may  supervene.  For  the  characters  of 
the  prostatic  myomata,  see  Chapter  XXXVII. 

Tumours  consisting  of  striped  muscle  fibres  (Rhabdomyoma) 
have  been  described,  but  are  exceedingly  rare. 

Neuroma. — True  Neuroma  is  seldom  met  with,  only  five  un- 
doubted cases  being  on  record.  It  is  formed  by  a  mass  of  newly- 
formed  ganglion  cells  and  nerve  fibres,  which  may  be  medullated 
or  not.  In  all  but  one  case  it  involved  the  sympathetic  system, 
and  occurred  in  children  or  young  people.  The  tumours  may 
attain  considerable  dimensions,  are  often  multiple,  and  may  be 
quite  soft,  like  a  lipoma,  or  firm.  They  are  insensitive  and  inno- 
cent, and  may  be  freely  removed. 

False  Neuromata,  or  those  developing  in  connection  with  the 
sheaths  of  nerves,  are  more  common,  and  may  be  described  under 
three  headings : 

1.  Solitary  Pseudo-Neuroma,  which  may  be  innocent  or  malig- 
nant, the  former  being  a  fibroma  or  myxoma,  the  latter  usually  a 


1 68 


A  MANUAL  OF  SURGERY 


Fig.  37.  —  Pseudo  -  Neuroma  : 
Fibrous  Tumour  growing 
from  Nerve  Sheath,  and 
causing  the  Fibres  to  be 
widely  stretched  over  it. 


sarcoma.  It  may  project  from  one  side  of  the  nerve,  or  more 
frequently  causes  the  nerve  fibres  to  be  separated  and  spread  out 
over  it  (Fig.  37).     It  moves  more  freely  in  a  direction  at  right 

angles  to  the  axis  of  the  nerve 
than  along  its  course.  When  de- 
veloping from  a  small  nameless 
subcutaneous  twig,  it  is  termed  a 
painful  subcutaneous  nodule,  and  then 
gives  rise  to  intense  pain  of  a 
neuralgic  type,  especially  when 
compressed  or  irritated,  or  when 
exposed  to  cold.  A  false  neuroma 
growing  from  a  larger  mixed  nerve 
(trunk  neuroma)  is  less  painful, 
because  there  are  relatively  fewer 
nerve  fibrillae,  and  the  mass  is  less 
exposed.  A  growth  on  a  pure 
motor  nerve,  though  sensitive,  is 
not  associated  with  radiation  of 
pain.  It  is  uncommon  for  tumours 
of  this  nature  to  lead  to  complete 
paralysis  or  anaesthesia,  unless 
they  are  of  a  malignant  nature. 
They  occur  most  frequently  in 
healthy  adults,  and  in  women  a 
little  more  commonly  than  in  men. 

Treatment. — A  neuroma,  if  painful,  should  be  removed,  care 
being  taken,  if  possible,  not  to  interfere  with  the  continuity  of  the 
nerve  fibrillae.  If  this  cannot  be  accomplished,  the  nerve  must  be 
divided,  and  the  ends  united  by  immediate  suture. 

2.  Diffuse  or  Generalized  Neuro- fibromatosis  [Recklinghausen 's 
disease). — This  consists  of  a  diffuse  thickening  of  the  nerve  sheaths, 
causing  multiple  elliptic  or  spherical  tumours,  or  a  generalized 
enlargement.  The  growths  may  be  encapsuled  and  limited  or  not ; 
they  may  be  few  in  number,  or  hundreds  may  be  present,  and  they 
are  usually  whitish  and  firm  in  texture.  They  originate  from  the 
endoneurium  of  the  primary  nerve  bundles.  Any  part  of  the  peri- 
pheral nervous  system  may  be  affected,  including  the  sympathetics, 
but  it  is  most  common  in  connection  with  the  cranial  nerves  and 
the  large  plexuses  of  the  trunk.  The  actual  symptoms  are  some- 
times very  slight,  but  the  tumours  may  be  sensitive  to  pressure, 
and  some  one  of  them,  more  exposed  than  the  others,  may  be  ex- 
quisitely tender.  Motor  phenomena  are  rare,  and  paralysis  is 
usually  due  to  involvement  of  the  nerve  roots  in  the  spinal  canal, 
or  to  the  supervention  of  sarcoma,  which  is  a  not  uncommon  ter- 
mination. The  disease  may  start  at  any  time  during  life,  and 
although  progressing  slowly,  sooner  or  later  terminates  fatally. 
No  known  treatment  is  of  any  avail,  but  should  any  particular 
tumour  become  large  and  tender,  it  may  be  removed. 


TUMOURS  AND  CYSTS  169 


In  connection  with  this  disease  one  frequently  finds  a  large 
development  of  fibrous  growths  of  the  skin,  similar  to  what  we 
have  already  described  as  molluscum  fibrosum.  On  careful 
microscopical  examination  of  specimens  stained  by  Weigert's 
method,  the  presence  of  nerve  fibrillae  can  be  demonstrated  in 
these  growths,  showing  that  they  are  really  neuro-fibromatous  in 
origin.  So  excessive  does  this  overgrowth  occasionally  become 
that  a  form  of  elephantiasis  is  produced,  e.g.,  the  irregular  hyper- 
plasia of  the  scalp  tissues  known  as  a  pachydermatocele. 

A  Plexiform  Neuroma  is  a  special  modification  of  this  process, 
occurring  congenitally  or  in  young  people,  and  usually  involving 
the  trigeminal  or  superficial  cervical  nerves ;  it  may  be  associated 
with  the  former  condition.  The  overgrowth  is  of  a  softer,  more 
gelatinous  type  (myxo-fibromatous),  and  the  resulting  tumour 
consists  of  a  plexus  of  thickened,  tortuous,  vermiform  strands,  of 
soft  consistence,  held  together  by  loose  connective  tissue,  but 
easily  separable  into  their  constituent  elements,  which  are  of  a 
nodulated  character,  so  that  the  dissected  mass  looks  "  not  unlike 
grains  of  boiled  tapioca  on  a  string"  (Alexis  Thomson).  The 
plexiform  neuroma  is  almost  always  subcutaneous,  but  often  dips 
deeply  between  and  into  the  substance  of  muscles.  When  limited 
in  extent,  the  growth  may  be  dissected  out,  and  this  is  usually 
required  for  cosmetic  purposes.  The  final  prognosis  is  rather 
better  than  in  the  former  condition,  as  secondary  sarcomatous 
changes  are  rare. 

3.  The  bulb  formed  upon  the  proximal  end  of  a  nerve  after  its 
division  is  sometimes  described  as  a  neuroma  (Traumatic  Neuroma). 
It  consists  of  a  mass  of  fibro-cicatricial  tissue  containing  spaces, 
coiled  up  within  which  are  numbers  of  newly-formed  axis  cylinders 
(p.  328).  They  are  almost  always  present  in  amputation  stumps, 
but  are  not  painful  unless  adherent  to  the  periosteum  of  the 
neighbouring  bone,  or  to  the  cicatrix,  when  every  movement  of 
the  nearest  joint  causes  traction  upon  them,  and  induces  severe 
neuralgia. 

Angioma. — Several  distinct  varieties  of  tumour  consisting  of 
dilated  arteries  or  veins  exist,  but  the  term  angioma  is  applied 
only  to  those  in  which  a  new  formation  of  bloodvessels  occurs ; 
hence  aneurisms  and  varicose  veins  are  not  included  in  this 
catagory. 

Three  main  types  of  angioma  may  be  described:  (1)  The  simple 
naevus ;  (2)  the  cavernous  naevus ;  and  (3)  the  plexiform  angioma. 

The  Simple  Naevus  is  exceedingly  common,  and  consists  of  a 
mass  of  dilated  capillaries,  bound  together  by  a  small  amount 
of  connective  tissue.  It  is  usually  congenital,  and  may  increase 
rapidly  in  size  during  the  first  few  months  of  life.  It  is  located 
in  the  skin,  or  may  also  involve  the  subcutaneous  tissues,  but  the 
tubular  form  of  the  constituent  vessels  always  remains.     It  may 


170 


A  MANUAL  OF  SURGERY 


be  of  a  bright  red  colour  or  of  a  dusky  tint.  For  a  fuller  account, 
see  Chapter  XI.  If  untreated,  simple  naevi  may  persist  unchanged, 
or  may  disappear  ;  in  a  few  instances  they  increase  rapidly  in  size, 
either  early  or  late  in  life,  sometimes  giving  rise  to  a  considerable 
vascular  growth,  purplish  in  colour,  and  occasionally  becoming 
prominent  and  pendulous.  Such  a  tumour  is  soft  and  easily 
compressible,  being  in  reality  a  cavernous 
ulcerate,  and  profuse  haemorrhage  may  result, 
in  electrolysis,  if  excision  is  impracticable. 

The  Cavernous  Nsevus  consists  of  dilated  spaces,  where  the 
tubular  form  of  the  constituent  vessels  is  lost,  the  arteries  usually 
opening  directly  into  thin-walled  cavities  lined  with  endothelium 
without  the  intervention  of  capillaries  (Fig.  38).  The  tumours 
are  thus  more  or  less  erectile  in  nature,  somewhat  resembling  the 

corpus  cavernosum.     They  are 


angioma ;    it   may 
Treatment  consists 


met  with  in  the  skin  and  sub- 
cutaneous tissues,  constituting 
diffuse  or  circumscribed  tumours 
of  a  reddish-blue  colour,  which 
can  be  emptied  on  pressure,  but 
rapidly  refill  when  such  is  re- 
moved, and  in  which  pulsation  is 
occasionally  present.  A  similar 
condition  arises  in  the  viscera, 
especially  the  liver,  and  then  is 
always  acquired,  and  it  is  not 
difficult  in  suitable  cases  to 
demonstrate  that  it  has  been 
formed  by  a  dilatation  of  the 
capillaries  between  the  lobules, 
the  liver  substance  meanwhile 
disappearing  by  a  process  of 
simple  atrophy.  Occasionally  a 
cavernous  angioma  undergoes  a 
process  of  spontaneous  cure  as  the  result  of  some  inflammatory 
affection  similar  in  nature  to  phlebitis,  a  non-vascular  fibro-cystic 
mass  remaining. 

Under  the  term  Plexiform  Angioma  may  be  included  the  cirsoid 
aneurism,  or  aneurism  by  anastomosis,  the  former  term  being 
applied  by  some  authors  to  tumours  consisting  of  large  vessels, 
and  then  most  commonly  seen  about  the  scalp  and  face,  and  the 
latter  to  a  congeries  of  small  vessels.  The  treatment  is  always  a 
matter  of  considerable  difficulty  (see  Chapters  XVIII.  and  XXIV.). 
Odontoma. — Tumours  originating  from  some  abnormal  condi- 
tion of  the  teeth  or  teeth-germs  are  known  as  '  odontomes.' 
Bland  Sutton,  in  his  work  on  tumours,*  has  described  seven 
different  varieties,  several  of  which  are,  however,  rarely  met  with 
*  Bland  Sutton,  'Tumours  and  Cysts.'     Cassell  and  Co. 


Fig.  38. 


-Section   of  Cavernous 
Angioma. 


TUMOURS  AND  CYSTS  171 

in  man.  We  can  only  deal  here  with  the  more  important  of 
these,  and  must  refer  our  readers  to  Chapter  XXV.  and  to 
Sutton's  book  for  a  fuller  description.  (1)  Epithelial  Odontome. 
In  this  condition,  formerly  known  as  '  fibro-cystic  disease  of 
the  jaw,'  the  mandible  is  most  commonly  affected.  A  tumour 
forms,  consisting  of  spaces  lined  by  epithelium,  which  are 
developed  as  irregular  outgrowths  from  the  enamel  organ. 
It  occurs  most  frequently  in  young  people,  and  may  give  rise 
to  a  growth  of  enormous  size.  (2)  Follicular  Odontomes,  or,  as 
they  are  often  termed,  '  dentigerous  cysts,'  are  produced  by  the 
development  of  a  cavity  around  a  misplaced  or  ill-developed  tooth 
of  the  permanent  set,  which  often  lies  horizontally,  so  that  its 
eruption  is  impossible.  (3)  Fibrous  Odontomes  are  the  result 
of  a  thickening  and  condensation  of  the  connective  tissue 
around  a  tooth  sac.  They  are  most  frequently  observed  in  the 
lower  animals,  but  are  also  said  to  occur  in  rickety  children. 
(4)  Radicular  Odontome  is  the  term  applied  to  a  tumour  composed 
of  cement,  developing  at  the  root  of  a  tooth.  It  gives  rise  to 
severe  pain,  and  may  result  in  septic  inflammation  of  the 
surrounding  bone.  (5)  Composite  Odontomata  consist  of  a  con- 
glomeration of  the  various  forms  of  tissue  entering  into  the 
formation  of  a  tooth,  and  developing  in  the  neighbourhood  of 
the  jaw.  They  may  be  very  large,  and  probably  some  of  the  bony 
tumours  described  as  osteomata  of  the  antrum  are  of  this  nature. 

Lymphadenoma  and  Lymphangioma.  —  The  primary  tumours 
developing  in  lymphatic  glands  are  described  in  Chapter  XII.,  as 
also  the  conditions  arising  from  the  dilatation  of  lymphatics. 

II.  Tumours  derived  from  Epiblastic  or  Hypoblastic  Structures. 

These  are  either  innocent  or  malignant  in  nature,  the  innocent 
tumours  being  the  papillomata  and  adenomata,  and  the  malignant 
the  carcinomata. 

Papillomata  consist  in  an  outgrowth  of  the  papillae  of  the  skin 
or  mucous  membrane,  which  may  be  simple  in  nature,  or  compo- 
site from  the  development  of  lateral  offshoots,  giving  rise  to  a 
cauliflower-like  mass ;  they  may  be  sessile  or  pedunculated.  The 
connective  tissue  of  the  papillae,  with  its  vessels,  also  extends 
into  the  growth,  which  is  sometimes  exceedingly  vascular.  The 
epithelium  never  dips  down  into  the  subcutaneous  or  submucous 
tissue,  the  growth  being  only  centrifugal  in  development,  and  not 
centripetal,  as  in  the  case  of  the  epitheliomata.  Not  unfrequently, 
however,  a  papilloma  which  has  become  irritated  may  take  on 
malignant  action.  Clinically,  a  papilloma  is  distinguished  from 
an  epithelioma  by  the  base  being  free  from  infiltration. 

Papillomata  of  the  skin  are  met  with  in  the  form  of  hard 
excrescences,    such    as    warts   or   corns ;    but   if  growing    from 


172  A   MANUAL  OF  SURGERY 

moist  parts,  as  from  the  prepuce,  they  may  be  soft  and  vascular. 
Occasionally  warts  may  grow  to  such  an  extent  as  to  constitute 
horn-like  projections  or  cauliflower-like  growths. 

Papillomata  of  the  mucous  membranes  are  usually  villous  in 
character,  constituting  long,  fimbriated  tufts,  covered  with  a  thin 
layer  of  epithelium,  and  containing  delicate  bloodvessels,  which 
readily  give  way,  and  may  lead  to  considerable  haemorrhage. 
They  are  most  commonly  observed  in  the  bladder,  but  occasion- 
ally in  the  pelvis  of  the  kidney,  and  on  the  intestinal  mucous 
membrane,  especially  in  the  rectum.  They  also  occur  on  the 
true  vocal  cords,  and  are  then  wart-like,  and  hard  in  consistency. 
Growths  of  a  very  similar  nature,  but  somewhat  more  solid  in 
texture,  are  found  within  the  ducts  or  acini  of  glandular  viscera, 
such  as  the  breast.  Condylomata  and  mucous  tubercles,  develop- 
ing in  the  course  of  syphilis,  are  also  of  a  papillomatous  nature. 

Adenomata  consist  of  new  growths  arising  in  connection  with 
secreting  glands,  and  in  structure  simulating  somewhat  closely  the 
organs  from  which  they  rise.  They  differ  from  them,  however, 
in  that  they  are  incapable  of  producing  the  characteristic  secretion, 
that  they  are  devoid  of  ducts,  and  that  the  mimicry  is  incomplete, 
since  the  alveoli  are  less  perfectly  developed,  and  may  be  entirely 
occupied  by  several  layers  of  epithelial  cells.  The  epithelium, 
however,  does  not  pass  beyond  the  basement  membrane  into  the 
connective  tissue,  and  hence  they  also  are  distinguished  from  can- 
cerous tumours  by  the  new  formation  being  centrifugal,  and  not 
centripetal,  in  its  growth.  A  variable  amount  of  connective  tissue 
is  always  present,  and  may  be  normal  in  texture,  or  may  mani- 
fest various  modifications.  Adenomata  are  usually  encapsuled, 
being  merely  connected  with  the  original  gland  by  a  pedicle, 
through  which  the  vessels  enter.  When  growing  from  mucous 
membranes,  they  are  sometimes  pedunculated,  as  in  the  so-called 
polypus  recti.  The  alveoli  in  some  cases  become  distended  with 
effusion,  giving  rise  to  a  cysto-adenoma  or  adenocele.  They  are 
absolutely  free  from  malignancy,  except  when,  as  occasionally 
happens,  the  connective  tissue  undergoes  a  sarcomatous  change, 
whilst  sometimes  carcinoma  supervenes.  When  of  large  size, 
they  may  cause  trouble  by  compression  of  important  structures. 
Any  glandular  organ  may  become  affected  with  adenoma,  and 
several  varieties  will  be  described  hereafter  in  the  chapters  on  the 
breast,  thyroid  body,  prostate,  testis,  etc.  They  are  also  found  as 
congenital  tumours  in  connection  with  the  thyroid  body,  post-anal 
gut,  and  possibly  the  kidney.  The  growth  is  usually  slow,  but 
occasionally  becomes  rapid. 

Carcinoma. — The  malignant  forms  of  epithelial  new  growth  are 
known  as  cancers  or  carcinomata,  of  which  the  following  varieties 
are  described,  viz.,  epithelioma,  rodent  ulcer,  columnar  carcinoma, 
and  glandular  or  acinous  cancer.     The  term  'colloid  cancer'   is 


TUMOURS  AND  CYSTS  173 

also  used  to  indicate  a  degenerative  change  occurring  in  some 
forms. 

The  essential  character  of  a  cancerous  growth  consists  in  an 
unlimited  multiplication  of  the  epithelial  elements  of  the  organ 
attacked.  In  some  cases  this  may  result  in  the  formation  of  a 
superficial  outgrowth  of  a  papillomatous  type,  while  deep  pro- 
cesses or  columns  of  cells  advance  into  the  tissues  along  the 
lymphatic  channels,  and  even  burst  through  the  basement  mem- 
brane of  glandular  alveoli.  The  irritation  of  this  development 
leads  to  an  infiltration  of  the  surrounding  structures  with  round 
cells,  which  are  presumably  inflammatory  in  origin,  by  the  agency 
of  which  the  normal  tissues  are  disintegrated  and  removed,  and 
a  stroma  of  variable  density  develops  around  the  epithelial 
outgrowths.  Hence  all  cancerous  tumours  may  be  said  to  consist 
of  a  fibro-cellular  or  fibro-cicatricial  stroma  (Plate  V.,  Fig.  1), 
within  the  alveoli  of  which  are  collections  of  epithelial  cells, 
sometimes  arranged  in  a  methodical  manner,  but  more  often 
packed  irregularly  together,  and  with  no  intercellular  tissue 
between  them.  The  alveolar  spaces  are  in  reality  dilated 
lymphatics,  and  hence  it  is  easy  to  understand  that  carcinomata 
are  disseminated  along  these  vessels ;  the  cancer  cells  are 
epithelial  in  origin,  and  of  very  variable  size  and  shape ;  but  they 
always  retain  more  or  less  the  characters  of  the  epithelium  from 
which  they  are  originally  developed,  so  that,  e.g.,  a  squamous 
epithelioma  is  never  derived  from  a  part  covered  with  columnar 
epithelium,  or  vice  versa.  Bloodvessels  ramify  through  the  stroma, 
and  are  more  or  less  abundant  according  to  its  density.  The 
tumours  are  not  necessarily  tender  to  the  touch,  but  a  consider- 
able degree  of  pain,  usually  of  a  neuralgic  type,  is  often  com- 
plained of,  especially  in  the  harder  forms,  where  tissues  get 
dragged  upon  by  the  contracting  stroma. 

iEtiology. — Formerly  cancer  was  considered  to  be  of  constitu- 
tional origin,  resulting  from  some  morbid  condition  of  the  blood, 
and  in  favour  of  this  view  the  immense  difficulty  of  eradicating  it 
was  educed,  as  also  its  hereditary  nature  in  many  cases.  It  is 
now,  however,  generally  admitted  to  be  primarily  local  in  origin, 
and  probably  the  result  of  the  inoculation  and  development  of 
some  specific  organism.  The  chief  arguments  in  favour  of  its 
local  origin  are  as  follows  :  (1)  That  it  often  occurs  in  individuals 
who,  up  to  the  time  of  its  onset,  have  been  in  perfect   health  ; 

(2)  that  cachectic  symptoms  only  manifest  themselves  in  the  later 
stages  of  the  disease,  being  then  readily  explicable  by  excessive 
pain,  the  absorption  of  septic  discharges,  loss  of  blood,  or  possibly 
the   toxic  effect  of  some    material   absorbed   from   the  growth ; 

(3)  that  the  original  neoplasm  is  always  single,  multiple  tumours 
being  the  result  of  infection  from  the  primary  growth  ;  (4)  that 
some  definite  focus  of  local  irritation  may  frequently  be  traced  as 
the  cause  of  the  tumour — e.g.,  the  irritation  of  the  lip  by  a  short 


174  A  MANUAL  OF  SURGERY 


clay  pipe,  the  presence  of  ulceration  or  cicatrices  of  the  tongue, 
resulting  from  ragged  teeth,  syphilitic  affections,  etc.  It  is  also 
interesting  to  note  that  cancer  usually  involves  the  intestinal 
canal  in  situations  where  there  is  a  sudden  change  of  calibre, 
giving  rise  to  increased  friction  from  the  passage  of  the  contents — 
e.g.,  at  the  upper  and  lower  ends  of  the  oesophagus,  at  the  pylorus, 
the  ileo-caecal  valve,  either  end  of  the  sigmoid  flexure,  the  lower 
part  of  the  rectum,  and  the  anus.  (5)  Moreover,  if  an  early  and 
thorough  operation  is  undertaken,  the  growth  can  be  completely 
eradicated  from  the  system,  whilst  even  if  it  recurs,  it  usually 
attacks  the  cicatrix  or  the  neighbouring  glands,  indicating  that 
the  removal  has  been  incomplete. 

The  infective  nature  of  cancer  is  still  sub  judice.  Clinical  evidence 
exists  to  indicate  that  cancer  can  be  transmitted  from  one  person 
to  another,  but  it  is  somewhat  scanty  in  amount.  Thus,  cancer  of 
the  cervix  uteri  has  been  known  to  be  followed  ■  by  epithelioma  of 
the  penis  in  the  husband.  Again,  it  has  been  shown  by  Shattock 
that  in  certain  houses  (called  by  him  '  cancer  houses ')  one  set 
of  indwellers  after  another  has  been  attacked  by  this  disease. 
Experimental  research,  as  to  the  transmissibility  of  cancer  from  one 
individual  to  another,  is  necessarily  unobtainable,  although  it  has 
been  proved  that,  in  a  person  already  suffering  from  cancer,  a 
portion  of  the  growth  transplanted  to  a  distant  part  of  the  body 
will  grow,  and  lead  to  the  formation  of  a  similar  tumour  at  the  site 
of  inoculation.  Attempts  have  also  been  made  to  transmit  the 
disease  to  animals,  but  with  a  very  slight  degree  of  success,  even 
in  cases  where  the  point  of  inoculation  has  been  previously 
irritated.  Hence  the  view  that  cancer  is  due  to  infection  depends 
rather  on  the  analogy  of  the  disease  to  other  chronic  infective  dis- 
orders than  on  any  well-ascertained  facts.  The  relation  of  cancer 
to  Psorospermiae  has  been  much  discussed  of  recent  years,  and  by 
some  authorities  the  disease  is  supposed  to  be  due  to  these 
organisms.  Their  opinions,  which  are  not  generally  accepted, 
are  based  on  the  following  facts :  (a)  That  in  the  majority  of 
cancerous  growths  certain  abnormal  bodies  resembling  the  coccidia 
of  psorosperms  have  been  demonstrated  within  the  epithelial 
cells  ;  but  even  if  these  '  cancer  bodies '  are  of  this  nature,  it  has 
yet  to  be  proved  that  they  are  causative,  and  not  concurrent 
manifestations,  whilst  it  is  probable  that  they  are  merely  foci  of 
colloid  degeneration,  (b)  In  rabbits  suffering  from  undoubted 
psorospermosis,  outgrowths  somewhat  similar  in  nature  to  epithe- 
lioma have  been  detected  in  the  biliary  ducts  and  certain  viscera, 
and  these  growths  have  even  been  produced  by  artificial  inocula- 
tion with  the  organisms.  Mention  must  be  made  here  of  Dr. 
Lack's  interesting  experiment  in  which  he  caused  an  extensive 
intraperitoneal  development  of  cancer  in  a  rabbit  by  scattering 
broadcast  throughout  the  cavity  the  scrapings  of  an  ovary  which 
necessarily  contained  a  vast  number  of  living  epithelial  cells.    His 


TUMOURS  AND  CYSTS 


175 


idea  is  that  cancer  is  merely  the  outcome  of  the  development  of 
epithelium  placed  in  unusually  favourable  nutritive  conditions, 
e.g.,  in  lymphatic  spaces. 

Epithelioma  {syn. :  Squamous  Epithelioma,  Epithelial  Cancer). — 
By  this  term  is  meant  a  cancerous  tumour  growing  from  skin  or 
from  those  portions  of  the  mucous  membranes  which  are  covered 
with  squamous  epithelium.  The  variety  formerly  known  as 
columnar  epithelioma  is  really  of  glandular  origin,  and  will  be 
described  separately. 

Epithelioma  is  usually  met  with  in  middle-aged  or  elderly 
individuals,  although  occasion- 
ally it  is  seen  in  young  adult 
life.  Any  portion  of  the  skin 
may  be  the  site  of  this  tumour, 
as  also  the  mucous  membrane 
of  the  mouth,  pharynx  and  oeso- 
phagus, and  that  lining  the 
genito- urinary  tract.  It  com- 
monly results  from  some  long- 
continued  irritation,  as  in  the  lip 
or  tongue,  whilst  on  the  penis  it 
is  always  associated  with  a  long 
foreskin.  Old  scars,  especially  if 
they  become  ulcerated,  are  likely 
to  be  invaded,  and  the  disease 
may  supervene  on  intractable 
lupus. 

Clinically,  epithelioma  may  be 
looked  on  as  a  malignant  wart, 
which  not  only  grows  outwards 
from  the  surface,  but  also 
burrows  deeply  into  adjacent 
tissues  ;  sooner  or  later  ulcera- 
tion follows.  Several  character- 
istic forms  are  described  :  (a)  It 
may  occur  as  a  nodular  indurated 
mass,  with  hard  everted  edges 
and  central  ulceration,  giving 
rise  to  a  somewhat  crateriform 
ulcer  (Fig.  39).  (b)  The  destruc- 
tive process  may  extend  equally  with  the  new  formation,  leading 
to  the  appearance  of  a  depressed  sore,  with  sharply-cut  edges, 
closely  resembling  a  rodent  ulcer,  (c)  Occasionally  the  superficial 
outgrowth  is  excessive,  and  the  destructive  process  limited, 
giving  rise  to  a  projecting  cauliflower-like  mass,  which  is  soft  and 
easily  _  bleeds  {malignant  papilloma),  (d)  A  chronic  epithelioma  is 
sometimes  seen,  in  which  the  fibrous  stroma  contracts  and  com- 


\ 

A 

/  A 
1 

7 

Fig.  39. — Typical  Epitheliomatous 
Ulcer,  showing  Heaped-up  Mar- 
gins and  Deep  Central  Crateri- 
form Excavation.  (College  of 
Surgeons'  Museum.) 


I76  A  MANUAL  OF  SURGERY 


presses  the  columns  of  epithelial  cells;  the  surface  is  then 
indurated  and  wart-like,  with  but  little  ulceration,  whilst  the  base 
is  very  hard,  and  the  progress  of  the  case  much  less  rapid  than  in 
other  forms. 

The  disease,  as  a  rule,  early  infects  neighbouring  lymphatic 
glands,  which  become  the  seat  of  a  similar  growth,  and,  if  super- 
ficial, sooner  or  later  involve  the  skin  and  give  rise  to  charac- 
teristic ulceration.  As  the  disease  progresses,  more  distant 
groups  of  lymphatic  glands  are  attacked ;  it  is  unusual  to  find 
this  form  of  cancer  disseminated  through  the  internal  viscera. 
The  glands  sometimes  become  cystic,  especially  in  the  neck,  and  on 
cutting  into  them  a  thin,  turbid  fluid  like  sero-pus  escapes,  mixed, 

j* 


.■oaooo 


Fig.  40. — Section  of  Epithelioma.     (Ziegler.) 

a,  Epidermis  ;  b,  corium  ;  c,  subcutaneous  areolar  tissue  ;  d,  sebaceous  gland  ; 
e,  hair  follicle ;  /,  cancerous  ingrowths  from  the  epidermis  ;  g,  deeply-set 
cancerous  cell  groups  ;  h,  proliferating  fibrous  tissue  ;  i  (above),  cell  nesl 
or  epidermic  globe ;   i  (below),  sweat  gland. 

perhaps,  with  masses  of  epithelial  debris ;  from  time  to  time 
similar  material  is  discharged  through  the  resulting  sinuses. 
Ulceration  into  the  main  vessels  of  the  neck  may  also  follow, 
and  cause  death  from  haemorrhage  ;  otherwise  the  fatal  event  is 
due  to  cachexia  and  exhaustion. 

Microscopically,  an  epithelioma  consists  of  club-shaped  columns 
of  epithelial  cells,  ramifying  in  the  subcutaneous  tissues,  and 
interlacing  freely  with  each  other,  so  as  to  produce  an  irregular 
network,  the  meshes  of  which  are  occupied  by  a  fibro-cellular 
growth  (Fig.  40).    The  superficial  cells  in  epithelioma  are  usually 


TUMOURS  AND  CYSTS 


177 


squamous  in  type,  but  in  the  deeper  parts  prickle  cells  are  not 
unfrequently  observed,  whilst  the  processes  are  bounded  by  a 
tolerably  definite  layer  of  cuboidal  epithelium,  tending  to  become 
columnar.  Within  the  processes,  concentrically  arranged  collec- 
tions of  squamous  cells  round  one  or  more  enlarged  cells  are  often 
seen,  known  as  'epithelial  nests '  (Fig.  40,  i).  The  stroma  in  the 
neighbourhood  of  the  advancing  columns  is  always  infiltrated 
with  an  abundant  exudation  of  leucocytes. 

Rodent  Ulcer  is  generally  admitted  to  be  a  cancerous  tumour  of 
an  epitheliomatous  type,  commencing  probably  in  the  sebaceous 
glands.  It  is  usually 
met  with  in  elderly 
patients,  though 
occasionally  observed 
in  those  under  forty, 
and  is  seen  with 
special  frequency  on 
the  upper  two-thirds 
of  the  face,  the  skin 
below  the  inner  and 
outer  canthi  being 
the  chief  seats  of 
election.  It  com- 
mences as  a  papule 
or  flat-topped  nodule 
in  the  skin,  sur- 
rounded, perhaps,  by 
an  area  of  hyperemia. 
The  infiltration  ex- 
tends gradually  in  all 
directions,  but  the 
ulceration  usually 
keeps  pace  with  the 
new  growth.  The 
ulcer  has  a  smooth 
but  somewhat  de- 
pressed surface,  is 
perhaps  covered  with 
granulations,  and 
bounded  by  a 
slightly-raised,  indurated,  rolled-over  edge  (Fig.  41).  In  the 
later  stages  one  can  often  detect  evidences  of  the  new  forma- 
tion beneath  the  skin  beyond  the  edge.  If  kept  aseptic,  there  is 
but  little  discharge,  and  imperfect  attempts  at  cicatrization  are 
often  observed,  the  scar,  however,  readily  breaking  down;  but 
when  septic,  the  surface  is  covered  with  sloughs,  and  an  abundant 
offensive  discharge  escapes.     The  condition  is  painless ;    neigh- 

12 


-Rodent  Ulcer. 
Photograph. 


178  A  MANUAL  OF  SURGERY 

bouring  lymphatics  are  not  enlarged,  and  the  general  health  does 
not  suffer,  except  in  the  later  stages.  The  progress  of  the  case  is 
slow,  but  continuous,  and  although  it  spreads  superficially  rather 
than  deeply,  sooner  or  later  underlying  structures  become  in- 
volved, and  nothing  hinders  the  destructive  process,  even  the 
bones  of  the  skull  being  eroded,  and  the  dura  mater  exposed. 

Microscopically,  the  growth  is  very  similar  to  an  epithelioma, 
consisting  of  interlacing  columns  of  epithelial  cells,  interspersed 
with  fibro-cellular  tissue.  The  chief  differences  consist  in  the 
facts — (i.)  that  the  constituent  cells,  although  epithelial,  are  not 
epidermic  in  character,  being  smaller,  more  globular,  never  of  the 
'  prickle-cell '  type,  and  rarely  showing  signs  of  keratinization  ; 
hence,  '  cell  nests '  are  uncommon,  although  they  are  sometimes 
observed,  (ii.)  The  deep  processes  are  not  so  distinctly  columnar 
or  club-shaped,  spreading  laterally  beneath  the  unaffected  skin 
rather  than  deeply ;  their  outline  is  also  more  clearly  defined,  and 
frequently  angular  on  section,  (iii.)  There  is  less  cell  infiltration 
around  the  new  formation. 

The  Treatment  of  rodent  ulcer  consists  in  free  excision  when 
practicable,  a  margin  of  at  least  half  an  inch  being  allowed  all 
round,  and  the  defect  made  good  by  skin-grafting  or  by  some 
plastic  operation.  Where  such  cannot  be  undertaken,  the  ulcer 
may  be  thoroughly  scraped,  and  the  surface  treated  with  nitric 
acid,  chloride  of  zinc  paste,  or  some  other  caustic,  the  wound 
being  allowed  to  heal  by  granulation.  The  X  rays  have  also 
proved  beneficial  in  these  cases,  the  patient  being  submitted  to 
their  influence  for  about  ten  minutes  daily.  The  surrounding 
parts  are  protected  by  plates  of  soft  metal  foil  carefully  fitted  to 
them,  and  with  a  suitable  hole  in  the  centre  exposing  the  sore. 
Sometimes  a  good  deal  of  irritation  results,  but  frequently  the 
ulcer  rapidly  cleans  up  and  commences  to  heal. 

Columnar  Carcinoma.  —  This  affection,  which  was  formerly 
termed  '  columnar  epithelioma,'  is  in  the  majority  of  cases  a  true 
glandular  cancer.  It  is  met  with  most  frequently  in  the  alimentary 
canal,  arising  from  any  portion  of  it  in  which  columnar  epithelium 
occurs,  and  usually  originating  as  an  overgrowth  of  Lieberkiihn's 
follicles  (Fig.  42).  These  form  a  projecting  growth  from  the 
surface  in  the  same  way  as  a  papilloma  springs  from  the  skin,  but 
also  penetrate  deeply  into  the  submucous  and  muscular  coats. 
The  deep  processes  retain  an  imperfect  alveolar  arrangement,  and 
between  them  is  found  a  certain  amount  of  fibro-cellular  stroma, 
upon  the  character  of  which  the  hardness  of  the  tumour  depends. 
In  the  firmer  types  the  stroma  is  abundant,  and  fibro-cicatricial 
in  quality,  the  growth  of  the  tumour  being  slow  ;  in  the  softer  and 
more  rapidly-growing  forms  the  stroma  is  less  abundant,  and  more 
of  a  simple  fibro-cellular  nature.  On  section  of  a  limited  portion 
of  the  growth,  it  would  often  be  impossible  to  distinguish  it  from 
a  simple  adenoma  of  Lieberkiihn's  follicles ;  but  if  a  large  section, 


TUMOURS  AND  CYSTS  179 

including  the  whole  thickness  of  the  intestinal  wall,  is  examined, 
the  extension  of  the  glandular  tissue  into  and  between  the  mus- 
cular fasciculi  at  once  indicates  the  malignant  nature  of  the  case. 
Ulceration  usually  occurs,  giving  rise  to  a  typical  sore,  bounded 
in  the  more  chronic  forms  by  indurated  and  everted  edges.  Neigh- 
bouring lymphatics  are  implicated,  as  in  the  case  of  all  cancers, 
whilst  later  on  the  disease  spreads  to  the  viscera,  and  may  be 


02 


i 

I 

1 


Fig.  42. — Section  through  Advancing  Margin  of  Columnar  Cancer  of 
Stomach,      x  25      (Ziegler.) 

a,  Mucosa;  b,  submucosal  c,  muscularis;  (/.serosa;  e,  neoplasm  which,  starting 
from  the  mucosa,  has  invaded  the  other  layers.  Small-celled  infiltration 
has  accompanied  here  and  there  the  formation  of  the  neoplastic  tubules. 

generally  disseminated.  A  similar  type  of  growth  occurs  in  the 
cervical  portion  of  the  uterus,  and  occasionally  in  the  ducts  of 
glands  such  as  the  liver  and  breast.  It  is  also  met  with  in  the 
superior  maxilla,  originating  in  the  tubular  glands  of  the  mucous 
membrane  lining  the  antrum. 

Glandular  or  Acinous  Cancer. — Glandular  cancer  may  be  looked 
on  as  a  malignant  form  of  adenoma,  bearing  the  same  relation  to  the 
latter  as  does  an  epithelioma  to  a  benign  papilloma.  The  epi- 
thelium of  the  glandular  acini,  from  which  it  originates,  is  not 
retained  by  the  basement  membrane,  but  travels  beyond  it  along 

12 — 2 


180  A  MANUAL  OF  SURGERY 

the  lymphatics  into  surrounding  parts,  which  are  transformed 
by  a  process  already  described  into  the  tumour  substance.  The 
amount  of  stroma  varies  considerably,  and  according  to  whether 
it  is  abundant  or  small  in  quantity,  the  tumour  is  hard  or  soft  in 
consistence,  and  slow  or  rapid  in  growth.  To  the  former  type 
the  term  Scirrhus  is  applied ;  to  the  latter,  Encephaloid. 

Scirrhus  is  met  with  most  frequently  in  the  breast,  but  also 
occurs  in  the  prostate,  pancreas,  and  pyloric  end  of  the  stomach. 
The  clinical  features  of  the  disease  as  seen  in  the  breast  are 
described  in  Chapter  XXXI.  On  naked-eye  examination  a 
scirrhous  tumour  appears  as  a  hard  nodular  mass,  the  limits  of 
which  are  imperfectly  defined.  When  cut  across,  it  creaks  under 
the  knife,  and  presents  a  yellowish-white  surface,  which  rapidly 
becomes  concave  owing  to  the  contraction  of  the  fibrous  stroma. 
It  has  often  been  compared  to  the  section  of  an  unripe  pear  or 
turnip,  both  on  account  of  the  grating  sensation  imparted  to  the 
knife,  and  from  its  appearance.  On  scraping  the  cut  surface  with 
the  blade  of  a  knife,  a  typical  cancer  juice  is  obtained,  consisting 
of  epithelial  cells  and  debris. 

On  microscopical  examination,  the  tumour  is  found  to  consist 
of  an  abundant  and  well-marked  stroma,  the  acini  of  which  are 
filled  with  epithelial  cells  (Plate  V.,  Fig.  i).  In  the  centre  fatty 
degeneration  is  often  present,  small  cysts  being  occasionally 
produced  in  this  way.  At  the  periphery  the  growth  may  be  seen 
extending  in  all  directions  along  the  lymphatics,  whilst  a  round- 
celled  infiltration  of  the  surrounding  tissues  is  also  evident. 

Where  the  stroma  is  very  excessive,  the  cell  elements,  and, 
indeed,  the  whole  tumour,  may  undergo  atrophy,  owing  to  the 
compression  of  the  nutrient  vessels,  constituting  the  variety 
known  as  atvopliic  scivrluis. 

Encephaloid,  Medullary,  or  Acute  Cancer,  is  the  term  given  to 
a  growth  of  a  similar  nature,  in  which  the  stroma  is  much  less 
abundant  than  the  cell  elements.  It  constitutes  a  soft,  rapidly 
growing  tumour  abundantly  supplied  with  bloodvessels,  and  very 
early  affecting  neighbouring  lymphatic  glands.  The  skin  over 
such  a  tumour  is  stretched,  and  dilated  blue  veins  can  be  seen 
through  it.  Ulceration  occurs  early,  and  from  this  surface  a  foul, 
bleeding,  fungating  mass  sprouts  up,  formerly  known  as  a  '  fungus 
haematodes.'  Encephaloid  cancer  is  met  with  in  the  breast,  testis, 
kidney,  and  a  few  other  glandular  organs. 

On  section  it  is  found  to  be  composed  of  a  soft  whitish  mass, 
somewhat  resembling  brain  substance.  It  is  usually  very  vascular, 
perhaps  pulsating,  and  haemorrhagic  extravasation  into  its  tissues 
is  not  uncommon.  An  abundant  juice  is  obtained  on  scraping. 
Under  the  microscope  large  groups  of  spheroidal  epithelial  cells 
are  seen,  held  together  by  a  scanty  stroma. 

Colloid  Cancer  results   from  a  degeneration   of   the   epithelial 


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TUMOURS  AND  CYSTS 


cells  of  a  glandular  or  columnar  cancer.  Its  most  frequent  site  is 
within  the  abdominal  cavity,  in  connection  with  cancers  arising 
from  the  stomach,  intestine,  or  omentum. 

To  the  naked  eye  colloid  cancer  presents  an  alveolar  structure, 
the  spaces  being  filled  Avith  translucent  gelatinous  material  of 
varying  density.  Microscopically,  the  epithelial  cells  are  rarely 
distinguishable,  being  replaced  by  a  structureless  colloid  sub- 
stance. Towards  the  growing  margin,  however,  the  cells  may  be 
seen  in  process  of  degeneration,  globules  of  the  material  forming 
within  them  and  pressing  the  nucleus  to  one  side. 

The  Treatment  of  Cancer  consists  in  the  removal  of  the  tumour 
by  operation,  together  with  a  wide  margin  of  healthy  tissue  around 
it,  or,  in  some  cases,  of  the  whole  organ  affected,  as  well  as  the 
lymphatic  area  concerned,  and,  if  practicable,  in  one  mass,  so  as 
not  to  cut  across  the  lymphatic  vessels  passing  from  the  growth 
to  the  glands.  If  such  is  conducted  in  a  thorough  manner  and  at 
a  sufficiently  early  date,  a  good  result  may  be  anticipated  ;  but, 
owing  to  the  tendency  of  all  cancers  to  spread  along  lymphatics, 
its  eradication  is  usually  a  matter  of  the  greatest  difficulty. 
Recurrence  is  therefore  very  liable  to  ensue. 

In  cases  where  removal  of  the  disease  by  the  knife  is  im- 
practicable, owing  to  its  extent,  it  may  sometimes  be  possible  to 
remove  a  portion  of  the  disease,  the  remainder  being  dealt  with  by 
caustics.  Of  these  the  most  satisfactory  is  chloride  of  zinc,  which 
is  usually  applied  as  a  paste,  a  little  opium  being  added  to  allay 
pain.  In  other  instances  it  has  been  proposed  to  starve  the 
growth  by  tying  the  chief  nutrient  artery,  and  to  diminish  pain 
by  division  of  sensory  nerves ;  such  can,  however,  only  give  the 
most  temporary  relief. 

Of  recent  years  other  methods  have  been  suggested  for  the 
treatment  of  inoperable  malignant  disease — e.g.,  the  interstitial 
injection  of  pyoktanin  or  methyl  violet,  or  of  various  bacterial 
products,  such  as  Coley's  fluid  (p.  160).  The  evidence  at  present 
forthcoming  suggests  that  the  practical  value  of  these  proceedings 
is  very  small  in  the  case  of  the  cancers.  Superficial  cancers,  such 
as  epithelioma  labii,  can  be  cured  by  exposure  to  the  X-rays,  but 
it  is  doubtful  whether  deeply-seated  foci  can  be  influenced  in 
this  way. 

In  hopeless  cases,  all  that  can  be  done  is  to  keep  any  ulcerated 
surface  free  from  irritation,  and  if  possible  aseptic,  whilst  the 
general  health  is  maintained  by  suitable  diet  and  drugs,  and 
excessive  pain  is  kept  in  check  by  the  administration  of  opium  or 
morphia. 

Cysts. 

By  a  cyst  is  usually  meant  a  more  or  less  rounded  cavity,  with 
a  distinct  lining  membrane,  distended  with  some  fluid  or  semi- 


182 


A   MANUAL  OF  SURGERY 


solid  material.  The  term  is  used  very  loosely,  being  applied  to  a 
variety  of  manifestations  which  it  is  difficult  to  classify,  owing  to 
the  fact  that  conditions  which  are  pathologically  similar  in  origin 
are  sometimes  termed  cysts  in  one  part  of  the  body,  and  not  so  in 
another.  For  practical  purposes,  however,  they  may  be  grouped 
as  follows  : 

I.  Cysts    of    embryonic   origin,    or    arising    in    connection    with 
embryonic  remains. 

II.  Cysts  arising  from  the  distension  of  pre-existing  spaces  (dis- 
tension cysts). 

III.  Cysts  of  new  formation. 

IV.  Cysts  of  degeneration. 


I.  Cysts  of  Embryonic  Origin,  or  arising  in  connection  with 
Embryonic  Remains. 

i.  The  most  important  cysts  to  be  considered  under  this  head- 
ing are  those  known  as  Dermoids.  These  are  characterized  by  the 
existence  in  abnormal  situations  of  cavities  lined  with  epithelium, 
from  which  may  be  developed  any  form  of  cutaneous  appendage 

— e.g.,  hairs,  nails,  teeth,  etc. 
— whilst  the  space  is  usually 
occupied  by  sebaceous  or 
mucous  contents.  The  struc- 
ture of  the  lining  wall  is 
very  similar  in  nature  to 
l||#^v!V  skin    or    mucous    membrane, 

% * ;1^  •  P  \^  3      consisting    of    stratified    epi- 

fflMi*^^^\V.  ..  iasaia*,       »      thelium,    from  which   a   con- 

siderable growth  of  sebaceous 
glands  and  hair  follicles  often 
takes  place. 

Several  varieties  of  dermoids 
are  described : 

(a)  Sequestration  Dermoids 
are  cysts  arising  from  the 
incomplete  disappearance  of 
surface  epithelium  in  situa- 
tions where,  during  embryonic 
life,  fleshy  segments  coalesce. 
Thus,  in  almost  any  part  of 
the  middle  line  of  the  body 
such  tumours  may  develop, 
owing  to  the  fact  that  there  is 
here  a  union  of  two  lateral  segments.  Similarly,  they  are  not 
uncommon  about  the  face  and  neck,  occurring  along  the  lines 
of  the  facial  and  branchial  clefts.  Perhaps  the  most  common 
position    for   them   in   this  region    is   the   upper  portion  of  the 


Fig.  43. — Dermoid  Cyst,  growing  at 
the  Outer  Angle  of  the  Orbit. 
(Bland  Sutton.) 


TUMOURS  AND  CYSTS  1S3 

orbito-nasal  cleft,  behind  and  to  the  outer  side  of  the  eye 
Fig.  43).  It  is  not  unusual  to  find  the  skull  defective  beneath 
them,  and  a  pedicle  extending  from  the  deep  side,  connecting 
them  with  the  dura  mater.  Sequestration  dermoids  appear 
as  rounded,  definitely  limited  tumours,  over  which  the  skin 
glides  freely,  but  are  usually  somewhat  adherent  to  the  deeper 
parts.  They  are  firm  and  elastic  to  the  touch,  and  filled 
with  sebaceous  material,  containing  fatty  debris,  flattened 
epithelial  cells,  perhaps  hairs,  and  occasionally  teeth.  This 
form  of  dermoid  may  be  removed  without  difficulty,  but  in 
those  occurring  about  the  scalp,  with  the  bone  hollowed  out 
beneath  them,  it  is  perhaps  advisable  to  delay  operation  till  adult 
life,  unless  the  tumours  are  rapidly  increasing  in  size.  The  reason 
for  this  is  that  the  bone  gradually  grows  up  around  the  pedicle, 
and  thus  closes  the  communication  with  the  cranial  cavity.  In 
some  cases  it  may  be  difficult  to  remove  the  whole  of  the  lining 
membrane  by  dissection,  and  under  these  circumstances  the 
portion  left  behind  should  be  destroyed  with  cautery  or  caustics  : 
otherwise,  recurrence  is  almost  certain  to  follow. 

(b)  Dermoids  may  also  arise  in  connection  with  embryonic 
canals  and  passages,  and  have  then  been  called  Tubulo-Dermoids. 
These  are  chiefly  met  with  in  connection  with  the  thyro-glossal 
duct  (Chapter  XXIX.)  and  the  post-anal  gut  (Chapter  XXII.). 

(c)  Ovarian  Dermoids  are  usually  unilocular,  and  of  large  size. 
They  are  lined  with  skin,  from  which  an  abundant  development 
of  cutaneous  appendages  is  sometimes  observed.  Thus,  the 
cavity  may  be  more  or  less  filled  with  hair,  whilst  large  masses 
of  teeth  set  in  bony  alveoli  are  also  seen  in  this  situation,  and  even 
nipples  and  mammae. 

2.  Cysts  occasionally  arise  in  connection  with  the  formation  of  the 
teeth  ;  such  have  been  already  alluded  to  under  the  terms  follicular 
and  epithelial  odontomes  (p. 171),  the  former  being  also  known  as 
dentigerous  cysts,  the  latter  as  fibro-cystic  disease  of  the  jaw. 

3.  Various  cysts  develop  in  connection  with  the  remains  of 
the  Wolffian  body,  as  also  from  its  tubules  and  duct.  It  must  be 
remembered  that  this  body  arises  in  the  posterior  abdominal  wall 
near  to  the  origin  of  the  kidney  and  testis,  and  that  part  of  it 
enters  into  the  formation  of  the  latter ;  hence  one  is  not  surprised 
to  find  that  its  remains  are  closely  associated  with  that  organ  in 
the  scrotum. 

In  the  male  (Fig.  44)  the  Wolffian  body  atrophies  almost  com- 
pletely, being  represented  by  a  few  blind  tubules,  situated  close 
to  the  epididymis,  and  known  as  the  paradidymis,  or  organ  of 
Giraldes.  Fibro-cystic  disease  of  the  testis  (adenoma  testis)  is 
said  to  arise  from  this  structure.  The  majority  of  the  ducts  of 
the  Wolffian  body  form  the  vasa  efferentia  testis ;  a  few  of  the 
upper  ones,  however,  contract  no  attachment  to  the  gland,  and 
their  free  ends  (known  as  Kobelt's  tubes)  may  become  dilated, 


1 84 


A   MANUAL  OF  SURGERY 


and  form  small  cysts,  situated  close  to  the  hydatid  of  Morgagni, 
which  structure  represents  the  remains  of  the  Miillerian  body  and 
duct.  It  is  possible  that  an  encysted  hydrocele  of  the  epididymis 
sometimes  arises  from  one  of  these  unobliterated  tubules.  The 
main  duct  of  the  Wolffian  body  forms  the  lower  portions  of  the 
epididymis  and  vas  deferens. 

In  the  female  (Fig.  45)  the  remains  of  the  Wolffian  body  are 
sometimes  met  with  as  a  series  of  closed  tubes  in  the  neighbour- 
hood of  the  ovary  (paroophoron).  Cysts  may  arise  in  connection 
with  this  structure,  and  are  chiefly  characterized  by  their  inner 
walls  being  the  seat  of  proliferating  papillomata.  The  Wolffian 
tubules  can  almost  always  be  recognised  in  the  broad  ligament, 


Paradidymis  or 

Ai'jJ~$£      Mesonephros. 

Kobeh's  tubes. 


Fig.  44. 


-Diagram  of  Adult  Testicle,  to  show  Relation  of  Mesonephros 
and  its  Ducts.     (Bland  Sutton.) 


constituting  the  parovarium,  or  organ  of  Rosenmuller.  Parovarian 
Cysts  formed  from  the  distension  of  this  structure  are  usually 
unilocular,  and  filled  with  a  clear  limpid  serous  fluid ;  they  have 
no  definite  pedicle,  and  strip  up  the  layers  of  the  broad  ligament. 
Some  of  the  terminal  tubes  may  be  converted  into  small  cysts 
which  project  from  the  fimbriated  ends  of  the  Fallopian  tube,  and 
are  known  as  cysts  of  Kobelt's  tubes.  The  main  Wolffian  duct 
generally  atrophies,  but  occasionally  runs  down  between  the  layers 
of  the  broad  ligament  close  to  the  uterus,  to  open  in  the  vagina 
near  the  urethral  orifice,  being  then  known  as  Gartner's  duct. 
Cysts  may  occasionally  arise  in  connection  with  this  structure, 
projecting  into  the  lateral  fornix  of  the  vagina. 

4.  The  processus    vaginalis,    or    funicular    process,   is   the    term 
applied  to  the  protrusion  of  peritoneum  which  precedes  the  testis 


TUMOURS  AND  CYSTS 


185 


to  form  the  tunica  vaginalis,  and  which  in  the  female  accompanies 
the  round  ligament  (canal  of  Nuck).  Normally  it  becomes 
obliterated,  but  sometimes  portions  of  it  remain  patent,  and  are 
distended  with  a  clear  straw-coloured  serous  fluid,  constituting 
in  the  male  an  encysted  hydrocele  of  the  cord,  and  in  the  female  a 
hydrocele  of  the  round  ligament. 

II.  Cysts  due  to  the  Distension  of  Pre-existing  Spaces. 

(a)  Exudation  Cysts  arise  from  the  distension  of  cavities  which 
are  unprovided  with  excretory  ducts,  and  are  frequently  of  an 
inflammatory  nature.  Such  spaces  may  be  lined  with  epithelium 
or   endothelium.      As    illustrations    of    epithelial    cysts   may   be 


Fig.  45  — Diagram  to  represent  the  Cyst  Regions  of  the  Ovary. 
(Bland  Sutton.) 

A,  Oophoron,  or  ovarian  tissue;  B,  paroophoron,  or  tissue  of  the  hilus ;  C, 
parovarium  ;  K,  Kobelt's  tubes  ;  G,  Gartner's  duct    (=  main  Wolffian  duct). 

mentioned  those  which  arise  in  connection  with  the  thyroid  body, 
as  also  conditions  due  to  the  distension  of  the  central  canal  of 
the  nervous  system  (syringo-myelocele),  and  those  forms  of 
ovarian  cysts  which  arise  from  distension  of  Graafian  follicles. 

Exudation  cysts  lined  by  a  serous  or  endothelial  wall  are  much 
more  numerous.  Enlargements  of  bursas,  hydroceles  of  the 
tunica  vaginalis,  funicular  process,  or  canal  of  Nuck,  and  some 
forms  of  ganglia,  are  of  this  nature.  Diverticula  or  hernial  pro- 
trusions of  the  synovial  membrane  of  joints  also  occur,  and  are 
known  as  Baker's  cysts. 

A  Serous  Cyst  is  supposed  to  arise  from  the  distension  of  lymph 
spaces,  giving  rise  to  uni-  or  multi-locular  cavities,  lined  with 
endothelium,  and  containing  a  limpid  straw-coloured  fluid.     They 


186  A  MANUAL  OF  SURGERY 

are  seen  most  commonly  in  the  neck,  axilla,  or  breast,  and  in  the 
latter  structure  may  be  surrounded  by  a  dense,  sclerosed,  fibrous 
tissue.  It  is  usually  possible  to  dissect  them  out,  but  occasionally 
one  has  to  rely  on  draining  them  or  on  stuffing  them,  so  as  to 
insure  healing  by  granulation. 

Adventitious  bursae  are  formed  in  a  precisely  similar  manner. 

(b)  When  a  collection  of  blood  forms  in  a  pre-existing  cavity,  a 
so-called  Cyst  of  Extravasation  is  produced.  Such  is  met  with  in 
the  pelvis  or  tunica  vaginalis  (hematocele),  and  also  occasionally 
on  the  surface  of  the  brain,  constituting  what  is  known  as  an 
arachnoid  cyst. 

(c)  Retention  Cysts  always  arise  from  obstruction  to  the  escape 
of  some  natural  secretion  from  a  gland  duct  or  tubule.  The 
cavity  thus  formed  is  lined  with  epithelium,  whilst,  owing  to  the 
irritation  produced  by  the  tension,  a  fibro-cicatricial  wall  of 
variable  thickness  is  developed  outside.  There  is  often  a  con- 
siderable formation  of  intracystic  growths,  especially  in  the 
breast,  whilst  the  contents  generally  consist  of  the  inspissated 
secretion,  perhaps  mixed  with  blood. 

Retention  cysts  may  develop  in  connection  with  any  glandular 
tissue.  The  majority  are  described  under  the  appropriate  headings, 
viz.,  Mammary  cysts,  Renal  cysts,  Pancreatic  cyst,  etc. 

III.  Cysts  of  New  Formation  are  such  as  occur  apart  from 
any  embryonic  condition  or  pre-existing  cavity.  The  following 
varieties  may  be  described  : 

(a)  An  Implantation  Cyst  is  one  which  arises  from  the  accidental 
intrusion  into  the  subcutaneous  or  submucous  tissues  of  epithelial 
cells  which  retain  their  vitality,  and  are  enabled  to  develop  a  cyst 
very  similar  in  nature  to  a  dermoid  ;  in  fact,  it  may  be  looked 
on  as  an  Acquired  or  Traumatic  Dermoid.  Such  an  occurrence  is 
usually  brought  about  as  the  result  of  an  injury,  especially  from 
punctured  wounds  ;  thus,  cysts  of  this  nature  have  been  met 
with  in  the  fingers  or  palm  of  the  hand  as  a  consequence  of  the 
penetration  of  some  sharp  instrument,  whilst  they  are  also  occa- 
sionally seen  in  the  anterior  chamber  of  the  eye,  following  an 
iridectomy.  They  are,  moreover,  observed  in  the  axillae  of  cattle, 
as  a  result  of  goading  them  with  a  sharp  implement.  The  clinical 
signs  and  treatment  are  similar  to  those  of  a  dermoid  cyst. 

(b)  Cysts  sometimes  form  around  foreign  bodies,  which  thus 
become  encapsuled.  They  are  lined  by  granulation  tissue  or 
endothelium,  surrounded  by  a  variable  amount  of  fibro-cicatricial 
tissue. 

(c)  Blood  Cysts  are  sometimes  of  doubtful  origin.  Some  of  them 
certainly  arise  from  extravasation  of  blood,  and  in  such  cases 
coagulated  blood,  or  a  thin  serous  fluid,  is  found  within,  the  cavity 
being  perhaps  lined  with  laminated  fibrin.  In  many  cases  a  so- 
called  blood  cyst  is  really  a  soft  sarcoma,  into  which  haemorrhage 


TUMOURS  AND  CYSTS 


.87 


has  occurred ;  but  in  addition  to  these,  a  few  instances  are  on 
record  in  which  a  thin-walled  cavity  existed,  occupied  by  blood, 
and  readily  refilling  after  it  had  been  tapped.  Such  conditions 
have  been  most  frequently  observed  in  the  neck  (see  Chapter 
XXIX.). 

(d)  Parasitic  Cysts  are  produced  by  the  irritation  caused  by  the 
growth  within  the  tissues  of  certain  living  organisms.  Thus,  in 
the  disease  known  as  trichinosis,  derived  from  eating  unsound 
pork,  the  Trichina  spiralis,  a  small  round  worm, 
develops  in  large  numbers  in  the  voluntary 
muscles,  and  becomes  surrounded  by  a  capsule 
which  is  subsequently  calcified. 

The  most  important  of  these  parasitic  cysts 
is  that  caused  by  the  development  within  the 
body  of  the  scolex  stage  of  the  Tania  echino- 
coccus,  giving  rise  to  what  are  known  as  Hydatid 
Cysts.  This  disease  is  much  more  common  in 
Australia  than  in  this  country.  The  Tceuia 
ecliinococcus  (Fig.  46)  is  a  minute  tapeworm,  less 
than  half  an  inch  in  length,  which  inhabits  the 
intestinal  canal  of  dogs ;  it  consists  of  four 
segments,  the  posterior  one  being  larger  than 
the  rest  of  the  body,  and  containing  the  genital 
organs.  When  mature,  this  last  segment  be- 
comes filled  with  ova,  which  are  discharged, 
and  these  find  their  way  into  the  human 
stomach  by  the  media  of  water  or  uncooked 
vegetables,  such  as  watercress,  which  have  been 
contaminated  with  the  dog's  excreta.  The  pro- 
cess of  digestion  sets  the  embryo  free,  and  by 
means  of  a  crown  of  little  hooks  which  it  pos- 
sesses, as  well  as  four  suckers,  it  is  enabled  to 
bore  its  way  through  the  walls  of  the  stomach, 
and  thence  travels  by  the  bloodvessels  to  the 
liver  or  some  other  part  of  the  body.  As  a  result 
of  the  irritation  caused  by  its  presence,  a  sac 
forms  which  originally  consists  of  three  layers ; 
externally,  a  fibro-cicatricial  layer,  then  an  inter- 
mediate lamellated  layer  of  chitinous  material 
(true  ectocyst),  and  finally  the  cyst  is  lined  by  a 
protoplasmic  germinal  layer  (endocyst),  from 
which  may  be  developed  solitary  taenia  heads  or  scolices,  also 
provided  with  four  suckers  and  a  circlet  of  hooks,  whilst  some- 
times groups  of  them,  known  as  brood-capsules,  may  arise  in  the 
same  way  (Fig.  48).  Daughter-cysts  are  not  unfrequently  formed 
from  the  scolices,  and  they  in  their  turn  may  pass  through  the 
same  changes,  although  as  a  rule  they  are  barren.  Occasionally 
even  the  main  cyst  may  be  sterile  (acephalocyst),  and  in  such  cases 


&-, 


ViX^ 


Fig.    46. — T.3;nia 
Echinococcus. 

X    ABOUT    20. 


A  MANUAL  OF  SURGERY 


the  walls  become  very  definitely  laminated.     The  fluid  contained 
in  the  cyst  varies  much  in  amount,  but  is  always  of  low  specific 


Fig.   47. — Hydatid  Cyst  (Diagrammatic)  showing  Daughter-Cysts   and 
Brood-Capsules  growing  from  the  Walls.     (After  Bland  Sutton.) 


Fig.  48.— Diagrammatic  Section  of  Wall  of  Cyst. 
a,  Fibro-cellular  capsule,  here  somewhat  exaggerated  ;  b,  lamellated  chitinous 
layer,  or  ectocyst ;  c,  brood-capsules  developing  from  the  protoplasmic 
layer,  or  endocyst ;  d,  scolex,  or  separate  head,  enlarged. 

gravity,  not  more  than  1007  ;  it  is  colourless,  but  slightly  opales- 
cent, limpid,  and  contains  but  a  trace  of  albumen,  although  a 
considerable    amount    of    chloride    of    sodium    is    present.     On 


TUMOURS  AND  CYSTS 


examining  the  fluid  microscopically,  the  characteristic  hooklets 
are  observed.  The  organs  usually  affected  by  hydatid  disease 
are  the  liver,  kidneys,  and  brain,  but  any  part  of  the  body  may 
be  attacked.  Occasionally  in  the  liver,  and  usually  in  bone, 
multiple  cysts  develop  quite  distinct  from  each  other,  and  with  no 
general  cyst- wall  (exogenous  multiplication).  This  can  only  occur 
when  the  ectocyst  is  thin,  allowing  the  scolices,  which  always 
have  a  retractile  neck,  to  push  through  and  '  swarm  off '  into 
surrounding  tissues. 

Hydatid  cysts  give  rise  to  no  special  symptoms,  except  those 
caused  by  their  size  and  situation,  and  they  are  likely  to  go  on 
growing  until  operative  treatment  becomes  imperative  on  account 
of  some  complication,  or  from  the  size  of  the  mass.  At  any  time 
the  cyst  may  rupture,  either  spontaneously  or  as  the  result  of  some 
injury  ;  if  into  a  serous  cavity,  such  as  the  peritoneal  or  pleural, 
this  becomes  infected,  and  an  abundant  development  of  scolices 
and  cysts  ensues,  giving  rise  to  considerable  localized  inflam- 
matory reaction  ;  moreover,  the  escape  of  the  cyst  fluid  may 
cause  serious  toxaemia,  or,  at  any  rate,  urticaria,  owing  to  the 
presence  therein  of  some  toxic  substance. 

Occasionally  the  organism  dies  spontaneously,  and  then  the  cyst 
shrivels  up,  and  the  laminated  walls  and  daughter-cysts  form 
a  firm  leathery  mass,  perhaps  infiltrated  with  lime  salts  and  of 
the  consistency  of  wet  mortar  ;  a  thick  fibro-cicatricial  capsule 
encloses  the  whole.  At  other  times  suppuration  takes  place  within 
the  cyst  and  an  abscess  results.  If  acute,  it  bursts  either  exter- 
nally, or  may  open  into  some  serous  cavity  or  hollow  viscus  ;  in 
the  last  case,  the  cyst  may  evacuate  itself,  and  a  spontaneous  cure 
result.  Sometimes  the  abscess  becomes  chronic  and  encapsuled, 
and  may  then  remain  quiescent  for  years. 

For  the  diagnosis  and  treatment  of  hydatid  cyst  of  the  liver,  see 
Chapter  XXXII.).  In  other  regions,  if  the  tumour  cannot  be 
removed  by  dissection,  reliance  must  be  placed  on  drainage, 
where  the  situation  of  the  growth  renders  this  practicable,  or 
aspiration,  since  it  is  usually  found  that  removal  of  the  fluid 
contents  causes  death  of  the  organism,  probably  by  altering  the 
intra-cystic  tension. 

IV.  Cysts  of  Degeneration  arise  in  connection  with  tumours, 
especially  those  where  the  blood-supply  is  not  very  abundant. 
Thus,  mucoid  degeneration  is  not  uncommon  in  fibromata,  fibro- 
myomata,  chondromata,  and  even  in  the  harder  forms  of  cancer. 
Occasionally  cysts  form  in  the  sarcomata  from  this  cause,  but 
more  frequently  as  a  result  of  haemorrhage. 


CHAPTER  VIII. 

WOUNDS. 

A  wound  has  been  defined  as  the  forcible  solution  of  continuity 
of  any  of  the  tissues  of  the  body  ;  but  the  term  is  more  commonly 
limited  to  injuries  of  the  soft  parts,  involving  the  skin  or  mucous 
membranes.  Lesions  in  which  the  skin  does  not  participate,  and 
in  which  the  deeper  structures,  such  as  bones,  ligaments,  etc.,  are 
not  involved,  are  spoken  of  as  contusions. 

A  Contusion  is  any  subcutaneous  wound  or  injury  due  to  the 
agency  of  external  violence,  causing  laceration  of  the  cellular 
tissue,  without  necessarily  involving  such  deeper  structures  as 
muscles,  tendons,  nerves  or  bones.  The  signs  are  usually  very 
obvious,  viz.,  pain,  bruising,  or  discoloration  of  the  part,  and 
swelling.  These  are  readily  explained  by  the  injury  inflicted  on 
the  subcutaneous  tissues,  which  in  the  worst  cases  may  be  entirely 
disorganized  and  separated  from  the  skin.  The  amount  of  bruising 
varies  with  the  part  injured  and  the  severity  of  the  lesion  ;  thus, 
in  the  eyelids,  scrotum,  and  vulva,  where  the  tissues  are  lax,  the 
ecchymosis  will  be  very  extensive  and  of  a  black  colour ;  on  the 
scalp  there  is,  on  the  other  hand,  but  little  swelling,  if  the  injury 
does  not  include  bleeding  beneath  the  aponeurosis  of  the  occipito- 
frontalis.  Again,  the  condition  of  the  patient's  general  health 
influences  the  amount  of  blood  effused ;  in  a  strong  man  in  good 
training,  but  little  bruising  is  seen,  whilst  in  those  of  a  languid 
temperament  and  relaxed  tissues,  a  slight  injury  often  produces  a 
very  conspicuous  ecchymosis.  Blebs  and  bullae  may  form  over 
the  injured  spot  in  bad  cases.  The  changes  that  occur  in  a  bruise 
are  well  known,  the  colour  passing  from  a  blackish-purple  through 
various  shades  of  brown  and  green  to  a  yellow,  which  gradually 
fades  and  disappears ;  this  is  due  to  the  disintegration  of  the  red 
corpuscles,  and  staining  of  the  tissues  by  the  haemoglobin  thus 
set  free,  or  by  the  products  formed  during  its  removal.  When 
haemorrhage  has  taken  place  into  the  deeper  parts  or  under  dense 
fasciae,  it  is  often  some  days  before  the  bruise  '  comes  out,'  and 
this  may  occur  at  some  distant  spot,  e.g.,  in  the  eyelids  after  a 
blow  on  the  scalp,  whilst  after  a  fracture  of  the  neck  of  the 


WOUNDS  191 


humerus  the  blood  may  travel  along  the  muscular  and  fascial 
planes,  and  the  bruise  first  appear  about  the  elbow. 

In  a  bruise  or  ecchymosis,  the  tissues  are,  as  a  rule,  merely 
infiltrated  with  blood,  but  occasionally  the  extravasation  is  more 
localized,  collecting  in  a  cavity  formed  by  the  laceration  of  the 
tissues,  and  remaining  as  a  fluid  swelling,  or  Haematoma.  If 
somewhat  resembles  an  abscess  to  the  touch,  but  differs  from  it  in 
its  history,  having  supervened  immediately  after  an  injury,  and 
having  appeared  without  any  heat  or  other  sign  of  inflammation  ; 
moreover,  though  at  first  fluid  and  soft,  it  soon  becomes  harder, 
whereas  an  abscess  is  preceded  by  a  stage  of  brawny  infiltration, 
and  the  softening  occurs  later.  The  subsequent  history  of  a 
haematoma  varies  somewhat  according  to  circumstances,  (a)  A 
deposit  of  fibrin  may  be  formed  peripherally,  leaving  for  a  time  a 
fluid  centre,  which  gradually  disappears,  and  the  whole  is  finally 
absorbed.  This  is  well  exemplified  in  a  sub-pericranial  cephal- 
hematoma, where  the  contrast  between  the  fibrinous  deposit  with- 
out and  the  fluid  centre  is  sometimes  so  accentuated  as  to  give 
the  impression  of  a  depressed  fracture,  (b)  The  fluid  portion  of 
the  blood  may  be  absorbed  almost  entirely,  and  the  solid  fibrinous 
residuum  may  become  organized  into  a  firm  fibroid  tumour  which 
persists  indefinitely ;  the  mass  is  more  or  less  laminated,  and  not 
unfrequently  pigmented,  (c)  The  fibrin  may  be  entirely  absorbed, 
and  a  slightly  pigmented  fibrous  capsule  formed  containing  serous 
fluid,  and  constituting  a  definite  cyst ;  such  is  best  seen  in  con- 
nection with  the  cerebral  tunics  (arachnoid  cyst),  (d)  Suppuration 
may  ensue  owing  to  infection  from  within  the  body,  or  from  an 
invasion  of  organisms  through  abraded  skin. 

In  forming  an  opinion  as  to  the  gravity  of  a  subcutaneous 
injury,  one  must  be  guided  by  the  part  injured,  the  extent  of 
tissue  involved,  the  amount  of  blood  extravasated,  and  the  age 
and  vitality  of  the  individual.  In  the  less  severe  cases,  though 
there  may  be  a  good  deal  of  bruising,  recovery  will  ensue,  but 
under  less  favourable  conditions  sloughing  and  death  of  the 
injured  tissues  may  result. 

The  Treatment  of  a  bruise  usually  consists  in  the  application  of 
cold  or  evaporating  lotions  and  pressure  in  order  to  check  the 
bleeding,  but  such  must  be  used  with  care  in  old  weakly  individuals 
or  where  much  laceration  of  the  tissues  has  taken  place,  for  fear 
of  the  injured  parts  dying.  The  skin  should  never  be  incised 
except  under  special  circumstances,  such  as  the  rupture  of  a  large 
artery,  or  when  some  definite  advantage  is  to  be  gained  by  dealing 
at  once  with  the  injured  structures;  for  though  under  careful  anti- 
sepsis the  dread  of  opening  recent  collections  of  blood  no  longer 
exists,  yet  it  should  not  be  lightly  undertaken.  At  the  same  time, 
when  a  tense  and  painful  haematoma  exists,  as  under  the  fascia 
lata  of  the  thigh,  recovery  can  be  hastened  and  pain  relieved  by 
an  aseptic  puncture,  followed  by  careful  compression.    In  general 


192  A   MANUAL  OF  SURGERY 

bruising  of  the  body  from  a  fall  or  extensive  injury,  pain  can  often 
be  relieved  by  applying  fomentations  or  by  a  hot  bath.  There  is 
generally  a  certain  amount  of  fever  and  constitutional  disturbance 
for  a  few  days,  and  these  are  dealt  with  by  purgatives  and  a  suit- 
able limitation  of  diet. 

Open  Wounds. 

An  open  wound  may  be  defined  as  a  solution  of  continuity  of 
any  superficial  part  of  the  body,  including  skin  or  mucous  mem- 
brane. Various  kinds  of  wounds  are  described,  such  as  the 
incised,  lacerated,  contused,  punctured,  poisoned,  and  gunshot ; 
but,  of  course,  the  most  important  distinction  to  draw  is  between 
the  infected  and  the  non-infected. 

1.  Incised  Wounds. — An  incised  wound  is  one  made  by  any 
sharp  cutting  instrument,  but  occasionally  a  wound  not  produced 
in  this  manner  may  be  characterized  by  similar  appearances ; 
e.g.,  the  skin  of  the  knee  or  elbow  may  be  cleanly  split  open  from 
falling  on  it  with  the  limb  flexed,  and  occasionally  a  policeman's 
truncheon  will  lay  open  the  scalp  almost  as  evenly  as  if  a  knife 
had  been  employed. 

The  special  features  of  an  incised  wound  are  as  follows  : 
i.  The  haemorrhage  is  free,  from  the  fact  that  the  vessels  are 
cleanly  divided.  The  amount  necessarily  depends  on  the  size  of 
the  vessels  involved,  and  the  vascularity  of  the  part ;  its  continu- 
ance, upon  the  density  of  the  structures  allowing  or  not  of  con- 
traction and  retraction  of  the  severed  ends. 

2.  Separation  of  the  lips  of  the  wound  also  occurs,  the  amount 
depending  upon  the  elasticity  and  character  of  the  parts  involved. 

3.  Bruising  of  the  margins  of  the  incision  is  absent,  so  that  under 
ordinary  circumstances  rapid  healing  (by  first  intention)  should 
obtain.  The  surfaces,  to  begin  with,  are  lined  by  a  microscopic 
layer  of  damaged  tissue,  some  of  which  may  be  actually  dead ; 
but  if  suitable  precautions  are  taken,  this  is  absorbed,  and  in  no 
way  interferes  with  satisfactory  union. 

Treatment  of  Incised  Wounds.  —  Seven  essentials  must  be 
attended  to  if  healing  by  first  intention  is  to  be  obtained,  viz. : 

(i.)  The  Arrest  of  all  Bleeding. —If  there  is  general  oozing, 
exposure  to  the  air  is  often  quite  sufficient ;  or  sometimes  it  may 
be  supplemented  by  pressure  for  a  few  minutes  with  an  aseptic 
sponge.  Arteries  and  veins  will  need  a  ligature,  but  if  situated 
close  to  the  skin,  they  may  often  be  secured  by  passing  under  the 
bleeding  spot  the  needle  used  for  the  suture. 

(ii.)  Sterilization  of  the  Wound  and  its  Surroundings. — When 
made  by  the  surgeon  through  skin  which  has  been  previously 
purified,  and  if  efficient  precautions  as  to  hands,  instruments,  etc., 
have  been  taken,  there  is  no  need  to  flush  out  the  wound  with 
any  antiseptic.  All  such  substances  are  more  or  less  irritating, 
and  when  introduced  into  a  fresh  wound  are  likely  to  increase 


WOUNDS  193 


exudation  and  render  drainage  necessary.  In  such  cases  it  will 
suffice  to  cleanse  the  parts  with  sterilized  salt  solution. 

In  casualty  work,  however,  a  wound,  though  cleanly  cut,  is 
made  through  dirty  skin,  and  portions  of  clothing,  dirt,  and 
splinters  of  wood  or  glass  may  be  carried  in.  Under  these 
circumstances  the  wound  and  its  surroundings  must  be  thoroughly 
purified,  according  to  the  rules  given  on  p.  18,  and  a  free  use  of 
1  in  20  carbolic  lotion,  or  even  of  Lister's  '  strong  mixture ' 
(5  per  cent,  of  carbolic  acid  with  'i  per  cent,  of  corrosive  sub- 
limate), is  advisable,  whilst  foreign  bodies  are  removed. 

(iii.)  The  coaptation  of  the  opposed  surfaces  by  means  of  sutures 
may  now  be  undertaken.  Many  substances  have  been,  and  are, 
employed  for  this  purpose,  but  amongst  the  best  are  fine  silver 
wire,  silk,  horsehair,  silkworm  gut  and  catgut.  In  casualty  work, 
and  for  parts  of  the  body  where  but  little  scar  is  subsequently 
desirable,  as  in  the  face,  horsehair  and  silkworm  gut,  being  non- 
absorbent,  are  perhaps  the  best  materials  to  employ ;  but  in 
ordinary  operative  work,  which  will  be  more  certainly  aseptic, 
and  where  the  after-treatment  is  more  efficient,  fine  catgut  or  silk 
may  be  used.  There  are  three  chief  varieties  of  sutures,  viz., 
the  buried,  the  deep,  and  the  superficial. 

Buried  sutures  are  now  largely  employed,  since  a  foreign  body 
may  be  safely  inserted  into  the  tissues,  if  both  it  and  the  wound 
are  aseptic.  Catgut  and  silk  are  the  agents  made  use  of,  and 
nerves,  tendons,  muscles  or  fasciae  are  the  structures  mainly  dealt 
with.  In  deep  wounds  it  is  always  most  desirable  to  effect  union 
in  this  way  of  all  the  divided  tissues  (that  is,  to  build  the  part  up 
again),  and  not  merely  to  unite  the  skin  over  them. 

Deep  stitches,  or  sutures  of  relaxation,  are  required  in  cases  where 
there  is  difficulty  in  bringing  the  edges  of  the  wound  together,  in 
order  to  transfer  the  tension  from  the  healing  margin  to  tissues 
further  away,  the  edges  being  thereby  relaxed.  For  this  purpose 
thick  silver  wire  may  be  employed,  inserted  ior  i|  inches  from 
the  margins,  and  tied  directly,  or  lead  buttons  may  be  interposed 
next  to  the  skin,  and  the  ends  of  the  wire  fastened  round  the 
projecting  edges,  thus  diffusing  the  pressure  over  a  greater  space. 
They  are  generally  removed  at  the  end  of  two  or  three  days. 

Superficial  stitches,  or  sutures  of  coaptation,  must  be  so  inserted 
as  to  bring  the  edges  of  the  wound  into  contact  without  undue 
pressure,  and  without  any  folding  in  of  the  skin.  Various 
methods  are  employed,  viz.:  I.  The  interrupted  suture  (Fig.  49,  A), 
in  which  each  stitch  is  separately  finished  off,  the  knot  lying  well 
to  one  side  of  the  incision.  This  is  generally  utilized  for  wounds 
which  are  of  irregular  shape  or  in  which  there  is  tension.  2.  The 
glover  s  stitch  (Fig.  49,  B)  is  a  continuous  one,  in  which  the  thread 
is  carried  on  from  point  to  point,  and  only  fastened  at  the  ends  ; 
it  is  not  to  be  recommended.  3.  The  blanket  or  buttonhole  stitch 
(Fig.  49,  C)  is  the  form  of  continuous   suture  which  should  be 

J3 


£94 


A   MANUAL  OF  SURGERY 


employed  for  extensive  wounds  or  incisions.  In  it  the  needle, 
after  traversing  the  lips  of  the  wound,  is  carried  under  the  slack 
of  the  thread,  so  that  the  loop  of  each  stitch,  as  it  is  tightened,  is 
maintained  at  right  angles  to  the  edge  of  the  wound,  whilst  the 
intermediate  portion  lies  parallel  to  it.  To  fasten  it  off,  the  needle 
is  passed  in  the  opposite  direction  through  the  edges  of  the 
incision,  with  the  free  end  long  enough  to  prevent  it  coming 
through,  and  so  enable  it  to  be  tied  to  the  double  portion  carried 
through  by  the  needle.     4.  The  quilled  suture  is  not  often  employed. 


Fig.  49. — Various  Forms  of  Suture. 

A,  interrupted  suture  ;  B,  continuous  suture  ;  C,  blanket  stitch.  At  the  lower 
end  the  needle  has  just  been  passed,  and  the  way  in  which  it  catches  up 
the  loop  :*s  indicated.  At  the  upper  end  the  method  of  finishing  off 
(originally  suggested  by  the  late  Mr.  Maunsell)  is  shown  :  viz.,  the  needle 
is  passed  in  the  opposite  direction  to  all  the  other  stitches,  the  free  end 
being  left  long,  so  as  to  enable  it  to  be  tied  into  a  knot  with  the  double 
thread  which  the  needle  has  carried  through. 

It  consists  in  tying  the  stitches  round  a  quill  or  portion  of  catheter 
on  either  side  of  the  wound,  so  that  the  deep  surfaces  may  be 
maintained  in  apposition,  whilst  the  superficial  portions  are  left 
clear  for  additional  sutures.  The  only  conditions  under  which  it 
is  now  used  are  in  the  operations  for  ruptured  perineum,  or  for 
extensive  perineal  or  urethral  fistulae.  5.  The  twisted  or  jigure-of-8 
suture  is  still  occasionally  made  use  of  for  harelip  or  scalp  wounds, 


WOUNDS 


195 


but  has  many  disadvantages.  A  pin  or  needle  is  passed  through 
the  sides  of  the  wound,  which  are  brought  into  apposition  with 
the  fingers,  and  maintained  by  twisting  silk  around  either  end  of 
the  needle  in  a  figure-of-8  fashion. 

Plasters  are  sometimes  used  instead  of  sutures,  but  the  wounds 
must  be  very  small  and  insignificant  which  only  require  such 
treatment.     A  fine  aseptic  suture  is  in  most  cases  preferable. 

(iv.)  Drainage  must,  if  necessary,  be  provided,  in  order  to 
guard  against  the  irritation  and  tension  caused  by  retained  blood 
or  exudations.  In  wounds  where  there  is  doubt  as  to  the  com- 
pleteness of  the  haemostasis,  or  where  there  has  been  much 
tearing  or  laceration  of  the  tissues,  it  is  wise  to  insert  a  tube  for 
24  or  48  hours,  in  order  to  allow  effused  blood  to  escape ;  but  if 
the  wound  is  dry  and  aseptic,  and  efficient  pressure  can  be  exerted 
by  the  dressings,  it  may  be  dispensed  with. 

When  drainage  is  required,  the  indiarubber  tube  introduced  by 
Chassaignac  answers  well ;  the  end  should  be  cut  flush  with  the 
surface,  and  stitched  to  the  edges  of  the  wound  so  as  to  prevent  it 
slipping  in  or  out.  Decalcified  bone  tubes  have  been  substituted, 
but  wTith  no  distinct  advantage.  For  small  wounds,  a  strand  of 
horsehair  or  a  strip  of  gauze  or  protective  will  usually  suffice. 

(v.)  All  fresh  sources  of  irritation  and  infection  of  the  wound 
must  be  excluded  by  some  form  of  antiseptic  or  aseptic  dressing. 

(vi.)  Rest  to  the  injured  part  must  be  secured  by  such  an 
arrangement  of  splints,  slings,  or  bandages  as  may  be  necessary. 

(vii.)  The  general  health  of  the  patient  is  a  most  important 
item  to  attend  to.  In  an  operation  case  the  bowels  should,  if 
possible,  be  previously  opened,  and  the  patient's  diet  carefully 
regulated  ;  in  casualty  work  a  good  purge  should  be  administered 
as  soon  as  convenient,  and  the  food  and  drink  limited. 

Under  ordinary  circumstances  an  aseptic  incised  wound  heals 
in  about  five  to  seven  days,  but  the  actual  time  when  it  is  safe  to 
remove  the  stitches  varies  with  the  age  and  vigour  of  the  indi- 
vidual, the  part  of  the  body,  and  the  amount  of  tension  required 
to  draw  the  lips  of  the  wound  together.  In  ordinary  aseptic 
operation  wounds  one  usually  removes  the  stitches  on  the  eighth 
day  ;  but  in  the  face  it  is  often  possible  and  advisable  to  take 
them  out  earlier,  partly  because  the  healing  process  is  quickly 
accomplished  in  such  a  vascular  region,  partly  in  order  to  mini- 
mize the  amount  of  scarring. 

Many  conditions  may  arise  to  prevent  the  healing  of  an  incised 
wound  by  first  intention,  and  they  may  be  epitomized  as  essenti- 
ally the  reverse  of  the  seven  conditions  mentioned  above — viz., 
(i.)  Non-arrest  of  the  bleeding,  causing  separation  of  the  lips  or 
deeper  portions  of  the  wound  ;  (ii.)  the  presence  of  impure  foreign 
bodies  or  other  septic  material ;  (iii.)  the  edges  not  being  brought 
into  contact ;  (iv.)  imperfect  drainage,  leading  to  tension  on  the 
stitches ;    (v.)    subsequent    infection    of   the    wound    owing    to    a 


196  A  MANUAL  OF  SURGERY 


faulty  dressing,  etc.  ;  (vi.)  lack  of  rest  to  the  part  ;  and 
(vii.)  constitutional  conditions,  such  as  deficient  general  vitality 
from  disease  or  other  causes,  resulting  in  want  of  action  in  the 
wound. 

The  most  common  cause  of  non-union  is  without  question  septic 
contamination  of  the  part.  The  essential  nature  of  this  process 
and  its  dependence,  either  on  pathogenic  or  non-pathogenic 
germs,  have  been  already  explained  (p.  5).  The  inflammatory 
trouble  is  acute  or  subacute,  according  to  the  virulence  of  the 
organisms  and  the  resisting  powers  of  the  patient ;  it  may  mani- 
fest itself  merely  as  a  suppurative  process  within  the  wound,  or  as 
an  active  cellulitis  spreading  into  the  adjacent  tissues.  It  may 
commence  deeply  around  a  buried  stitch  or  superficially.  In  the 
latter  case  the  lips  of  the  wound  look  red  and  puffy,  the  tissues 
often  swell  up  between  the  stitches,  which  look  as  if  they  were 
too  tight ;  the  patient  complains  of  pain,  usually  of  a  throbbing 
nature,  and  there  is  some  rise  of  temperature,  and  in  bad  cases 
even  a  rigor.  In  the  milder  forms,  the  trouble  is  limited  to  the 
immediate  neighbourhood  of  the  wound  ;  but  if  neglected,  or  in  an 
unhealthy  subject,  or  if  due  to  virulent  germs,  the  phenomena  of 
an  acute  cellulitis  may  supervene,  whilst  the  general  condition 
may  constitute  an  attack  of  septic  traumatic  fever,  or  may  even 
run  over  into  a  true  septicaemia. 

When  the  process  starts  quietly  in  the  deeper  parts  of  the 
wound,  nothing  may  be  obvious  on  the  surface  for  a  few  days, 
except  perhaps  some  fulness  and  tenderness  on  pressure.  It  will 
usually  be  found,  however,  that  the  temperature  is  slightly  raised, 
and  that  some  tensive  pain  is  present.  Sooner  or  later  an  abscess 
develops  and  comes  to  the  surface. 

The  local  treatment  of  a  septic  wound  consists  essentially  in  the 
relief  of  all  tension,  the  removal,  as  far  as  possible,  of  all 
putrescible  material,  and  the  application  of  warmth  and  moisture 
to  the  part,  if  superficial,  to  encourage  the  local  reparative  activity 
of  the  tissues.  Stitches  must  be  immediately  removed,  and  the 
wound  widely  opened  up,  care  being  taken  to  ascertain  whether 
or  not  the  pus  has  burrowed,  as  if  so  it  must  be  followed  up. 
Sloughs  may  be  cut  or  scraped  away  under  an  anaesthetic,  and  all 
putrid  or  putrescible  material  removed,  if  possible. 

The  parts  are  then  thoroughly  washed  out  with  some  antiseptic 
solution,  and  may  advisably  be  treated  with  peroxide  of  hydrogen 
or  liquefied  carbolic  acid  ;  but  it  must  not  be  forgotten  that  where 
the  organisms  have  invaded  the  living  tissues,  no  antiseptic  is 
likely  to  reach  them,  at  any  rate,  not  without  also  destroying  the 
tissues.  The  wound  is  then  lightly,  though  thoroughly,  packed 
with  gauze  soaked  in  an  emulsion  of  iodoform  and  glycerine, 
and  if  there  is  a  deep  cavity,  it  may  be  desirable  to  introduce  a 
drainage-tube,  especially  when  suppuration  is  present,  since  pus 
does  not  easily  escape  along  a  gauze  drainage  wick.     It  is  not 


WOUNDS  197 

advisable  to  pack  the  gauze  into  the  wound  too  tightly,  as  there- 
by the  escape  of  secretions  may  be  prevented,  and  pain  and 
tension  may  ensue,  whilst  possibly  bacteria  may  be  driven  into 
the  tissues  and  give  rise  to  further  trouble  in  the  nature  of 
erysipelas  or  cellulitis.  Warm,  moist  dressings,  such  as  an  anti- 
septic fomentation,  are  then  applied,  or  it  may  be  desirable  either 
to  immerse  the  limb  in  a  hot  antiseptic  bath  for  an  hour  or  two 
daily,  or  to  keep  it  in  for  some  days.  At  the  same  time  the  bowels 
must  be  freely  opened,  and  the  general  health  of  the  patient  care- 
fully watched.  The  more  serious  cases  are  dealt  with  in  the  same 
manner  as  an  attack  of  cellulitis  (q.v.  on  p.  91). 

When  the  union  of  the  wound  is  interfered,  with  owing  to  an 
accumulation  of  blood  or  serum  in  the  deeper  parts  whilst  the 
integument  is  healing,  it  often  suffices  to  partially  open  the 
incision,  squeeze  or  press  out  the  fluid,  and  insert  a  small  tube  or 
gauze  drain. 

II.  Lacerated  or  Contused  Wounds. — Such  injuries  are  caused 
by  blunt  instruments,  by  machinery,  missiles,  the  wheels  of  a 
vehicle,  etc.     They  are  characterized  by  the  following  signs  : 

1.  The  Haemorrhage  is,  as  a  rule,  but  slight,  since  the  vessels 
are  torn  across  irregularly,  and  not  cut  cleanly  ;  the  middle  and 
inner  coats,  wrhich  give  way  first,  are  curled  up  within  the  con- 
torted outer  coat,  forming  a  barrier  sufficient  to  prevent  loss  of 
blood.  The  vessels,  being  elastic,  may  be  pulled  out  of  their 
sheaths,  and  are  sometimes  seen  pulsating  upon  the  surface. 

2.  The  Lips  gape  less  than  in  an  incised  wound,  and  are  irregular, 
torn,  and  bruised.  More  or  less  extensive  portions  of  dead  tissue 
have  to  be  disposed  of  before  repair  can  take  place,  and  hence  this 
form  of  wound  usually  heals  by  granulation.  When  a  limb  is 
torn  completely  off,  the  tendons  are  often  left  long,  and  the 
muscular  bellies  project  from  their  fascial  sheaths,  as  flabby  con- 
gested masses,  since  the  skin  gives  way  at  a  higher  point  than  the 
subjacent  structures. 

The  Progress  of  the  case  depends  largely  upon  the  question 
whether  the  wound  is  or  is  not  aseptic. 

In  an  Aseptic  lacerated  wound  it  may  be  possible  to  bring  the 
edges  together  by  suture  or  otherwise,  and,  even  though  they 
are  a  little  bruised,  healing  by  a  slightly  delayed  first  intention 
is  possible,  if  drainage  is  provided.  If  the  wound  remains  open, 
the  dead  tissue  is  absorbed  or  separated,  and  an  aseptic  granulating 
surface  results.  There  may  be  some  simple  traumatic  fever  for  a 
day  or  two,  but  it  is  of  little  consequence. 

If  the  wound  is  Septic,  however,  inflammatory  phenomena 
supervene,  resulting  finally  in  a  granulating  surface.  Three 
stages  may  be  described  in  the  course  of  the  case,  viz.  : 

(a)  The  stage  of  injury,  resulting  in  shock. 

(b)  The  stage  of  inflammation  and  sloughing,  associated  with 

septic  traumatic  fever. 


198  A  MANUAL  OF  SURGERY 


(c)  The  stage  of  repair  by  granulation,  or  prolonged  suppura- 
tion, with  exhaustion  and  hectic  fever  in  the  worst  cases. 
The  inflammatory  period  lasts  a  week,  ten  days,  or  more,  accord- 
ing to  circumstances,  and  during  this  period  the  patient  is  liable 
to  various  forms  of  septic  trouble,  including  secondary  haemor- 
rhage, toxaemia,  pyaemia,  and  traumatic  gangrene. 

The  Treatment  of  contused  and  lacerated  wounds  varies  with- 
their  character,  and  no  absolute  rule  of  practice  can  be  laid  down 
to  suit  all  cases.     The  following  routine  is  that  usually  adopted  : 

(a)  Immediate  Treatment. — The  great  desideratum  in  all  these 
cases  is  to  render  the  wound  aseptic.  To  accomplish  this  in 
severe  injuries,  it  is  wise  to  anaesthetize  the  patient,  and  then, 
after  shaving  the  skin,  if  necessary,  the  wound  and  its  surround- 
ings are  scrubbed  with  soap  and  carbolic  lotion  (i  in  20)  by  means 
of  a  sterilized  nail-brush.  Foreign  bodies  are  removed,  and  dead 
or  doubtful  tissues  cut  away,  if  unimportant,  whilst  bleeding 
vessels  are  secured  by  ligature.  Ample  provision  must  be  made 
for  drainage,  since  the  carbolic  irrigation  of  itself  causes  much 
exudation  ;  occasionally  it  is  desirable  to  make  a  counter-opening 
for  this  purpose.  The  wound  is  closed  by  sutures,  but  it  is 
advisable  to  remove  ragged  and  torn  fragments  of  skin  with  the 
scissors  or  knife,  if  there  is  sufficient  tissue  around  ;  an  antiseptic 
dressing  of  the  usual  type  is  then  applied.  If,  however,  the  skin 
is  scanty  and  asepsis  not  assured,  it  is  better  to  leave  the  wound 
open,  or,  at  any  rate,  only  to  partially  close  it,  packing  it  care- 
fully with  gauze  impregnated  with  iodoform. 

(b)  Subsequent  Treatment  depends  on  whether  or  not  the 
measures  adopted  to  obtain  asepsis  have  been  successful.  If  the 
wound  remains  free  from  infection,  nothing  special  is  called  for 
beyond  careful  dressing.  If  it  becomes  septic,  and  the  surface 
is  covered  with  sloughs,  these  must  he  removed  by  natural  or 
artificial  means  before  healing  can  occur ;  the  use  of  antiseptic 
poultices  will  considerably  expedite  matters,  but  it  must  be 
remembered  that  secondary  haemorrhage  may  occur  when  the 
dead  tissues  are  finally  detached.  During  this  period  inflam- 
matory fever  continues,  and  the  patient's  general  health  must 
be  closely  watched.  When  once  a  clean  granulating  surface  is 
obtained,  it  is  treated  in  the  same  way  as  any  healing  wound, 
skin-grafting  possibly  being  needed  in  the  more  extensive  cases. 

The  question  of  Amputation  will  sometimes  be  raised  in  dealing 
with  the  graver  forms  of  lacerated  wounds,  although  many  limbs 
are  now  saved  which  would  inevitably  in  former  days  have  been 
sacrificed.  Hard-and-fast  rules  cannot  be  laid  down  as  to  when 
to  amputate  and  when  not  to  do  so ;  each  case  must  be  treated 
on  its  own  merits.  Apart  from  the  local  lesion,  the  following 
points  must  be  carefully  considered  :  (a)  The  age  and  vitality  of 
the  patient.  An  old  person  has  less  recuperative  power  than  a 
young  one,  and  hence  a  damaged  limb  may  often  be  left  in  a  youth 


WOUNDS  199 


which  one  would  certainly  remove  in  an  elderly  person.  The 
vitality  of  the  individual  is  perhaps  even  more  important  than 
the  age,  for  some  men  at  sixty  are  in  a  much  more  healthy  and 
resistant  state  than  others  at  forty.  The  habits,  as  to  temperance, 
etc.,  must  also  be  taken  into  consideration,  and  the  existence  of 
general  diseases,  such  as  diabetes  or  albuminuria,  might  induce 
one  to  resort  to  radical  rather  than  conservative  measures. 
(b)  The  vitality  of  the  extremity  injured.  A  leg  has  to  be  sacrificed 
more  frequently  than  an  arm,  since  the  vitality  and  reparative 
power  of  the  latter  are  so  much  greater,  (c)  The  septicity  or  not 
of  the  wound  is  of  the  greatest  significance,  since,  if  infection  can 
be  prevented,  the  chances  of  preserving  the  limb  are  greatly  im- 
proved, and  one  would  then  often  delay  operation,  whereas  sepsis 
would  turn  the  scale  in  favour  of  radical  interference. 

The  local  conditions  which  suggest  or  determine  the  perform- 
ance of  an  amputation  may  be  conveniently  divided  into  two 
groups,  viz.,  where  amputation  is  essential,  or  where  it  is  doubtful. 

A.  Amputation  is  certainly  called  for — 

1.  To  trim  up  the  stump  of  a  limb  torn  off  by  machinery,  or  cut 
off  by  a  railway  train,  or  carried  away  by  a  cannon-ball. 

2.  When  the  whole  limb  or  one  complete  segment  of  it  has 
been  totally  disorganized,  or  crushed  to  pulp,  though  still  retain- 
ing its  connection  with  the  body. 

3.  In  cases  wdiere  gangrene  is  imminent  or  has  supervened, 
especially  if  it  is  of  the  spreading  type. 

4.  When  severe  septic  symptoms  develop  in  a  case  where  an 
attempt  is  being  made  to  save  a  limb,  the  retention  of  which  was 
from  the  first  doubtful  ;  or  when  exhaustion  supervenes  from  pro- 
longed suppuration. 

5.  In  severe  compound  lacerations  of  the  foot  in  old  people, 
involving  the  bones  and  laying  open  the  common  synovial  cavity. 
Septic  arthritis  and  necrosis  are  then  very  apt  to  ensue,  whilst  the 
distance  of  the  foot  from  the  centre  of  the  circulation  increases  the 
likelihood  of  gangrene. 

B.  Amputation  is  doubtful  in  the  following  conditions  : 

1.  Compound  comminuted  fractures  in  parts  other  than  the 
foot  do  not  pev  se  require  amputation,  even  if  neighbouring  joints 
are  implicated.  By  careful  attention  to  antisepsis,  free  drainage, 
and  the  removal  of  detached  fragments  of  bone  and  foreign  bodies, 
which  should  usually  be  accomplished  under  an  anaesthetic,  limbs 
formerly  condemned  to  amputation  can  not  only  be  preserved,  but 
also  restored  to  a  considerable  degree  of  functional  usefulness. 
The  final  decision  will  mainly  depend  on  the  age,  condition,  and 
previous  habits  of  the  individual. 

2.  When  the  soft  parts  have  borne  the  brunt  of  the  injury,  and 
have  been  extensively  stripped  from  the  bones,  amputation  is  by 
no  means  an  essential,  provided  that  they  can  be  restored  to  their 
original  position,  that  there  is  a  reasonable   probability  of  their 


A   MANUAL  OF  SURGERY 


vitality  being  maintained,  and  that  the  utility  of  the  limb  will 
not  be  hopelessly  impaired,  as  a  result  of  lesions  to  the  nerves, 
after  the  wound  has  healed.  The  surgeon  has  here  to  carefully 
balance  the  risk  run  if  an  attempt  is  made  to  save  the  limb,  and 
the  value  that  the  limb  if  saved  will  subsequently  be  to  the 
patient.  For  instance,  when  the  muscles  of  the  forearm  have 
been  extensively  torn  up  in  a  machine  accident,  it  is  a  question 
whether  it  is  worth  while  exposing  the  patient  to  the  risk  of  grave 
sepsis,  when  it  is  probable  that  under  the  best  circumstances  the 
limb  will  be  of  little  practical  use. 

3.  Laceration  of  the  main  artery  of  a  limb  need  not  in  itself 
determine  amputation  ;  but  if  in  addition  to  this  the  bones,  veins, 
or  nerves  are  injured,  and  especially  in  the  lower  extremities  of 
old  people,  amputation  should  be  undertaken  without  delay. 

As  to  the  Period  when  a  limb  should  be  removed  after  an  acci- 
dent, there  is  no  doubt  that,  as  a  general  rule,  the  sooner  amputa- 
tion is  performed,  the  better  ;  the  longer  it  is  delayed,  the  greater 
the  risk  of  septic  infection  and  absorption.  On  the  other  hand, 
the  shock  in  some  cases  may  be  so  profound  that  it  is  better  policy 
to  delay  interference  until  reaction  is  established  ;  this  is  especially 
the  case  in  severe  crushes  close  to  the  hip-joint,  primary  amputa- 
tion in  this  locality  being  frequently  fatal.  At  the  same  time,  if 
shock  is  being  perpetuated  by  the  presence  of  a  crushed  limb,  it 
should  be  immediately  removed.  When  sepsis  is  present,  and  it 
seems  desirable  to  remove  the  limb,  there  is  no  need  to  wait  until 
defervescence  has  occurred,  as  used  to  be  taught  ;  as  soon  as  the 
septic  part  is  taken  away,  the  fever  and  concurrent  phenomena 
cease,  provided  that  the  amputation  wound  is  maintained  aseptic. 

III.  Punctured  Wounds  and  Stabs. — These  may  be  brought 
about  by  any  form  of  penetrating  instrument,  from  a  pin  or  needle 
to  a  sword  or  bayonet.  The  external  opening  may  be  in  itself 
insignificant,  the  chief  danger  arising  from  the  damage  to  deep 
structures  —  bloodvessels  or  nerves  being  divided,  and  serous 
cavities  or  viscera  opened.  The  subsequent  symptoms  depend 
almost  entirely  upon  the  question  of  sepsis ;  there  is  always  con- 
siderable difficulty  in  efficiently  draining  the  depths  of  a  long  and 
narrow  wound,  and  therefore  collections  of  pus  readily  form  and 
burrow  in  all  directions. 

Wounds  resulting  from  the  modern  sword-bayonet,  though  very 
serious  from  their  size  and  depth,  are  not  so  difficult  to  heal  as 
those  inflicted  by  the  old  triangular  blade.  They  should  be 
thoroughly  syringed  out  with  warm  carbolic  lotion  (1  in  20),  well 
drained,  and  the  skin  opening  not  allowed  to  close  until  all  dis- 
charge has  ceased  ;  if  necessary,  a  counter-opening  is  made  at  a 
dependent  spot.  Serious  haemorrhage  or  paralysis,  indicating 
that   important  vessels   or   nerves  have  been   divided,  calls  for 


PLATE  VI. 


Skiagram  of  Hand,  with  Needle  embedded  in  the  Palm,  close  to  the 

Carpus. 

To  face  p.  200.] 


PLATE  VII. 


Splinter    of   Glass   in   Hand,  close  to  Metacarpal   Bone  of   the   Index 

Finger. 
It  will  be  noted  that  the  glass  casts  quite  as  dense  a  shadow  as  the  needle  in  Plate  \  I. 

TofolUw  Plate  VI.] 


IVOUNDS 


immediate  opening  up  of  the  wound,  so  as  to  expose  and  deal 
with  the  injured  structures. 

The  commonest  punctured  wounds  met  with  in  civil  practice 
are  those  produced  by  needles,  which  are  frequently  broken  off 
short  in  the  body,  especially  in  the  hands,  feet,  knees,  or  nates. 
If  seen  soon  after  the  injury,  it  is  advisable  to  undertake  their 
immediate  removal,  a  proceeding  sometimes  very  simple,  but 
occasionally  necessitating  a  deep  and  difficult  dissection.  Should 
the  needle  not  be  removed,  it  may  travel  about  the  body  along 
the  muscular  and  fascial  planes,  and  there  is  no  knowing  where 
it  may  lodge  or  come  to  the  surface,  or  how  long  it  may  remain 
in  the  body.  It  occasionally  finds  its  ways  into  the  pelvis  of  the 
kidney,  and  constitutes  the  nucleus  of  a  renal  calculus. 

One  of  the  most  troublesome  and  painful  forms  of  penetrating 
wound  is  that  caused  by  a  fish-hook,  since  the  barbed  end  catches 
in  the  tissues,  and  it  is  impossible  to  withdraw  it  without  in- 
creasing the  size  of  the  wound  considerably.  The  simplest  plan 
of  treatment  is  to  push  the  hook  on  and  make  it  protrude  through 
the  skin  elsewhere  to  such  an  extent  as  to  enable  the  barb  to  be 
cut  away,  when  the  remainder  of  the  hook  will  be  set  free. 

For  the  detection  of  penetrating  foreign  bodies  of  a  metallic 
nature,  or  of  splinters  of  glass  or  stone,  the  so-called  X  rays  of 
Rontgen  are  exceedingly  valuable.  They  are  produced  by  passing 
a  powerful  electric  current  through  a  modified  Crookes  tube,  or, 
as  it  is  now  termed,  a  '  focus  tube.'  This  consists  of  a  thin  glass 
bulb,  into  which  are  fixed  two  terminals— one,  the  negative, 
concave,  and  the  other,  or  positive  pole,  a  platinum  plate  set  at 
an  angle  so  as  to  reflect  the  rays  generated  at  the  negative  end  to 
the  convexity  of  the  bulb.  A  very  high  vacuum  must  be  present 
in  the  tube.  The  rays  thus  generated,  though  invisible  to  the 
naked  eye,  have  an  actinic  power,  and  are  capable  of  affecting  a 
photographic  plate  in  the  same  way  as  ordinary  sunlight.  They 
are  also  able  to  penetrate  many  substances  which  are  impermeable 
to  ordinary  light,  although  others  resist  their  passage.  Most  of 
the  soft  tissues  of  the  body  are  readily  traversed,  but  bones  and 
to  a  much  less  degree  tendons  are  sufficiently  resistant  to  cast  a 
shadow  on  the  plate,  and  it  is  the  fixation  of  these  shadows  that 
constitutes  the  peculiarity  of  the  so-called  '  skiagram.'  If  a  limb 
with  a  supposed  foreign  body  within  it  is  placed  over  a  sensitive 
dry  plate,  held  in  a  non-metalic  dark  slide  or  a  black  envelope, 
and  the  tube  just  above  it,  so  that  the  convex  portion  on  which 
the  rays  impinge  is  nearest  the  limb,  a  skiagram  is  produced 
which,  on  development,  shows  the  osseous  tissues,  the  outline  of 
the  limb,  and  the  foreign  body,  if  it  exist  (Plates  VI.  and  VII.). 

A  modification  of  this  process  has  led  to  the  production  of  the 
Cryptoscope.  This  consists  of  a  cardboard  screen  coated  with 
platino-cyanide  of  potassium  or  tungstate  of  soda,  and  if  employed 
instead  of  a  sensitive  plate  on  the  further  side  of  the  limb  to  the 


A  MANUAL  OF  SURGERY 


tube,  the  appearances  produced  can  be  seen  by  the  naked  eye. 
Since  it  is  possible  in  this  case  to  move  the  limb  from  side  to  side, 
or  to  rotate  it,  a  better  idea  can  be  obtained  of  the  position  of  the 
foreign  body  ;  by  simple  skiagraphy,  it  is  often  difficult  to  tell  on 
which  side  of  a  bone  the  foreign  substance  lies.  Still  better  results 
have  been  obtained  by  the  application  to  this  method  of  the 
principle  of  the  stereoscope.  Special  methods  of  localizing  foreign 
bodies  have  been  introduced  of  late,  but  they  are  too  complicated 
to  be  referred  to  here. 

IV.  Gunshot  Wounds. — It  is  impossible  in  a  work  such  as  this 
to  go  minutely  into  the  subject  of  gunshot  wounds,  but  it  is 
essential  to  indicate  their  most  important  features,  and  in  what 
respect  they  differ  from  other  forms  of  injury  already  described. 
The  character  of  a  gunshot  wound  varies  according  to  the  nature 
of  the  projectile,  the  arm  employed,  the  velocity  of  the  missile, 
the  distance  from  the  body  at  which  the  firearm  was  discharged, 
the  part  of  the  body  struck,  and  the  direction  of  the  shot. 

The  wounds  inflicted  by  the  modern  small-bore  rifle  (e.g.,  the 
Lee-Metford,  Mauser,  or  Krag-Jorgenson)  are  very  different  to 
those  produced  in  former  days.  The  desiderata  that  have  been 
considered  in  the  evolution  of  the  modern  rifle  have  been  to  secure 
great  muzzle  velocity,  a  low  trajectory,  and  clean  and  hard  hitting. 
To  this  end  the  barrel  has  been  rifled  so  as  to  cause  the  bullet  to 
rotate  on  its  own  logitudinal  axis  (without  such  rifling  the  bullet 
would  rotate  on  its  short  axis),  and  the  bullet  has  been  greatly 
modified,  whilst  the  old  form  of  gunpowder  has  given  way  to 
more  highly  explosive  substances. 

The  modern  bullet  is  a  long,  thin,  conical  body,  consisting  of 
a  core  of  lead  hardened  by  the  addition  of  2  per  cent,  of  antimony, 
enclosed  in  a  cover,  jacket  or  mantle  of  some  smooth,  hard  metal, 
e  g.,  80  per  cent,  of  copper  and  20  per  cent,  of  nickel  (Lee-Metford 
and  Mauser).  The  muzzle  velocity  is  very  high,  amounting  to 
2,000  feet  per  second  for  a  Lee-Metford  rifle,  and  2,300  feet  per 
second  for  a  Mauser  The  trajectory  is  nearly  flat  ;  anything 
within  500  yards  may  be  fired  at  point-blank,  whilst  in  a  range 
of  2,000  yards  the  bullet  only  rises  194  feet,  as  compared  with 
866  feet  for  a  Snider  bullet. 

The  effect  of  these  arms  varies  to  some  extent  with  the  range, 
but  not  nearly  so  much  so  as  was  formerly  maintained  ;  and 
although  the  worst  wounds  are  usually  produced  at  a  short  range, 
say  500  or  750  yards,  yet  quite  simple  wounds  with  no  disruptive 
phenomena  may  also  be  caused  at  a  similar  distance.  One  of  the 
best  marked  features  of  these  wounds  is  that  the  bullet  travels 
straight  and  direct,  without  lateral  deviation  or  deflection,  as  was 
so  commonly  the  case  in  the  old  days.  Simple  flesh  wounds  are 
of  no  great  importance  per  se,  granted  that  important  vessels  and 
nerves  are  not  injured.     The  aperture  of  entry  is  small,  and  looks 


WOUNDS  20^5 


somewhat  '  like  a  bug- bite  ' ;  the  aperture  of  exit  is  slightly  larger, 
and  tends  to  be  a  little  more  slit-like.  A  certain  amount  of  extra- 
vasation occurs  into  the  tissues  around  the  track,  but  the  external 
bleeding  is  often  slight.  There  is  but  little  tendency  to  carry  in 
portions  of  clothing  or  septic  material,  and  the  wound  heals  by 
first  intention  if  reasonable  precautions  are  taken.  The  external 
cicatrices  finally  look  very  similar  to  those  produced  by  bad  acne 
pustules.  Vessels  and  nerves  are  not  likely  to  be  injured  unless 
they  are  actually  in  the  line  of  the  bullet ;  the  accurate  limitation 
of  the  damage  to  this  line  is  evident  when  one  hears  of  a  bullet 
passing  between  the  abdominal  aorta  and  the  vena  cava  without 
either  being  injured.  If  a  large  artery  is  cleanly  hit,  the  patient 
bleeds  freely,  and  may  die  of  haemorrhage,  unless  it  can  be  con- 
trolled by  a  tourniquet.  If  the  artery  is  button-holed,  a  traumatic 
aneurism  may  result,  whilst  arterio-venous  wounds  have  been 
common  in  the  recent  South  African  campaign.  There  has  been 
some  difference  of  opinion  as  to  the  character  of  the  injuries  to 
bones  ;  that  large  masses  of  cancellous  tissue  (e.g.,  the  lower  end 
of  the  femur)  can  be  drilled  cleanly  without  fracture  is  certain  ; 
but  such  wounds  are  sometimes  associated  with  much  splintering 
and  involvement  of  neighbouring  joints,  possibly  as  a  result  of  a 
short  range,  or  of  expansion  of  the  bullet  from  the  tearing  down 
of  the  mantle.  If  a  bullet  hits  cleanly  the  compact  shaft  of  a  long 
bone,  it  may  smash  the  whole  bone  into  small  fragments,  or  the 
force  may  be  more  localized  in  its  action,  though  always  severe. 
Such  comminuted  wounds  are  very  likely  to  become  septic,  if 
there  is  a  long  transport  to  the  field  hospital,  and  then  fragments 
undergo  necrosis  and  serious  inflammatory  phenomena  may 
follow.  Head  wounds  are  much  less  fatal  than  might  be 
imagined  from  the  experimental  work  that  has  been  undertaken. 
At  close  range  frightful  disruptive  effects  are  produced  which  are 
almost  certain  to  be  fatal  (see  Chapter  XXIII.) ;  at  a  longer  range 
comparatively  little  mischief  is  done,  except  along  the  line  of  the 
missile.  The  inner  table  is  always  more  splintered  than  the 
outer,  and  of  course  a  certain  amount  of  brain  substance  may 
escape.  Abdominal  wounds  are  also  much  less  serious  than 
formerly,  a  mortality  of  90  per  cent.  (American  Civil  War)  being 
replaced  by  one  of  40  per  cent,  in  the  recent  campaign,  and  that 
without  operation  (Treves).  The  mere  penetration  of  one  or  more 
coils  of  intestine  is  not  sufficient  to  cause  general  peritonitis  ;  the 
wound  is  very  small,  and  peristalsis  seems  to  come  to  an  end 
entirely  as  soon  as  the  patient  is  struck,  so  that  neighbouring  coils 
of  intestine  or  the  omentum  suffice  to  prevent  faecal  extravasa- 
tion ;  indeed,  many  of  the  patients  suffer  but  little  constitutional  or 
local  disturbance.  Of  course,  an  empty  intestinal  canal  is  a  favour- 
able condition,  and  this  is  not  unfrequently  present  on  the  field 
of  battle.  Bloodvessels  may  be  wounded  in  the  mesentery,  and 
death  result  from  haemorrhage  ;  solid  viscera,  such  as  the  liver 


204  A  MANUAL  OF  SURGERY 

or  spleen,  are  often  damaged  but  little,  granting  a  fairly  long 
range.  On  the  whole,  the  effects  of  these  modern  bullets  is  to 
disable  without  killing,  unless  a  vital  part  is  struck. 

Soft-nosed  Bullets  {e.g.,  the  Dum-Dum)  are  characterized  by  the 
mantle  being  absent  at  the  top,  whilst  the  lead  core  is  usually  free 
from  antimony.  The  result  of  this  is  that  as  soon  as  the  bullet 
strikes,  the  lead  core  mushrooms  out,  and  terrible  mutilation  or 
destruction  of  surrounding  tissues  ensues,  whilst  bones  are  com- 
minuted and  solid  viscera  pulped.  A  similar  result  follows  from 
rubbing  or  cutting  off  the  top  of  the  Lee-Metford  or  Mauser 
bullet,  or  even  from  incising  the  cover  in  two  or  three  places. 

Martini-Henry  and  Snider  Bullets  produce  wounds  which  are 
intermediate  in  their  severity  between  the  preceding  two.  The 
aperture  of  entry  is  usually  small,  that  of  exit  large  and  with 
everted  edges.  Portions  of  clothing  are  frequently  carried  in  by 
these  missiles,  and  add  to  the  risks  of  sepsis. 

Shell  Wounds  have  no  special  peculiarities  beyond  their  severity 
and  the  ghastly  nature  of  the  injuries  which  may  be  inflicted  by 
them,  depending  on  the  irregular  shape  of  the  fragments  into 
which  the  shell  bursts. 

Dangerous  wounds  may  be  inflicted  by  small  shot,  as,  for 
instance,  when  one  of  the  pellets  enters  the  eye,  whilst  the  wads 
or  other  portions  of  the  cartridge  may  also  be  carried  into  the 
body.  A  blank  cartridge,  if  discharged  at  a  short  distance,  may 
produce  a  severe  wound,  and  under  such  circumstances  the  skin 
around  is  likely  to  be  burned  and  blackened,  leaving  a  permanent 
bluish-black  tattooing  of  the  tissues. 

The  Treatment  of  gunshot  wounds  is  conducted  in  accordance 
with  general  surgical  principles,  although  it  may  have  to  be 
somewhat  modified  by  the  patient's  environment  and  by  the  fact 
that  after  a  battle  the  pressure  of  work  may  be  such  that  all 
lengthy  operative  procedures  have  to  be  discarded.  The  first 
essential  is  to  protect  the  wound  from  infection,  and  for  this 
purpose  the  small  packet  of  antiseptic  dressing  carried  by  all  our 
soldiers  is  admirable.  Bleeding  is,  if  possible,  controlled  by  a 
tourniquet ;  and  splints  must  be  improvised  for  broken  limbs,  if 
practicable.  As  soon  as  the  wounded  man  reaches  the  field 
hospital,  the  wound  is  more  thoroughly  explored  and  cleansed  ; 
foreign  bodies  are  removed,  bleeding  points  secured,  and  if  the 
bullet  has  not  escaped  and  can  be  readily  detected,  it  should  be 
extracted.  When  lodged  deeply,  various  appliances  have  been 
introduced  to  locate  the  exact  position  of  a  bullet,  e.g.,  Nelaton's 
porcelain-ended  probe  or  more  complicated  electrical  contrivances, 
such  as  the  telephone  probe.  Skiagraphy  has  also  a  large  field 
of  usefulness  before  it  in  this  direction.  Comminuted  fractures 
are  carefully  investigated,  detached  fragments  of  bone  are 
removed,  and  if  an  attempt  is  made  to  save  the  limb,  splints,  etc., 
are  carefully  applied.       Primary  amputations  for  bullet  wounds 


WOUNDS  205 


are  not  very  common  at  the  present  day,  except  when  great  com- 
minution of  bone  or  hopeless  involvement  of  vessels  and  nerves 
has  occurred.  Wounds  of  the  skull  always  demand  the  most 
careful  attention  ;  even  when  the  bullet  has  penetrated  cleanly 
and  escaped,  each  opening  must  be  trephined  so  as  to  allow  of 
the  removal  of  depressed  splinters  of  the  inner  table.  This  rule 
holds  good  even  when  a  bullet  has  merely  ploughed  a  groove  or 
track  along  the  calvarium  without  penetration.  The  results  of 
such  treatment  have  been  most  admirable. 

The  treatment  of  abdominal  wounds  produced  by  small-bore 
rifle  fire  is  generally  one  of  expectancy.  It  has  now  been 
abundantly  proved  that  patients  can  recover  in  the  m@st  astonish- 
ing fashion  from  bullet  wounds  which  have  traversed  the 
abdomen  from  side  to  side  or  from  front  to  back,  and  therefore 
unless  there  is  some  very  clear  indication,  operation  is  better 
avoided.  Moreover,  the  practical  difficulties  connected  with 
abdominal  sections,  the  frequent  lack  of  sterilized  water,  of  towels, 
and  the  dirty  condition  in  which  the  patient  is,  owing  to  the 
exigencies  of  the  campaign,  together  with  the  length  of  time  that 
such  an  operation  takes — all  these  constitute  reasons  for  not 
interfering  unnecessarily.  Abdominal  distension  from  haemorrhage 
is  one  of  the  chief  indications  for  laparotomy.  In  civil  practice 
the  ordinary  rules  of  treatment  are  followed  (Chapter  XXXII.). 

V.  Poisoned  Wounds. — The  great  majority  of  poisoned  wounds 
are  due  to  some  definite  micro-organism,  and  we  have  discussed 
their  nature  and  characteristics  elsewhere.  A  few  only  remain  to 
be  dealt  with  here. 

Stings  of  Insects,  such  as  bees  and  wasps,  may  be  exceedingly 
irritating  and  painful,  but  are  not  dangerous,  unless  some  local 
complication,  such  as  erysipelas,  supervenes,  or  the  stings  are 
very  numerous,  as  when  a  swarm  of  angry  bees  settles  on  a 
person,  or  the  part  involved  is  such  as  to  lead  to  serious  swelling, 
as  in  the  pharynx  or  tongue,  cedema  of  the  glottis  possibly  arising 
under  such  circumstances.  All  that  is  usually  needed  is  the 
application  of  a  weak  alkaline  lotion,  whilst  a  common  and 
efficient  domestic  remedy  is  a  sliced  fresh  onion  applied  to  the 
part.  Care  must  also  be  exercised  to  ascertain  that  the  sting 
and  poison  sac  are  not  left  in  the  body. 

Some  varieties  of  flies  and  spiders  are  also  extremely  virulent, 
and  it  is  possible  that  actual  disease  can  be  transmitted  by  the 
former.  Thus,  if  a  fly  bites  a  person  after  feeding  on  putrid 
carrion,  some  form  of  septic  inflammation  may  be  originated  ; 
anthrax  may  also  be  spread  in  this  way.  Mosquitoes,  too,  play 
an  important  role  in  the  growth  and  development  of  filariae. 

Snake-bites  require  but  little  notice  here,  as  they  are  exceedingly 
rare  in  this  country,  the  common  adder  (Pelias  herns)  being  the 
only  venomous  one  likely  to  be  met  with,  and  even  with  this  the 


206  A  MANUAL  OF  SURGERY 

poison  is  not  sufficiently  virulent  to  do  much  harm  unless  the 
individual  attacked  is  a  child  or  a  person  in  a  very  bad  state  of 
health.  The  poison  is  conveyed  to  the  wound  from  the  glands 
and  poison  sac  situated  on  either  side  of  the  upper  jaw  through 
fine  canals  in  the  specialized  teeth,  which  open  at  their  apices  ; 
these  teeth  are  so  delicate  in  some  snakes  that  it  may  be  difficult 
to  find  the  wounds  produced  by  them.  The  effects  of  an  adder's 
bite  are  not,  as  a  rule,  noticed  immediately,  but  come  on  in  the 
course  of  an  hour  or  so  ;  extreme  prostration  supervenes,  with  a 
weak  pulse,  cold  clammy  perspiration,  dilatation  of  the  pupils, 
and  perhaps  delirium  in  bad  cases,  merging  into  coma. 

The  Treatment  consists  in  preventing  the  absorption  of  the 
virus  by  tying  a  ligature  firmly  above  the  wound,  which  should 
then  be  laid  open  so  as  to  allow  of  free  bleeding,  and  the  surface 
excised  or  cauterized.  The  collapse  resulting  from  absorption  of 
the  poison  is  best  remedied  by  the  administration  of  stimulants  or 
the  hypodermic  injection  of  strychnine. 

In  India  and  other  countries  many  varieties  of  poisonous  snakes 
are  met  with,  and  wounds  are  frequently  fatal ;  indeed,  in  India  it 
is  stated  that  12,000  individuals  are  yearly  destroyed  in  this  way. 
The  symptoms  come  on  rapidly,  and  are  extremely  severe,  although 
they  are  modified  according  to  the  variety  of  snake.  The  treatment 
must  necessarily  be  more  energetic  ;  probably  the  introduction  of 
Fraser's  antivenine  will  be  the  means  of  saving  life. 

The  Anatomical  Tubercle,  or  Butcher's  Wart  (  Verruca  necrogenica), 
consists  in  a  papillomatous  development  usually  on  the  knuckles 
or  wrists,  of  those  who  are  exposed  to  wounds  either  in  the  dead- 
house  or  slaughter-house.  It  is  in  all  probability  a  manifestation 
of  tuberculous  infection,  and,  indeed,  resembles  somewhat  closely 
the  appearance  of  lupus  when  it  develops  on  the  hands.  Treat- 
ment consists  in  the  application  of  a  powerful  caustic,  whilst  in 
bad  cases  it  is  necessary  to  scrape  the  surface  before  cauterizing. 

Dissection  or  Post-mortem  Wounds  have  obtained  an  unenviable 
notoriety  as  being  fertile  in  the  production  of  serious  inflammatory 
disturbance,  and  although  the  graver  forms  are  less  common  now 
than  formerly,  yet  they  are  still  met  with  occasionally.  It  is 
well  known  that  bodies  are  most  virulent  within  a  few  hours  of 
death,  and  hence  the  post-mortem  room  is  more  frequently  respon- 
sible for  these  affections  than  the  dissecting  room  ;  moreover,  the 
care  which  is  expended  upon  the  preparation  of  subjects  by  in- 
jecting them  with  antiseptics  reduces  the  dangers  which  might 
arise  from  the  latter  source. 

Inflammatory  disturbances  may  arise  under  these  conditions 
from  several  distinct  causes  : 

1.  The  presence  of  strong  antiseptics,  such  as  arsenic,  often 
irritates  abrasions,  and  causes  tenderness  and  congestion  of  the 
matrices  of  the  nails. 

2.  The  organisms  occurring  in  actual  putrid  material  have  no 


WOUNDS  207 

power  of  attacking  living  tissues,  although  some  irritation  may  be 
caused  by  them  if  small  sores  or  abrasions  are  present. 

3.  Pathogenic  organisms  are  frequently  found  in  bodies  soon 
after  death,  and  are  especially  virulent  when  developing  in  the 
exudations  from  serous  membranes,  such  as  the  peritoneum,  and 
hence  both  the  surgeon  who  operates  on  the  living  subject,  and 
the  pathologist  who  examines  the  body  after  death,  are  alike 
exposed  to  serious  risk  either  from  an  accidental  puncture  or  from 
the  infection  of  some  abraded  surface.  It  is  even  possible  for 
infection  to  occur  through  the  hair  follicles  of  an  unbroken  skin. 

The  lesions  originated  by  any  of  these  means  vary  in  their 
nature  with  the  method  of  inoculation,  the  virulence  of  the 
organisms,  and  the  power  of  resistance  of  the  individual.  In  the 
simpler  cases  all  that  ensues  is  a  limited  irritation  of  some  abrasion 
or  scratch,  which  rapidly  disappears  on  the  application  of  some 
sedative  or  antiseptic  lotion.  Suppurative  folliculitis,  or  even 
boils,  arise  from  infection  of  the  hair  follicles,  and  in  worse  cases 
the  various  forms  of  onychia,  paronychia,  or  diffuse  cellulitis, 
with  or  without  suppuration  in  the  nearest  lymphatic  glands. 
Severe  toxaemic  symptoms  usually  accompany  the  last-named 
conditions,  and  even  acute  septicaemia  may  develop.  The 
immediate  treatment  indicated  for  a  dissection  wound  is  to  tie 
a  ligature  or  handkerchief  around  the  base  of  the  wounded 
finger,  so  as  to  encourage  bleeding  and  prevent  the  absorption 
of  toxic  materials  ;  the  part  is  then  well  washed  under  a  tap  of 
cold  water,  immersed  in  an  antiseptic  solution,  and  sucked  for 
some  minutes ;  an  antiseptic  dressing  must  then  be  applied. 
Any  inflammation  which  arises  subsequently  must  be  treated 
according  to  the  general  rules  of  surgery. 

A  common  result  of  poisoned  wounds  of  the  fingers,  whatever 
their  origin,  is  inflammation  of  the  nail  matrix  (Chapter  XIV.),  or 
of  the  tissues  of  the  fingers,  constituting  a  whitlow  ;  and  it  will 
be  convenient  to  describe  the  latter  condition  at  this  place. 

A  Whitlow  (Paronychia  or  Panaritium)  occurs  in  four  different 
forms,  of  which  one  is  a  true  cellulitis,  another  a  teno-synovitis, 
a  third  is  a  localized  inflammation  of  the  skin,  and  the  fourth 
involves  the  terminal  phalanx. 

(a)  The  Subcuticular  whitlow  consists  merely  in  a  development  of  pus 
beneath  the  cuticle  which  separates  it  from  the  cutis  vera.  It  is  very 
painful,  but  otherwise  is  of  little  importance  A  boracic  poultice,  preceded 
by  the  removal  of  the  loose  cuticle,  is  all  that  is  needed  in  its  treatment. 

(b)  The  Subcutaneous  whitlow  is  a  true  cellulitis,  commencing  in  the  pulp 
of  a  finger,  but  often  spreading  upwards  to  involve  the  palm.  The  finger 
becomes  swollen  and  painful,  the  pain  being  increased  by  pressure  or  by 
hanging  down  the  arm.  Gradually  both  these  symptoms  increase  in  amount, 
the  back  of  the  finger  becoming  cedematous,  and  the  pulp  more  or  less  red. 
The  swelling  is  at  first  hard  and  brawny,  and  even  when  pus  is  present  it  may 
be  difficult  to  detect  fluctuation  unless  the  abscess  is  nearly  pointing.  Con- 
stitutional symptoms  are  not,  as  a  rule,  very  severe,  though  the  intensity  of 


208 


A   MANUAL  OF  SURGERY 


the  pain  may  exhaust  the  patient.  The  hand  should  be  elevated,  and  the 
finger  poulticed.  A  free  incision  should  be  early  adopted,  but,  though  free, 
must  not  extend  too  deeply,  or  the  tendon  sheath  may  be  opened  and  infected. 
Occasionally  the  pus  forms  at  one  or  other  side  of  the  finger,  and  the  incisions 
must  then  be  suitably  modified.  Antiseptic  fomentations  may  be  continued 
after  such  an  incision,  the  constant  moisture  adding  greatly  to  the  patient's 
comfort. 

(c)  The  Thecal  form  of  whitlow  is  really  a  suppurative  teno-synovitis  of  the 
flexor  sheaths.  The  signs  are  much  the  same  as  in  the  former  variety,  only 
more  severe,  because  the  process  is  often  more  extensive.  As  special  features 
may  be  mentioned  the  inability  of  the  patient  to  bend  the  finger,  and  the 
extreme  pain  caused  on  attempting  to  do  so,  owing  to  the  involvement  of  the 
tendon.  The  swelling  also  is  more  marked,  and  usually  extends  to  the  dorsum 
of  the  hand.  It  is  important  to  remember  that  the  flexor  sheaths  communi- 
cate  with   the   common  palmar  sheath — always   in  the  case  of   the  thumb, 

usually  in  the  little  finger,  but  not  in  the  index, 
middle,  and  ring  fingers  (Fig.  50).  In  the  last 
case  suppuration  ceases  at  the  level  of  the 
heads  of  the  metacarpal  bones  ;  but  occasion- 
ally it  oversteps  this  limit,  and  involves  the 
palm  in  the  same  way  as  in  the  thumb  and 
little  finger.  Free  and  early  incision  must  be 
made  to  anticipate  such  extension,  and  also  to 
limit  as  far  as  possible  the  adhesions  which 
the  tendons  are  liable  to  contract,  or  to  prevent 
them  from  sloughing  owing  to  the  acuteness 
of  the  inflammation.  In  neglected  cases  the 
pus  may  burrow  to  the  dorsum  of  the  fingers, 
necessitating  counter-openings ;  or  the  peri- 
osteum may  be  affected,  leading  to  disease  or 
death  of  the  phalanges ;  the  interphalangeal 
joints  may  also  be  disorganized.  If  the  palm 
is  involved,  care  must  be  taken  in  incising  the 
abscess  not  to  wound  the  superficial  palmar 
arch  or  its  branches.  The  incision  should  be 
made  along  the  middle  of  the  metacarpal  bones 
involved,  and  not  higher  than  the  centre  of  the 
palm  ;  but  an  opening  may  also  be  necessary 
close  to  the  level  of  the  wrist-joint,  and  this 
can  be  made  in  the  middle  line  without  danger. 
(d)  The  Subperiosteal  whitlow  may  be  merely  a  complication  of  the  thecal 
variety ;  but  it  occasionally  starts  as  an  acute  necrosis  of  the  terminal  phalanx, 
arising  either  idiopathically  or  as  a  result  of  infection  from  the  nail  matrix. 
The  inflammation  may  be  limited  to  the  end  of  the  finger,  or  may  spread  to 
the  palm.  Free  incisions,  and  the  removal  of  the  bone,  if  dead,  constitute  the 
treatment  required 

Repair  of  Wounds. 

In  former  days  five  different  methods  of  repair  were  described, 
but  increased  knowledge  and  further  research  warrant  us  in 
making  the  statement  that  there  is  but  one  method  of  repair, 
which,  however,  is  modified  according  to  the  conditions  of  the 
wound,  and  that  this  process  is  essentially  the  same  whatever 
tissue  of  the  body  is  involved,  be  it  bone,  muscle,  tendon,  or 
subcutaneous  connective  tissue.  It  must  be  noted  that  repair  is 
not  synonymous  with  regeneration.  It  is  very  unusual  for  any 
tissue  which  has  suffered  from  a  serious  lesion  to  be  regenerated ; 


Fig.  50. — Diagram  of  Syno- 
vial Sheaths  of  Flexor 
Tendons  of  Hand.  (After 
Keen  and  White.) 


WOUNDS  209 


fibro-cicatricial  tissue,  or  some  modification  of  it,  forms  the  new- 
bond  of  union  between  the  damaged  parts.  In  a  few  tissues,  how- 
ever, true  regeneration  has  been  noted — e.g.,  in  striped  muscle, 
bone,  tendon,  nerves,  and  glandular  structures,  provided  the 
injured  parts  have  been  brought  into  close  opposition. 

The  general  facts  as  to  the  process  of  repair  may  be  stated  as 
follows :  The  margins  of  the  wound  are  always  bounded  by  an 
area  of  tissue  in  a  state  of  lowered  vitality,  even  if  no  bruising  or 
sloughing  of  the  parts  is  present.  The  divided  vessels  are  in  a 
condition  of  thrombosis  as  far  as  the  next  patent  branches,  which 
in  their  turn  are  slightly  dilated,  partly  as  a  result  of  this  obstruc- 
tion and  partly  from  the  reflex  irritation  of  the  injury.  The  surface 
of  the  wound  is  generally  covered  with  a  film  of  lymph  or  blood- 
clot,  whilst  any  spaces  left  in  the  interstices  of  the  tissues  are 
similarly  occupied. 

(a)  The  first  stage  in  the  process  consists  in  an  abundant 
exudation  of  small  round  cells,  presumably  ieucocytes,  whose 
function  is  to  remove  all  dead  or  damaged  tissue,  as  well  as  to 
break  up,  disintegrate,  and  finally  absorb,  any  blood-clot  which 
is  present.  These  cells  are  derived  from  the  surrounding  vessels, 
and  are  accompanied  by  a  certain  amount  of  serous  oozing,  so 
that  we  have  here  the  early  manifestations  of  a  slight  inflamma- 
tory reaction,  which,  if  it  does  not  extend  beyond  certain  limits, 
is  a  beneficial  proceeding.  Should  it,  however,  become  excessive, 
as  when  bacterial  invasion  is  present,  injurious  results  may  follow. 
Much  discussion  has  arisen  among  pathologists  as  to  whether  or 
not  this  stage  of  repair  is  to  be  considered  inflammatory  in  origin  ; 
the  phenomena  are,  however,  so  exactly  similar  to  those  occurring 
in  the  earliest  stages  of  inflammation  that  it  is  impossible  to  draw 
any  line  of  distinction  between  them. 

(b)  The  exudation  of  leucocytes  is  soon  followed  by  the  appear- 
ance of  a  number  of  larger  cells  with  more  distinct  nuclei,  and  in 
which  cell  division  is  always  accompanied  by  karyokinesis  ;  these 
are  termed  fibroblasts,  and  are  now  considered  the  active  agents  in 
the  reparative  process.  There  is  some  difference  of  opinion  as  to 
the  origin  of  these  cells  ;  formerly  they  were  supposed  to  be 
migrated  leucocytes,  but  more  recent  researches  indicate  that 
they  are  derived  from  the  multiplication  of  fixed  or  wandering 
connective  tissue  corpuscles  or  of  the  endothelial  cells  lining  the 
neighbouring  capillaries  or  lymphatics.  Whatever  their  origin, 
they  soon  form  a  layer  of  cellular  tissue  which  lies  upon  or 
between  the  surfaces  or  lips  of  the  wound,  whilst  the  previously 
effused  leucocytes  disappear,  some  finding  their  way  back  into 
the  circulation,  and  others  serving  as  pabulum  for  the  nutrition 
of  the  fibroblasts. 

{c)  The  vascularization  of  this  cellular  layer  forms  the  next 
stage  in  the  process.  This  is  brought  about  by  the  outgrowth 
from  the  walls  of  the  nearest  capillaries  of  solid  rods  of  proto- 

J4 


A   MANUAL  OF  SURGERY 


plasm  (Fig.  51,  (7),  which  appear  first  as  minute  buds,  but  rapidly 
increase  in  length,  and  may  be  single  or  double.  They  soon 
bend  over  to  unite  with  similar  threads  growing  out  from  other 
capillaries,  or  with  the  wall  of  another  vessel  (Fig.  51,  b),  or 
occasionally  they  unite  with  the  vessel  from  which  they  started. 
The  connective  tissue  cells  may  also  become  spindle-shaped, 
and  send  out  branching  processes  to  unite  with  the  offshoots 
from  the  vessel  walls.  After  a  time  these  protoplasmic  threads 
become  canalized  (Fig.  51,  c),  and  a  communication  is  estab- 
lished between  them  and  the  mother  vessel,  so  that  blood  passes 
into  them.     The  new  capillary  wall,  at  first  homogeneous,  soon 


Fig.  51. — New  Vessel  Formation.     (After  Tillmanns.) 

a,  A  small  bud-like  projection  from  the  wall  of  a  capillary;  b,  the  union  of 
such  buds  one  with  another,  or  with  the  branching  processes  of  connec- 
tive tissue  cells  ;  c,  the  canalization  of  these  processes. 


becomes  lined  with  definite  endothelial  cells,  and  strengthened  by 
the  connective  tissue  which  forms  around  it.  By  this  means 
a  soft  vascular  tissue  is  produced,  known  as  granulation  tissue 
(Plate  V.,  Fig.  2),  consisting  of  loops  of  capillaries  supported 
by  large  nucleated  cells  with  a  varying  amount  of  intercellular 
substance,  which  soon  becomes  fibrillated  in  texture. 

(d)  The  transformation  of  this  granulation  tissue  into  ftbvo- 
cicatricial  tissue  is  next  proceeded  with.  Formerly  it  was  sup- 
posed that  the  cells  of  the  granulation  tissue  were  themselves 
transformed  into  the  fibres  from  which  scar  tissue  is  developed, 


WOUNDS 


but  this  idea  is  now  abandoned  in  favour  of  one  which  maintains 
that  the  fibrillae  are  derived  as  an  intercellular  exudation.  By  the 
contraction  of  these  fibres  the  cells  become  flattened  out  and 
compressed,  and  the  newly-formed  vessels  constricted,  so  that  as 
time  passes  the  scar  tissue  becomes  less  and  less  vascular,  and 
consequently  firmer  and  denser,  as  well  as  smaller. 

(e)  Whilst  this  last  stage  is  in  progress,  the  surface  of  the 
wound  is  covered  over  with  cuticle,  which  spreads  inwards  from 
healthy  epithelium  in  the  neighbourhood  of  the  wound,  and 
especially  from  the  deeper  layers  of  the  rete  Malpighii. 

As  already  stated,  the  general  process  of  repair  sketched  above 


Fig.  52. — Diagram  of  Healing  by  First  Intention.     (After  Billroth.) 

The  wound  is  occupied  by  a  fibro-cellular  growth,  into  which  loops  of 
capillaries  extend,  constituting  granulation  tissue,  whilst  the  epithelium 
has  united  across  the  surface. 


is  modified  according  to  the  character  and  condition  of  the  wound. 
Four  chief  modifications  are  met  with  in  surgery  : 

1.  Healing  by  First  Intention  or  Primary  Union  occurs  in  cleanly- 
cut  aseptic  wounds  where  the  lips  are  unbruised  and  brought 
together,  so  that  no  extensive  collection  of  blood  or  discharge 
between  them  is  possible.  A  thin  layer  of  blood-clot  lies  between 
the  surfaces  of  the  wound  and  penetrates  into  its  meshes,  and  the 
contraction  of  this  clot  is  at  first  the  chief  means  of  keeping  the 
deeper  parts  in  apposition.  There  is  but  a  microscopic  line  of 
damaged  tissue,  which,  together  with  the  blood-clot,  is  easily 
absorbed,  and  the  process  runs  a  typical  course,  as  sketched 
out  above,  union  being  effected  in  five  to  seven  days.  (See 
Fig.  52,  and  Plate  VIII.,  Fig.  1.) 

2.  Healing  by  Granulation,  or  second  intention,  as  it  used  to  be 
termed,  is  met  with  (a)  in  cases  where  there  has  been  definite  loss 

14 — 2 


A  MANUAL  OF  SURGERY 


of  substance,  so  that  the  lips  of  the  wound  are  not,  or  cannot  be 
approximated  ;  as  also  (b)  when  the  surface  of  the  wound  is 
bruised  or  damaged  so  that  portions  of  tissue  have  to  separate  by 
sloughing ;  or  (c)  when  the  advent  of  sepsis  has  prevented  the 
occurrence  of  primary  union. 

When  a  small  amount  of  aseptic  dead  tissue  is  present,  it  is 
removed  as  previously  described  (p.  69)  by  an  invasion  of  leuco- 
cytes from  the  surrounding  vessels,  which  disintegrate  and  gradu- 
ally absorb  it.  These  are  followed  by  the  fibroblasts,  which  form 
a  layer  of  granulation  tissue  on  the  surface  of  the  wound  (Fig.  53). 
If  there  is  much  slough  to  be  dealt  with,  the  vitality  of  the  granu- 
lation tissue  cannot  be  maintained  beyond  a  certain  distance  from 
its  source  of  nutrition,  and  so  by  a  process  of  simple  anaemic 


Fig.  53. 


-Diagrammatic  Representation  of  the  Later  Stages  of 
Healing  by  Granulation.     (After  Billroth.) 


ulceration  the  unabsorbed  dead  portion  is  cast  off  and  a  granu- 
lating surface  remains.  If  the  slough  is  septic,  ulcerative  inflam- 
mation occurs  in  the  adjacent  living  tissue,  which  brings  about  a 
similar  result,  though  accompanied  by  suppuration  and  septic 
fever.  When,  however,  there  is  a  simple  loss  of  substance, 
with  no  bruising  or  damage  to  the  tissues,  the  course  of  events  is 
as  follows :  The  blood-stream  in  the  superficial  capillaries  having 
been  arrested,  adjacent  vessels  become  dilated,  and  from  these 
an  exudation  of  plasma  and  leucocytes  results.  The  plasma 
coagulates  on  the  surface  and  forms  a  layer  of  fibrin,  entangled 
in  the  meshes  of  which  are  a  number  of  white  corpuscles,  so 
that  the  wound  becomes  covered  with  a  film  of  whitish-yellow 
material  known  as  lymph.  This  gradually  increases  in  amount 
and  thickness,  and  is  vascularized  from  below  into  granulation 
tissue,  this  process  occupying  from  four  to  seven  days  (Plate  V., 
Fig.  2). 

The  healing  of  a  granulating  wound  is  brought  about  by  the 


WOUNDS  213 


conversion  of  the  granulations  into  fibro-cicatricial  tissue,  and 
by  the  surface  becoming  covered  with  cuticle.  The  contractile 
tendency  inherent  in  all  cicatricial  tissue  produces  two  results 
from  its  presence  in  the  base  of  the  wound  beneath  the  super- 
ficial layer  of  granulations  :  (i.)  The  surface  area  of  the  wound 
is  diminished  in  all  directions,  a  most  important  element  in 
the  healing  process,  since  if  the  base  is  adherent  to  some  dense 
resisting  structure  repair  is  slow  and  difficult,  and  the  wound 
may  remain  open  as  a  so-called  chronic  ulcer.  When  the  granu- 
lating surface  is  very  extensive,  contraction  may  proceed  to  such 
an  extent  as  to  obliterate  many  of  the  vascular  channels,  and  by 
thus  depriving  the  superficial  tissues  of  their  adequate  nutrition, 
the  healing  process  may  be  indefinitely  prolonged.  (ii.)  The 
depth  of  the  wound  is  diminished,  partly  by  the  continuous  growth 
of  granulation  tissue  from  below  upwards,  but  also  by  the  con- 
tractile base  lifting  the  deeper  structures  to  the  surface.  If 
the  base  of  the  wound  cannot  be  raised,  the  cicatrix  is  usually 
depressed  and  adherent  to  the  underlying  parts. 

During  the  process  of  repair  the  wound  takes  on  the  appearances 
already  described  as  characteristic  of  a  healing  ulcer  (p.  63). 

3.  Healing  under  a  Scab  is  a  proceeding  that  can  only  take  place 
in  very  small  wounds,  such  as  superficial  grazes  and  abrasions, 
and  is  practically  identical  with  the  granulating  process,  except 
that,  instead  of  an  artificial  dressing  applied  by  the  surgeon,  the 
lesion  is  covered  by  a  scab  which  consists  of  clotted  blood  or 
dried  exudation.  Should  sepsis  be  present,  pus  is  likely  to 
accumulate  beneath  the  scab  and  give  trouble. 

4.  Healing  by  Organization  of  Blood-clot  is  only  observed  in 
strictly  aseptic  wounds  where  there  is  definite  loss  of  substance, 
as  in  the  deep  channels  made  in  the  treatment  of  bones  thickened 
by  chronic  osteitis.  Blood  is  allowed  to  collect  and  coagulate  so 
as  to  fill  the  cavity,  and  the  surface  is  covered  with  protective  to 
prevent  irritation  from  the  dressings.  The  dark  coagulum  shows 
no  trace  of  change  for  some  days,  but  gradually  the  peripheral 
portions  become  granular  and  yellowish-white  in  colour ;  these 
are  gradually  vascularized  and  transformed  into  granulation 
tissue,  which  in  time  spreads  over  the  whole  surface  from 
periphery  to  centre,  and  then  healing  occurs  as  described  above. 
The  clot  is  absolutely  passive  in  this  process,  being  infiltrated  by 
leucocytes  and  removed  by  degrees,  and  thus  merely  serves  as  a 
basis  of  support  or  scaffolding  for  the  building  up  of  the  granula- 
tion tissue  which  replaces  it. 

A  Scar  is  a  mass  of  fibroid  tissue  covered  by  epithelium,  which 
has  been  formed  in  the  repair  of  a  wound  (Plate  VIII.,  Fig.  2).  It 
is  at  first  vascular,  and  contains  cells  of  the  connective  tissue  type ; 
but  after  a  time,  as  contraction  continues,  the  cell  elements  become 
flattened  out,  fewer  in  number  and  less  obvious,  the  intercellular 


2i4  A  MANUAL  OF  SURGERY 

fibrous  tissue  more  abundant,  and  the  vessels  constricted,  so  that 
finally  a  scar  becomes  well-nigh  bloodless.  Where  superficial,  its 
colour  changes  from  red  to  white,  and  if  of  small  size  it  may 
almost  disappear,  but  never  absolutely,  unless  the  subcutaneous 
tissue  has  not  been  involved.  When  the  parts  around  become 
injected  by  any  cause,  such  as  sharp  friction,  the  anaemic  scar 
tissue  again  becomes  evident  by  contrast.  Lymphatics,  nerves, 
hairs,  and  cutaneous  glands  are  all  absent,  except  perhaps  at  the 
periphery,  and  the  epithelial  covering  itself  is  merely  a  uniform 
layer  without  papilla?. 

The  Pathological  Phenomena  connected  with  scars  are  as 
follows : 

i.  Excessive  Contraction,  which  may  lead  to  great  deformity, 
especially  when  the  wound  has  occurred  in  the  flexure  of  any  of 
the  joints.  A  web-like  mass  of  fibroid  tissue  then  forms,  limiting 
movement,  and  requiring  operative  interference.  A  seriously 
burned  hand  may  by  cicatricial  contraction  be  fused  into  an  un- 
sightly mass,  rendering  the  fingers  of  little  use  ;  similarly,  the 
chin  may  be  drawn  down  and  practically  fixed  to  the  sternum, 
and  the  lower  lip  everted,  as  the  result  of  a  burn  on  the  front  of 
the  neck.  The  Treatment  of  such  conditions  consists  in  dividing 
the  cicatrix,  and  thus  freeing  the  parts,  during  which  process  it 
must  be  remembered  that  deeper  structures  of  importance,  such 
as  the  main  vessels  and  nerves,  may  be  adherent  to  the  under 
surface,  and  thus  be  endangered.  When  once  the  scar  has  been 
divided,  there  is  often  no  difficulty  in  restoring  the  parts  to  their 
normal  positions,  although  when  the  contraction  has  existed  for 
any  length  of  time  it  may  be  advisable  to  do  this  slowly,  even  by 
gradual  extension  with  a  weight  and  pulley,  so  as  to  avoid  any 
risk  of  lacerating  the  deeper  parts,  which  are  usually  contracted 
secondarily.  The  raw  surface  formed  by  the  opening  out  of  the 
contraction  has  now  to  be  covered  with  epithelium  by  some  form 
of  skin-grafting  or  by  a  plastic  operation  ;  most  of  the  cases  can 
be  dealt  with  by  Thiersch's  method,  but  the  results,  though 
promising  for  a  time,  are  often  ultimately  disappointing. 

2.  Overgrowth  of  the  scar  tissue  is  sometimes  met  with,  con- 
stituting what  is  known  as  the  false  or  Alibert's  Keloid.  This 
most  frequently  occurs  in  the  scars  of  burns  or  of  wounds  in 
tuberculous  patients,  but  may  arise  from  any  cicatrix,  presenting 
itself  as  a  fibroid  indurated  mass  of  a  dusky  red  colour,  with 
perhaps  a  number  of  dilated  vessels  coursing  over  it,  which 
occupies  the  region  of  the  old  scar,  and  may  possibly  send  claw- 
like processes  into  neighbouring  healthy  structures.  It  consists 
merely  of  a  hyperplasia  of  the  scar  tissue,  but  as  to  its  aetiology 
nothing  is  known.  With  the  exception  of  somewhat  severe 
pruritus  or  itching,  its  presence  entails  no  inconvenience,  although 
if  it  occurs  on  exposed  parts  it  may  be  very  disfiguring.  Removal 
is  useless,   since   the   keloid   almost   always   recurs   in  the  new 


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WOUNDS  215 


cicatrix  and  in  the  stitch  holes.     After  a  longer  or  shorter  interval 
it  often  disappears  spontaneously. 

3.  Ulceration  of  Scars,  the  result  of  defective  nutrition,  is  a 
troublesome  condition  to  deal  with,  as  repair  is  usually  slow. 

4.  Painful  Scars  arise  from  either  the  implication  of  a  nerve 
terminal  in  the  cicatrix,  or  the  pressure  of  a  contracting  scar  upon 
the  bulbous  end  of  a  divided  nerve,  as  in  amputation  stumps.  In 
each  case  further  operation  is  necessary  ;  in  the  former  the  cicatrix, 
or  at  any  rate  the  painful  portion  of  it,  is  excised,  whilst  in  the 
latter  the  stump  must  be  opened  up,  and  the  enlarged  end  of  the 
affected  nerve  removed. 

5.  Malignant  Disease  of  Scars  is  of  an  epitheliomatous  type,  and 
appears  as  a  hard  tumour  with  everted  edges,  a  thickened  base, 
and  usually  a  good  deal  of  foetid  discharge.  The  progress 
is  very  slow,  since  the  vascularity  of  the  tissue  is  slight.  It  is 
painless,  from  the  absence  of  nerves,  and  as  long  as  the  disease  is 
limited  to  the  scar,  no  lymphatic  implication  will  be  noted.  As 
soon,  however,  as  the  malignant  growth  invades  healthy  tissues, 
the  usual  phenomena  show  themselves.  The  diseased  tissues  may 
be  freely  dissected  out,  having  regard  to  subjacent  structures,  and 
the  wound  closed  by  some  plastic  method. 

General  Conditions  connected  with  Wounds. 

I.  Shock. — By  the  term  'shock'  is  meant  a  general  depressed 
condition  of  the  nervous  system,  resulting  from  some  energetic 
stimulus,  which  is  either  transmitted  to  the  vital  centres  in  the 
medulla  from  the  peripheral  sensory  or  sympathetic  nerves  of  an 
injured  part,  or  may  descend  to  them  from  a  disturbance  of  the 
emotional  centres  through  the  nerves  of  special  sense.  Local 
Shock  is  a  curious  condition  of  insensibility  to  pain  on  handling, 
which  is  sometimes  present  after  severe  injuries,  and  is  especially 
seen  in  gunshot  wounds.  Possibly  it  is  due  to  some  temporary 
paralysis  of  the  sensory  nerves. 

The  term  collapse  is  applied  to  a  condition  very  similar  in  nature  to  shock, 
but  differing  from  it  mainly  in  its  onset,  which  is  gradual,  and  often  preceded 
by  some  exhausting  disease,  and  by  the  fact  that  muscular  relaxation  is  more 
complete.  The  collapse  of  cholera  is  one  of  the  most  typical  manifestations, 
but  any  condition  associated  with  loss  or  derivation  of  fluids  from  the  vessels 
may  give  rise  to  it,  e.g.,  prolonged  vomiting  or  serious  haemorrhage.  If  at  the 
same  time  septic  absorption  is  taking  place,  the  symptoms  are  still  more 
marked  ;  thus  in  acute  peritonitis  the  two  factors,  removal  of  fluid  from  the 
circulation  and  toxaemia,  are  proceeding  concurrently.  Shock  usually  tends 
to  recovery,  unless  the  lesion  is  of  a  serious  nature,  and  then  collapse  may 
supervene  and  prove  fatal ;  thus,  after  rupture  of  the  intestine  the  immediate 
symptoms  are  the  result  of  shock,  but  they  are  quickly  followed  by  the  collapse 
due  to  acute  peritonitis. 

The  degree  of  shock  experienced  in  any  particular  case  is 
mainly  influenced  by  the  following  factors  : 

(fl)  The  severity  and  extent  of  the  injury,  wrhich  may  be  calcu- 


2i6  A  MANUAL  OF  SURGERY 

lated  either  by  the  number  of  sensory  nerve  terminals  affected, 
i.e.,  the  superficial  extent  of  the  lesion,  or  by  the  depth  to  which 
the  injury  extends.  Speaking  generally,  the  amount  of  shock 
varies  directly  with  the  depth  of  the  wound,  since  the  deeper  the 
wound,  the  greater  the  violence  which  has  produced  it ;  but  in 
some  cases  extensive  superficial  wounds  produce  a  more  severe 
effect  than  limited  deep  ones,  owing  to  the  larger  number  of  nerves 
involved,  along  which  stimuli  can  be  carried  to  the  centres  ;  thus, 
an  extensive  superficial  burn  is  more  likely  to  produce  fatal  shock 
than  the  complete  incineration  of  an  extremity. 

(b)  The  site  of  the  injury.  The  more  essential  and  sensitive  the 
organ  injured,  and  the  more  closely  it  is  connected  with  the  chief 
sympathetic  or  cerebral  centres,  the  greater  will  be  the  shock  ; 
thus,  a  small  wound  of  the  intestine,  stomach,  or  any  of  the  viscera, 
is  much  more  serious  than  an  extensive  accident  to  one  of  the 
limbs.  This  fact  is  sometimes  of  practical  value  in  the  determina- 
tion of  the  exact  nature  of  abdominal  injuries.  When  severe 
shock  with  abdominal  pain  lasts  for  twenty-four  hours  after  an 
accident,  the  surgeon  may  be  almost  certain  that  some  internal 
viscus  has  been  seriously  damaged,  and  should  at  once  consider 
the  advisability  of  performing  laparotomy. 

(c)  The  nervous  susceptibility  of  the  patient  is  a  most  important 
element,  for  the  more  highly  organized  the  nervous  system,  the 
greater  is  the  amount  of  shock  experienced,  and  vice  versa.  Prison 
surgeons  bear  this  out,  for  amongst  the  coarser  and  baser  types  of 
criminals  operations  may  be  performed  without  an  anaesthetic  in  a 
surprising  manner. 

(d)  The  expectation  or  not  of  the  injury.  When  the  whole  nervous 
system  is  maintained  in  a  state  of  tension,  anxiously  expecting  the 
receipt  of  some  painful  impression,  the  effect  produced  will  natu- 
rally be  increased ;  whilst  if  the  attention  is  diverted,  and  interest 
actively  aroused  in  other  things,  the  shock  at  the  time  is  much 
diminished,  though  its  effects  may  be  subsequently  greater.  Thus, 
in  the  keen  excitement  and  nervous  tension  of  a  battle,  soldiers 
have  often  been  wounded  severely,  and  yet  not  known  it  at  the 
time  ;  whilst  the  pain  of  the  most  trifling  cut  may  produce  deep 
shock  when  the  patient  is  in  a  state  of  dread  and  anticipation. 

The  Symptoms  vary  with  the  injury  inflicted,  from  a  slight 
momentary  giddiness  and  faintness  (known  ordinarily  as  an  attack 
of  syncope  or  a  fainting  fit)  to  immediate  and  complete  prostration, 
insensibility,  and  even  death.  The  pulse  is  at  first  small,  slow, 
and  weak,  but  soon  becomes  irregular,  extremely  rapid,  and  often 
imperceptible ;  the  countenance  is  pallid  and  shrunken,  and  the 
brow  covered  with  cold  sweat ;  the  respirations  are  slow  and 
shallow,  whilst  the  temperature  is  usually  subnormal. 

After  an  interval,  the  length  of  which  depends  on  the  severity 
of  the  lesion  and  the  treatment  adopted,  reaction  occurs,  being 
introduced  by  increased  depth  and  frequency  of  the  respirations  ; 


WOUNDS  217 


the  pulse  becomes  slower  and  fuller,  the  surface  warmer,  whilst 
consciousness  and  muscular  power  are  gradually  restored.  During 
this  period  it  is  not  unusual  for  an  attack  of  vomiting  to  supervene, 
probably  due  to  hyperaemia  of  the  brain  following  the  anaemia 
which  has  been  responsible  for  most  of  the  preceding  symptoms. 

When  the  accident  or  operation  has  resulted  in  serious  loss  of 
blood,  the  phenomena  of  haemorrhage  are  associated  with  those  of 
shock  ;  the  pulse  is  sometimes  of  the  haemorrhagic  type  (p.  223) ; 
the  blood  is  altered  in  its  characters,  and  great  restlessness  may 
be  present. 

Sometimes  reaction  is  accompanied  by  great  irritability,  either 
of  the  mental  or  muscular  systems  ;  in  the  one  case  leading  to 
traumatic  delirium,  which  is  always  of  grave  import,  and  in  the 
other  to  intense  restlessness,  as  in  the  shock  which  follows  exten- 
sive burns.  It  is  possible  that  in  both  these  conditions  a  toxic 
element  has  been  introduced.  The  term  evethitic  shock  is  some- 
times applied  to  these  manifestations. 

Occasionally  the  evidences  of  shock  are  delayed  in  their  ap- 
pearance for  some  time  after  the  injury,  and  come  on  gradually. 
Especially  is  this  the  case  after  railway  accidents  when  no  great 
injury  has  been  experienced  ;  for  a  time  the  anxiety  and  excite- 
ment are  such  that  no  depression  is  noticed,  but  as  the  mental 
perturbation  passes  off,  the  individual  experiences  symptoms  very 
similar  to  the  above,  but  probably  rather  of  the  nature  of  neuras- 
thenia than  of  real  shock  (see  Chapter  XXL).  When  an  accident 
occurs  to  a  person  in  a  state  of  intoxication,  it  is  not  unusual  for 
the  phenomena  of  shock  to  be  delayed  for  some  time,  only  showing 
themselves  when  the  effect  of  the  alcohol  has  passed  away. 

Pathology. — The  post-mortem  evidences  are  not  very  charac- 
teristic, but  they  all  point  to  a  loss  of  control  of  the  nervous  system 
over  the  vascular,  resulting  in  anaemia  of  the  brain  and  superficial 
parts  of  the  body,  and  enormous  engorgement  of  the  abdominal 
viscera,  lungs,  and  great  venous  trunks ;  the  heart  contains 
practically  no  blood,  although  it  is  probable  that  the  right  side  is 
much  distended  at  the  time  of  death,  especially  when  due  to 
sudden  injury,  and  subsequently  empties  itself  by  post-mortem 
contraction.  The  explanation  of  the  phenomena  of  shock  is  by  no 
means  simple,  and  several  factors  are  probably  needed  to  produce 
the  complex  result.  1.  Reflex  inhibition  of  the  heart's  action 
through  the  cardio-inhibitory  centre  in  the  medulla  explains  the 
early  syncope  with  slow  pulse.  It  is  a  well-known  physiological 
fact  that  if  a  frog's  abdomen  is  opened  and  the  exposed  intestine 
sharply  struck,  the  heart  stops  in  a  condition  of  diastole,  whilst  if 
the  vagi  are  previously  divided,  no  effect  is  produced.  Any  severe 
peripheral  injury  may  lead  to  such  a  result,  especially  those 
directed  to  the  great  sympathetic  centres  in  the  abdomen  which 
are  closely  connected  with  the  vital  centres  in  the  medulla.  In 
this  way  sudden  death  may  be  produced  by  a  severe  blow  in  the 


2i8  A  MANUAL  OF  SURGERY 

epigastrium,  or  by  drinking  a  glass  of  very  cold  water,  when 
hot.  Tins  inhibition  of  the  heart's  action  is  never  prolonged  in 
mammals.  2.  Inhibition  of  the  vasomotor  centre  in  the  medulla 
is  probably  the  cause  of  the  maintained  depression  of  the  patient 
after  an  injury.  This  produces  dilatation  of  the  smaller  arterioles, 
especially  in  the  splanchnic  area,  and  thus  a  marked  lowering  of 
the  general  blood-pressure  follows.  The  supply  of  blood  to  the 
brain  and  surface  is  therefore  diminished,  the  portal  system  being 
overfull.  Most  of  the  symptoms  of  shock  can  be  explained  in  this 
way,  although  it  is  evident  that  a  large  haemorrhage  ought  to 
produce  exactly  the  same  effects.  3.  A  third  factor  has  therefore 
been  suggested  in  the  production  of  shock,  viz.,  exhaustion  of  the 
nerve  centres,  which  thus  lose  their  control  over  the  muscular  and 
circulatory  systems. 

Diagnosis. — 1.  From  the  general  results  of  hemorrhage.  Rest- 
lessness and  thirst  are  then  prominent  signs,  together  with  a  sense 
of  dyspnoea,  causing  rapid  respiratory  efforts  ;  the  mental  con- 
dition, moreover,  is  less  affected,  and  the  patient  is  generally 
sensible  ;  the  surface  is  excessively  blanched,  and  the  pulse  may 
have  a  marked  haemorrhagic  wave.  2.  In  concussion  of  the  brain 
there  are  superadded  to  the  symptoms  of  shock  those  more  par- 
ticularly connected  with  the  region  affected,  i.e.,  the  intellectual 
centres,  so  that  unconsciousness  is  the  predominant  feature,  whilst 
loss  of  memory  of  the  accident  and  of  the  events  which  followed 
is  often  noticed.  3.  When  vomiting  is  approaching  under  the 
influence  of  an  anesthetic,  the  patient's  pulse  usually  becomes  weak 
and  rapid,  and  the  countenance  pale.  This  condition  closely  simu- 
lates shock,  and  is  often  distinguished  from  it  only  by  the  progress 
of  the  case.  Under  such  circumstances,  if  vomiting  is  plainly 
imminent,  it  is  sometimes  wise  to  increase  the  amount  of  anaes- 
thetic, as  the  patient  is  usually  not  fully  under  its  influence. 

Treatment. — In  slight  cases  very  little  is  needed  beyond  resting 
quietly  for  a  few  minutes,  or  the  exhibition  of  some  aromatic 
stimulant  to  the  nostrils,  such  as  ammonia  or  smelling-salts.  In 
the  more  severe  cases  the  patient  is  laid  recumbent,  with  the  head 
low ;  hot  bottles,  well  protected,  and  blankets  are  applied  to  the 
trunk  and  extremities  to  maintain  and  increase  the  bodily  tem- 
perature. If  able  to  swallow,  a  little  warm  tea  or  stimulant  may 
be  administered ;  but  if  unconscious,  a  hot  coffee  or  brandy 
enema,  small  in  bulk,  or  a  hypodermic  injection  of  ether  or 
strychnine  (11\_  ii.-vi.  of  the  B.P.  injection),  is  necessary.  It  must 
be  borne  in  mind  that  the  patient  has,  in  most  cases,  only  to  be 
tided  over  a  certain  period  of  depression  before  reaction  naturally 
follows,  so  that  it  is  important  to  economize  vital  power,  and  not 
to  waste  it  by  over-stimulation. 

The  injection  of  hot  saline  fluid  (1  drachm  of  chloride  of  sodium 
to  1  pint  of  water)  into  a  superficial  vein,  the  rectum,  or  the  subcu- 
taneous tissues  (submammary  or  gluteal  for  choice),    has  been 


WOUNDS  219 


employed  with  considerable  success  of  recent  years.  The  modus 
operandi  of  intravenous  infusion  is  described  at  p.  224  ;  the  fluid 
should  be  introduced  at  a  temperature  between  1050  and  no°  F. 
Several  pints  may  be  injected  to  begin  with,  the  exact  amount 
being  governed  by  the  reaction  of  the  patient.  If  after  a  few  hours 
symptoms  of  depression  again  supervene,  the  injection  should  be 
repeated. 

An  important  question  is  often  raised  as  to  the  advisability  of 
performing  an  operation  during  shock.  As  a  general  rule,  it  may 
be  stated  that  operation  should  be  deferred  until  reaction  has 
come  on,  unless  the  presence  of  the  injured  organ,  such  as  a  badly 
crushed  limb,  is  evidently  prolonging  the  condition.  Under  these 
circumstances  a  hypodermic  injection  of  morphia  may  improve 
the  condition  by  relieving  pain  ;  otherwise  the  condition  should  be 
at  once  dealt  with,  and  it  will  be  often  found  that,  as  the  patient 
passes  under  the  influence  of  the  anaesthetic,  the  pulse  improves, 
and  the  state  of  shock  disappears,  the  anaesthetic  shielding  the 
medullary  centres  from  the  painful  afferent  stimuli.  In  urgent 
cases,  especially  when  due  to  an  intra-peritoneal  lesion,  where 
operation  must  be  undertaken  without  delay,  the  use  of  a  saline 
injection  into  the  venous  system  prior  to  operation  is  often  most 
advantageous. 

Shock  may  to  a  large  extent  be  prevented  during  operation  by 
a  careful  attention  to  such  details  as  keeping  the  patient  well 
covered  up  and  as  warm  as  possible,  by  perhaps  operating  on  a 
hot-water  table,  by  minimizing  haemorrhage  through  bloodless 
methods  of  operating  or  the  use  of  forci-pressure  forceps,  and  by 
rapidity  of  execution.  A  hypodermic  injection  of  strychnine,  or  a 
brandy  and  beef-tea  enema,  given  just  before  the  operation,  is  also 
useful  ;  and  it  must  be  remembered  that  incomplete  anaesthesia 
tends  to  increase  the  shock  rather  than  to  prevent  its  occurrence. 
It  is  also  advisable,  in  cases  where  the  pulse  is  weak,  to  use  ether 
rather  than  chloroform. 

II.  Traumatic  Fever. — Traumatic  fever  is  that  which  follows 
the  receipt  of  an  injury,  whether  simple  or  compound,  or  after  an 
operation.     Two  main  varieties  are  described  : 

(a)  Simple  Traumatic  Fever  occurs  after  subcutaneous  injuries, 
such  as  sprains,  contusions,  fractures,  etc.,  and  after  aseptic 
operation  wounds  or  compound  injuries.  It  is  thus  found  in  con- 
ditions where  micro-organisms  are  absent,  or,  if  present,  are  in 
such  a  state  as  to  be  practically  impotent.  The  generally  acknow- 
ledged cause  is  the  absorption  from  the  blood-clot  or  inflammatory 
exudation  of  some  chemical  substance  (possibly  the  fibrin  fer- 
ment), which  has  a  pyrogenic  effect  upon  the  medullary  centres. 
Probably  the  fever  following  aseptic  operations  is  largely  de- 
termined by  the  use  of  irritating  antiseptics,  which  increase  the 
exudation,  and  lead  to  considerable  damage  of  the  tissues  ;  if  mild 


220  A  MANUAL  OF  SURGERY 

antiseptics  or  sterilized  salt  solution  are  alone  used  to  irrigate 
open  aseptic  wounds,  this  so-called  '  reactionary  fever  '  will  be 
absent,  unless  other  elements,  such  as  retained  serous  discharge 
or  accumulation  of  blood,  are  present.  Occasionally  fever  is 
observed  in  cases  where  we  have  no  grounds  for  supposing  that 
absorption  of  fibrin  ferment  is  taking  place  ;  it  may  then  be  due 
to  some  peripheral  irritation,  e.g.,  a  badly-fitting  splint,  and  dis- 
appears immediately  on  the  removal  of  the  cause. 

The  symptoms  are  those  of  slight  pyrexia,  reaching  ioo°  or 
ioi°  F.  within  twenty-four  or  forty-eight  hours  of  the  injury,  with 
coated  tongue,  loss  of  appetite,  etc.,  gradually  passing  off  in  three 
or  four  days.     If  thus  limited,  it  is  of  no  prognostic  importance. 

(b)  Symptomatic  Traumatic  Fever  is  that  caused  by  the  absorp- 
tion either  of  the  products  of  putrefaction,  resulting  from  the  vital 
activity  of  non-pathogenic  organisms  in  discharges,  blood-clot,  or 
dead  tissue  ;  or  from  the  absorption  of  the  toxins  connected  with 
a  development  of  pathogenic  organisms  in  the  wound  or  its  sur- 
roundings ;  or  from  the  supervention  of  some  general  infective 
disorder.  All  these  different  conditions  have  been  dealt  with  else- 
where, and  require  no  further  notice. 

III.  Traumatic  Delirium. — -Although  delirium  is  merely  a 
symptom  which  is  superadded  to  others  in  certain  cases,  it  is 
occasionally  of  so  pronounced  a  character  as  to  demand  special 
attention.     Three  forms  are  met  with  : 

(a)  The  Active  Delirium,  which  accompanies  severe  injuries, 
particularly  in  plethoric,  and  often  in  previously  healthy  indi- 
viduals, whose  environment  has  been  suddenly  changed  from  that 
of  everyday  life  to  a  sick-bed  in  a  hospital  ward.  Septic  con- 
tamination of  the  wound  is  usually  present,  and  the  delirious  state 
is  associated  and  runs  a  parallel  course  with  the  traumatic  fever. 
It  is  not  usually  of  a  violent  type,  although  the  patient  may  be 
irrational  and  restless  ;  he  moves  the  injured  part  without  any 
evident  appreciation  of  the  pain  which,  if  conscious,  he  must  suffer, 
but  he  is  easily  restrained  by  the  exhibition  of  firmness  and  tact 
on  the  part  of  the  attendant.  The  symptoms  are  most  marked  at 
night,  and  commence  at  the  end  of  forty-eight  hours,  lasting,  as  a 
rule,  for  two  or  three  days.  There  is  a  distaste  for  food,  which, 
however,  can  be  overcome  by  gentle  persuasion. 

Treatment. — Patients  in  this  condition  must  never  be  left ;  the 
diet  should  be  light,  but  nourishing  ;  the  bowels  are  thoroughly 
opened,  and  an  icebag  to  the  head  may  be  useful.  The  wound 
should  be  freed  from  any  septic  accumulation. 

(b)  Delirium  of  a  Low  Muttering  Type  is  met  with  in  individuals 
of  low  vitality,  exhausted  by  dissipation,  drink,  disease,  or  faulty 
hygienic  surroundings.  It  is  commonly  associated  with  fever  of 
an  asthenic  type,  such  as  is  seen  towards  the  end  of  septic  or 
infective  diseases.     The  patient  usually  lies  on  his  back,  staring 


WOUNDS 


vacantly  upwards,  is  incoherent,  takes  no  notice  of  surrounding 
objects,  and  is  observed  to  pick  at  the  bedclothes  and  mutter  to 
himself  unintelligibly.  There  is  often,  in  addition,  an  involuntary 
escape  of  urine  or  faeces.  The  mouth  is  generally  open,  the 
tongue  dry,  brown  and  cracked,  and  viscid  mucus  collects  about 
the  teeth  (sordes). 

The  Treatment  should  be  directed  to  careful  nursing  and  feeding, 
as  by  that  means  alone  can  the  patient  be  saved. 

(c)  Nervous  Traumatic  Delirium  is  observed  in  individuals  who, 
previously  of  intemperate  habits,  have  suffered  some  serious 
injury,  such  as  a  compound  fracture.  The  violent  symptoms  do 
not  set  in  till  about  the  third  day,  but  are  usually  preceded  by 
some  amount  of  sleeplessness  and  wandering  at  night,  or  the 
patient  may  have  short  snatches  of  sleep,  from  which  he  awakes 
semi-delirious.  This  gradually  increases,  and  is  followed  by 
violent  delirium  of  the  worst  type  (delirium  tremens),  in  which  the 
patient  is  haunted  by  terrifying  visions  of  reptiles,  horrible  insects, 
and  the  like,  from  which  he  tries  in  vain  to  escape.  During  this 
stage  of  excitement  he  is  with  difficulty  restrained  from  jumping 
out  of  bed  ;  in  many  instances  these  patients  are  remarkably 
cunning,  and,  managing  to  elude  the  vigilance  of  their  attendants, 
will  succeed  in  escaping  from  the  room  by  the  door  or  window, 
and  may  inflict  serious,  and  even  fatal,  injuries  upon  themselves  or 
others.  There  is  always  a  tremulous  condition  of  the  extremities 
and  of  the  tongue,  which  is  white  and  coated,  whilst  the  bowels 
are  obstinately  confined.  The  pulse  and  temperature  vary  con- 
siderably, and  the  skin  is  often  moist  and  clammy.  The  violent 
stage  is  always  followed  by  profound  exhaustion,  in  which  the 
patient  may  gradually  sink  into  a  state  of  coma  and  die.  In  the 
case  of  a  fractured  leg,  the  struggles  of  the  patient  will  cause  con- 
siderable displacement  of  the  limb,  and  necessitate  constant 
attention  to  prevent  further  mischief.  The  limb  should  never  be 
fixed  to  the  bed,  but  slung  in  a  Salter's  swing  or  immobilized  in 
plaster  of  Paris. 

Treatment. — In  cases  where  an  attack  of  delirium  tremens  is 
considered  imminent,  either  from  the  previous  history  of  the 
patient,  the  tremulous  state  of  his  hands  and  tongue,  or  his  sleep- 
lessness, the  best  treatment  to  adopt  is  to  support  the  strength  by 
suitable  food  and  a  medium  dose  of  stimulant,  combined  with  free 
purging  and,  if  need  be,  soporifics  (chloral,  bromide,  paraldehyde, 
or  morphia) ;  under  such  a  regimen  the  symptoms  usually  soon 
disappear.  In  the  acute  maniacal  attacks  the  patient  must  be 
fully  controlled  and  guarded,  but  with  as  little  manifestation  of 
restraint  as  possible.  Nourishing  food  (possibly  of  a  fluid  type), 
writh  a  certain  amount  of  stimulant,  should  be  administered  during 
the  quiet  intervals,  and  sleep  obtained  by  drugs,  especially  morphia 
hypodermically  ;  a  quarter  of  a  grain  should  be  given  at  first,  and 
more  if  necessary.     Free  purging  is  of  course  essential. 


C  H  A  P  T  E  R    IX. 

HEMORRHAGE. 

J  >Y  the  term  Jia  inorr/iage  is  meant  any  loss  of  blood,  whether  in- 
significant anci  immediately  arrested  by  natural  means,  or  more 
excessive  and  requiring  treatment  to  prevent  its  continuance. 
Although  most  commonly  due  to  some  injury,  whether  sub- 
cutaneous or  inflicted  through  the  skin,  it  may  be  predisposed  to 
by  weakness  of  the  vascular  tissues,  especially  if  associated  with 
increased  blood-pressure.  Certain  diseases,  such  as  purpura  and 
scurvy,  are  characterized  by  a  tendency  to  bleeding,  and  there  is 
one  congenital  condition,  haemophilia,  in  which  it  is  difficult  to 
stop  the  flow  of  blood  when  once  started. 

The  character  of  the  bleeding  differs  according  to  the  vessel 
from  which  the  blood  escapes.  Arterial  Haemorrhage  consists 
in  a  flow  of  bright  scarlet  blood,  which  escapes  at  first  per 
saltum,  i.e.,  in  jets  synchronous  with  the  heart's  beat,  and  may 
be  derived,  not  only  from  the  proximal,  but  also  from  the  distal 
end  of  the  divided  vessel,  if  the  collateral  circulation  is  suffi- 
ciently abundant.  If,  however,  it  is  derived  from  a  deep  artery, 
the  blood  may  well  up  from  the  depths  of  the  wound  and  not 
escape  in  gushes.  In  Venous  Haemorrhage  the  flow  is  usually 
continuous,  and  the  blood  of  a  dark  red  or  almost  black  colour. 
If,  however,  a  large  vein  is  wounded,  such  as  the  internal  jugular, 
the  blood  may  escape  with  a  very  definite  spurt,  owing  to  respira- 
tory or  other  influences.  Capillary  Haemorrhage  is  marked  by 
general  oozing  from  a  raw  surface,  the  blood  trickling  down  into 
the  wound,  and  filling  it  from  below  upwards.  By  Extravasation 
of  Blood  is  meant  the  pouring  out  of  blood  from  a  wounded  vessel 
or  vessels  into  the  lax  areolar  planes  immediately  adjacent,  which 
become  swollen  and  boggy.  The  usual  constitutional  signs  will 
be  manifested  as  a  result  of  such  extravasation,  and,  indeed,  fatal 
haemorrhage  may  occur  in  this  way  without  any  escape  upon  the 
surface  of  the  body.  Subcutaneous  or  submucous  haemorrhage 
is  also  met  with  in  the  form  of  small  localized  petechiae,  arising 
from  injuries,  or  from  changes  in  the  blood  or  vessel  walls 
(as  in  purpura,  scurvy,  and  septicaemia).     Epistaxis  is  the  term 


HEMORRHAGE 


given  to  bleeding  from  the  nose.  By  Hseinatemesis  is  meant  the 
vomiting  of  blood  ;  it  may  either  have  been  swallowed,  as  in  some 
cases  of  fractured  base  of  the  skull,  where  the  pharyngeal  mucous 
membrane  has  been  torn,  or  it  may  have  originated  from  the 
upper  part  of  the  intestinal  tract.  The  blood  is  usually  curdled 
and  brownish  in  colour,  somewhat  resembling  coffee-grounds, 
from  the  action  of  the  gastric  juice  upon  it.  Haemoptysis  is  the 
title  given  to  the  escape  of  blood  from  the  air-passages,  whether  it 
results  from  injury  or  disease.  Hematuria  is  a  condition  in  which 
blood  is  passed  in  the  urine.  By  Melaena  is  meant  the  passage  of 
dark  tarry  blood  with  the  faeces.  It  is  always  an  evidence  of 
disease  or  injury  to  the  intestine  sufficiently  far  from  the  anus  to 
allow  the  blood  to  become  altered  in  character  by  the  action  of 
the  intestinal  juices.  Blood  derived  from  the  rectal  mucous 
membrane  usually  retains  its  bright  red  colour. 

Constitutional  Effects. — If  the  haemorrhage  is  severe,  as  from 
division  of  a  large  artery,  death  results  from  syncope.  The 
surface  of  the  body  becomes  cold,  clammy,  and  pale  ;  the  lips, 
ears,  and  eyelids  are  livid  ;  the  patient  gasps,  his  respirations 
become  quick  and  sighing,  and  death  ensues  after  perhaps  a  few 
convulsive  twitches  of  the  limbs.  If  consciousness  is  retained  at 
all,  patients  often  complain  of  the  sight  failing,  and  a  sense  ot 
increasing  darkness,  immediately  preceding  the  fatal  termination. 
These  effects  depend  as  much  on  the  rapidity  of  the  bleeding  as 
on  the  total  amount  of  blood  lost ;  people  can  stand  gradual  loss 
of  blood  much  better  than  when  it  escapes  suddenly. 

If  the  haemorrhage  is  not  so  great  as  to  kill  immediately,  the 
patient  faints,  and  on  recovering  is  in  a  condition  of  severe  collapse 
and  weakness,  which  continues  for  some  time  ;  he  is  also  liable  to 
recurrent  attacks  of  syncope,  any  one  of  which  may  be  fatal. 

If  the  haemorrhage  is  more  gradual,  but  continuous,  as  in  cases 
of  piles  or  uterine  fibroids,  the  patient  becomes  profoundly  anaemic, 
and  the  lips,  ears,  and  conjunctivae  are  pearly  white  ;  dyspnoea 
ensues,  owing  to  the  insufficient  amount  of  blood  present,  and  in 
consequence  the  patient  is  extremely  restless,  tossing  about  in  bed. 
Any  sudden  exertion,  or  even  sometimes  the  attempt  to  sit  up,  is 
followed  by  a  sensation  of  faintness  ;  noises  are  heard  in  the  ears, 
the  sight  becomes  dim,  or  is  even  temporarily  lost  (amblyopia), 
and  severe  headache  may  be  complained  of,  all  arising  from 
cerebral  anaemia.  The  pulse  often  becomes  what  is  known  as 
hemorrhagic  in  character,  i.e.,  frequent,  large,  and  compressible, 
but  collapsing  entirely  between  each  beat,  and  markedly  dicrotic. 
These  peculiar  features  are  due  to  the  sudden  passage  of  a  small 
amount  of  blood  through  a  vessel  which  is  practically  empty  and 
entirely  collapsed.  From  the  defective  vis-a-tevgo,  oedema  of  the 
extremities  may  result. 

During  the  continuance  of  haemorrhage  the  blood  pressure 
necessarily  falls ;  but  unless  a  volume  equal  to  a  third  of   the 


224  A  MANUAL  OF  SURGERY 

total  bulk  of  blood  in  the  body  is  lost,  it  quickly  rises  again  to  the 
normal  after  the  bleeding  has  ceased.  This  rise  in  blood  pressure 
is  partly  due  to  a  diminution  in  the  size  of  the  vascular  area, 
owing  to  vasomotor  contraction  of  the  peripheral  arterioles  and  of 
the  splanchnic  area,  but  is  also  caused  by  an  increased  flow  of 
lymph  into  the  circulation.  This  lymph  is  accompanied  by  a 
large  number  of  leucocytes,  and  hence  well-marked  leucocytosis, 
lasting  for  five  or  six  days,  always  follows  any  severe  haemorrhage. 
The  number  of  red  blood-cells  is  also  reduced,  whilst  the  amount 
of  haemoglobin  in  each  is  diminished,  and  the  specific  gravity  of 
the  blood  falls  considerably. 

Children  and  elderly  people  alike  bear  the  loss  of  blood  badly  : 
but  whereas  children  rapidly  recover  from  the  immediate  effects, 
elderly  people  do  not. 

General  Treatment. — When  the  loss  of  blood  has  been  severe, 
the  patient  must  be  kept  quiet  with  the  head  low,  whether  syncope 
is  present  or  not.     Stimulants  may  be  necessary  to  maintain  the 
heart's  action,  but  should  be  given  with  discretion  for  fear  of  re- 
starting the  bleeding.     If  death  appears  to  be  imminent,  the  arms 
and  legs  should  be  bandaged,  or  the  abdominal  aorta  compressed  in 
order  to  confine  the  blood  as  much  as  possible  to  the  head  and  trunk. 
'  No  patient  should  be  allowed  to  die  of  haemorrhage.'     Such 
was  the  dictum  of  the  late  Mr.  Wooldridge,  of  Guy's  Hospital, 
based  on  a  knowledge  of  the  value  of  transfusion  and  infusion. 
By    Transfusion   is   meant    the  transference  of   blood  from   one 
individual  to  another  ;  it  may  be  accomplished  by  two  methods, 
the  direct  and  indirect.     Direct  or  immediate  transfusion  consists  in 
injecting  the  blood  of  the  donor  directly  into  the  vessels  of  the 
recipient.     The  objection  to  this  method  is  that  an  individual  can 
rarely  spare  sufficient  blood  to  be  of  any  real  use,  and  hence  the 
results  are  unsatisfactory.     Indirect  or  mediate  transfusion  is  carried 
out   by  whipping  the   blood   from    some   healthy   individual    or 
individuals  so  as  to  remove  the  fibrin,  and  after  straining  through 
fine  linen  it  is  injected,  either  pure,  or  diluted  with  saline  solution. 
During  the  last  few  years  it    has  been  recognised,  however, 
that  the  success  of  this  proceeding  depends  on  the  introduction  of  a 
sufficient  quantity  of  fluid  as  a  temporary  substitute  for  the  blood 
which  has  been  lost,  rather  than  on  its  quality ;  for  it  has  been 
proved  that  the   transfused  blood  of   another    person   is   rapidly 
destroyed  and  eliminated.      Hence  transfusion  has  now  been  re- 
placed by  what  is  known  as  Infusion,  which  consists  in  injecting 
large  quantities  of  some  bland  fluid  into  the  vessels,  and  by  this 
means  greatly  improved  results  have    been   obtained.      All  the 
apparatus  needed  is  a  metal  or  glass  cannula  (Fig.  54),  the  end  of 
which  is  bulbous,  blunt,  and  bevelled,  which  can  be  tied  into  a 
vein,  and  connected  by  means  of  a  rubber  tube  with  a  reservoir 
containing  the  fluid  (Fig.  55).     A  vein,  e.g.,  the  median  basilic  or 
internal  saphena,  should  be  exposed,  tied  below  and  opened  by  a 


HEMORRHAGE 


225 


longitudinal  or  oblique  incision  ;  the  cannula,  filled  with  lotion 
so  as  to  exclude  air,  is  then  inserted,  and  a  ligature  placed  round 
the  vessel  just  below  the  bulb,  so  that  on  withdrawal  it  can  be 
tightened.  The  amount  injected  varies  with  the  circumstances 
and  the  effects  produced,  but,  to  be  efficacious,  some  pints  are 
usually  needed  ;  4  or  5  pints  have  not  uncommonly  been  employed 
for  the  purpose.  As  a  rule,  one  injection  is  all  that  is  required  in 
dealing  with  ha-morrhage,  but  where  shock  is  present  it  may  need 
to  be  repeated  two  or  three  times. 


Fir,.  54 — Cannula  suitable  for 

Infusion. 


Fig.  55. — Infusion  into  Vein  of  Forearm. 

As  to  the  material,  a  warm  saline  solution  is  the  best,  consisting 
of  a  drachm  of  chloride  of  soda  to  a  pint  of  sterilized  water  .(or 
(about  -6  per  cent.),  at  a  temperature  of  105 °  to  no0  F.  The 
dried  crystals  of  salt  should  be  dissolved  in  a  small  quantity  of 
boiling  water,  so  as  to  sterilize  it,  and  this  is  then  diluted  to  the 
required  bulk.  Of  course,  the  apparatus  is  most  scrupulously 
purified,  either  by  boiling  for  some  minutes  or  by  effective 
immersion  in  carbolic  lotion,  and  no  air  must  be  admitted.  The 
injection  is  made  slowly,  so  that  the  solution  may  be  gradually 
mixed  with  the  blood.     It  has  been   found  by  experiment  that 

T5 


226  A   MANUAL  OF  SURGERY 


after  an  infusion  following  haemorrhage  the  specific  gravity  of 
the  blood  is  only  lowered  for  a  very  short  period,  and  rapidly 
rises  to  a  normal  level,  or  may  even  be  raised  above  the  normal. 
This  suggests  that  the  increased  amount  of  fluid  is  sucked  up  by 
the  tissues,  and  explains  why  it  is  sometimes  necessary  to  repeat 
the  injection  more  than  once. 

Another  plan  sometimes  used  with  success  consists  in  the  intro- 
duction of  warm  fluid  into  the  rectum,  or  through  an  aspirator 
needle  connected  with  a  tube  and  funnel  into  the  loose  connective 
tissue  of  the  buttock,  abdomen,  or  submammary  region.  In  the 
latter  case  the  funnel  must  be  held  at  some  height  in  order  to  gain 
sufficient  pressure,  and  by  this  means  several  pints  may  be  injected. 

Natural  Arrest  of  Haemorrhage. 

This  can  best  be  described  under  two  headings,  viz.,  (i)  the 
temporary  arrest,  and  (2)  the  permanent.  The  processes  are  much 
the  same  for  arteries,  veins,  or  capillaries  ;  but  since  the  arrest  of 
arterial  haemorrhage  has  been  more  thoroughly  investigated,  and 
is  the  most  important,  we  shall  deal  mainly  with  it. 

The  Temporary  arrest  of  arterial  haemorrhage  is  brought  about 
by  three  principal  factors  : 

(1)  The  coagulation  of  the  blood,  which  occurs  in  and  around 
the  vessel,  and  without  which  death  would  ensue  from  the  merest 
scratch.  The  greater  the  loss,  up  to  half  of  the  total  amount  of 
blood  in  the  body,  the  more  coagulable  it  becomes. 

(2)  Diminution  in  the  force  of  the  heart's  action  always  follows 
haemorrhage,  from  anaemia  of  the  cerebral  centres,  a  beneficent 
provision  whereby  coagulation  is  facilitated  and  the  flow  of  blood 
checked.  Unless  the  syncope  is  profound,  stimulants  should 
therefore  be  carefully  avoided,  for  fear  of  causing  a  recurrence  of 
the  bleeding  by  increasing  the  power  of  the  heart's  beat. 

(3)  Changes  in  and  around  the  vessel  play  a  most  important 
part  in  completing  the  process.  They  consist  in  the  retraction  of 
the  artery  within  its  sheath  by  reason  of  its  inherent  longitudinal 
elasticity  ;  if,  however,  it  is  only  partially  divided  (or,  as  it  is 
called,  '  button-holed '),  this  condition  cannot  obtain,  and  the 
haemorrhage  is  more  likely  to  continue.  As  a  result  of  this 
retraction,  the  rough  and  uneven  inner  lining  of  the  sheath  is 
exposed,  and  upon  this  the  blood  coagulates  as  it  flows,  thus 
gradually  producing  what  is  known  as  the  external  coagulum.  At 
the  same  time  the  transverse  muscular  and  elastic  fibres  in  the 
vessel  wall  cause  contraction  of  the  open  mouth,  and  thus,  as  the 
force  and  calibre  of  the  blood-stream  diminish,  the  external 
coagulum  is  able  to  increase  in  size  by  fresh  deposits  of  fibrin, 
until  at  last  its  resistance  is  too  great  for  the  diminished  cardiac 
impulse  to  overcome,  and  the  sheath  is  filled  with  clot,  which 
extends  to  the  divided  mouth  of  the  vessel.     From  this  an  internal 


HEMORRHAGE 


227 


coagulum  next  develops,  which  sometimes  extends  upwards  as 
far  as  the  nearest  patent  branch.  Thus  the  haemorrhage  is 
arrested  for  the  time  being,  and  preparation  made  for — 

The  Permanent  closure  of  the  wound  in  the  artery,  which  merely 
consists  in  a  modification  of  the  general  process  of  repair. 

After  the  cessation  of  the  haemorrhage,  the  internal  coagulum, 
soft  in  consistence  and  dark  red  in  colour,  extends  from  the  mouth 
of  the  vessel,  or  from  the  site  of  the  ligature,  for  some  distance, 
and  perhaps  to  the  next  collateral  branch  (Fig.  56).  The  vessel 
wall  contracts  upon  this  coagulum,  with  which,  however,  it  does 
not  unite,  except  at  and  near  its  base.  As  a  result  of  the  injury, 
a  simple  plastic  arteritis  is  set  up,  evidenced  by  a  hyperaemic 
condition  of  the  vessel  wall,  due  to  dilatation  of  the  vasa  vasorum, 


Fig.  56. — Early  Stage  of  Oblitera- 
tion of  Artery  after  Ligature. 

The  thrombus  is  seen  above  and  below 
the  site  of  ligature,  that  on  the  proxi- 
mal (upper)  side  being  the  larger ; 
commencing  cell  infiltration  of  the 
bases  of  the  clots  is  also  indicated. 

In  both  these  diagrams  the  arteries 
throughout  for  clearness'  sake;  in 
tracted. 


Fig.  57. — Later  Stages  of  the 
Same  Process. 

The  clots  are  shrinking,  and  the  lowest 
portions  are  being  transformed  into 
granulation  tissue.  Proliferation  of 
the  tunica  intima  is  also  seen,  reach- 
ing beyond  the  apices  of  the  clots, 
have  been  represented  of  the  same  size 
reality,  the  lumen  would  be  much  con- 


and  its  infiltration  with  leucocytes,  which  also  invade  the  coagulum 
and  cause  its  base  to  become  decolorized.  The  leucocytes  break 
up  the  clot,  traversing  the  natural  lines  of  cleavage  which  result 
from  its  contraction,  and  gradually  remove  it,  a  few  giant  cells, 
probably  derived  from  the  leucocytes,  occasionally  assisting  in 
this  process  (Fig.  59).  The  tunica  intima  proliferates  con- 
currently, causing  a  secondary  infiltration  with  the  larger  fibro- 
blastic cells  in  that  part  of  the  thrombus  which  is  adherent  to 
the  vessel  wall  (Fig.  58)  ;  whilst  a  growth  of  cellular  buds  or 
granulations,  which  gradually  increase  in  size  and  encroach  on 
the  lumen  of  the  vessel,  springs  up  in  those  parts  where  the  apex 
of  the  clot  lies  free  and  unadherent  (Fig.  57).     Thus,  the  base  of  the 


228 


A   MANUAL  OF  SURGERY 


clot  is  transformed  into  a  cellular  mass  derived  from  proliferation 
of  the  tunica  intima,  and  by  the  development  of  new  vessels  from 
the  vasa  vasorum  into  granulation  tissue ;  whilst  the  cellular 
buds  which  grow  from  the  walls,  and  extend  nearly  to  the  next 
collateral  branch,  are  also  similarly  changed.  The  free  conical 
extremity  of  the  clot  contracts,  and  is  gradually  removed,  partly 
by  the  activity  of  leucocytes  which  infiltrate  it  from  the  base, 
partly  by  the  erosive  action  of  the  surrounding  granulation  tissue. 
A  similar  set  of  changes  occurs  at  the  distal  side  of  the  ligature 
in  an  artery  tied  in  its  continuity,  although  the  thrombus  is 
smaller  and  less  firm.  The  ligature  itself  may  be  infiltrated  by 
leucocytes,  and  replaced  by  granulation   tissue,  or  may  be  en- 


Fig.  58. — Early  Stage  of  Organization  of  Thrombus,  to  show  the 
Infiltration  of  the  Clot  with  Leucocytes  and  Connective  Tissue 
Cells  derived  from  the  Endothelium.     (Tillmanns.) 

A,  Tunica  media.  B,  Tunica  intima,  undergoing  proliferative  changes,  and 
therefore  thickened.  C,  Blood-clot  lying  in  lumen  of  vessel,  becoming 
infiltrated  with  leucocytes  (small  dark  cells)  and  larger  fibroblasts  derived 
from  the  endothelium. 


capsuled.  A  rod  of  granulation  tissue  is  thus  developed,  blocking 
the  vessel,  and  this,  by  the  usual  process  of  repair,  is  transformed 
into  a  firm  cicatricial  cord  in  the  course  of  a  few  months  (Fig.  59). 
It  must  be  clearly  understood,  however,  that  the  presence  of  a 
coagulum  is  by  no  means  essential  to  the  obliteration  of  an 
artery.  Thus,  if  the  walls  are  merely  brought  into  close  and 
accurate  apposition  by  a  ligature  without  dividing  the  inner  or 
middle  coats,  a  proliferative  endarteritis  without  any  clot  forma- 
tion results,  which  is  quite  sufficient  for  the  occlusion  of  the 
vessel. 

The  arrest  of  haemorrhage  from  veins  and  capillaries  is  more 
easily  accomplished,  the  collapse  of  the  walls,  together  with  the 


HEMORRHAGE 


229 


formation  of  the  external  coagulum,  being  sufficient  for  this 
purpose.  The  later  steps  are  similar  to  those  occurring  in  an 
artery,  except  that  there  is  but  little  internal  coagulum.  In 
capillaries,  unless  some  constitutional  condition  such  as  haemo- 
philia is  present,  the  mere  falling  together  of  the  walls  is  sufficient 
to  allow  coagulation  to  take  place,  and  thus  stop  the  bleeding. 

Surgical  Treatment  of  Haemorrhage. 

Many  different    methods    are    needed,   under    varying  circum- 
stances, for  the  effective  arrest  of  haemorrhage.      It  may  be  laid 


Fig.  59. — Organized  Thrombus  in  Vessel,  showing  the  newly  formed 
Connective  Tissue  occupying  the  Lumen  of  the  Vessel,  and  vascu- 
larized   FROM    THE    VASA    VASORUM.       (TlLLMANNS.) 

Two  giant  cells  are  seen  in  the  centre. 

down  as  a  preliminary  axiom  that  digital  pressure  over  the 
bleeding-point  will  always  temporarily  check  the  most  furious 
outburst,  whilst  means  for  its  permanent  stoppage  are  being 
arranged. 

Where  the  bleeding,  though  profuse,  does  not  come  from  any  one 
particular  vessel,  the  following  measures  can  be  utilized : 

1.  Cold  may  be  employed  in  the  form  of  ice,  cold  water  or 
lotion,  or  simple  exposure  to  the  air,  all  clots,  rags,  pledgets,  etc., 
being  removed  for  this  purpose  ;  it  must,  however,  be  remembered 
that  ice  and  unsterilized  water  may  convey  sepsis.  Such  treat- 
ment is  of  most  value  for  general  oozing  from  vascular  structures 
or  into  cavities,  such  as  the  mouth,  vagina,  or  rectum. 

2.  Position. — Where  the  bleeding  is  from  one  of  the  extremities, 
especially  the  lower,  elevation  is  a  most  important  factor  in 
arresting  it.     The  veins  are  emptied  by  the  force  of  gravity,  and 


230  A  MANUAL  OF  SURGERY 

this  is  always  followed  by  a  reflex  contraction  of  the  arteries, 
a  proceeding  of  which  surgeons  also  avail  themselves  in  order 
to  exsanguinate  a  limb  previous  to  applying  the  rubber  tour- 
niquet in  operations  which  one  desires  to  render  as  bloodless  as 
possible. 

3.  Direct  Pressure. — The  skilful  application  of  an  antiseptic 
dressing,  combined  with  pressure,  is  often  effectual  in  arresting 
haemorrhage.  General  oozing  from  cut  surfaces,  which  can  be 
brought  into  apposition,  as  from  an  amputation  wound,  may  be 
checked  by  applying  a  Arm  bandage  over  them.  In  cavities  or 
hollows,  either  natural  or  made  by  operation,  bleeding  may  be 
stopped  by  plugging  with  strips  of  dressing,  or  by  graduated 
layers  of  antiseptic  wool.  This  form  of  packing  has  in  a  large 
measure  taken  the  place  of  the  old  '  graduated  compress,'  which 
consisted  of  layers  of  lint  devoid  of  antiseptic  qualities,  gradually 
increasing  in  size,  superposed  one  over  the  other.  Such  dressings 
should  be  retained  firmly  in  position  for  twenty-four  hours,  after 
which,  if  no  further  haemorrhage  has  occurred,  the  bandages  may 
be  slackened,  but  it  is  usually  advisable  to  retain  the  deep  plugs 
a  little  longer. 

4.  Hot  Water  (1300  to  1600  F.)  is  a  powerful  haemostatic.  A 
certain  proportion  of  carbolic  acid  or  corrosive  sublimate  should 
be  present  to  render  the  water  aseptic,  or  it  should  have  been 
previously  boiled  ;  it  must  also  be  sufficiently  hot,  otherwise  bleed- 
ing is  encouraged  rather  than  checked.  It  is  supposed  to  act  by 
stimulating  the  involuntary  muscular  fibres  of  the  vessel  wall  to 
contract  ;  but  probably  the  coagulation  of  the  albumen  of  the 
blood  is  an  important  factor,  as  unless  the  water  is  hot  enough  to 
blanch  the  surface  of  the  wound  the  bleeding  is  not  stayed. 

5.  Chemical  Agents  may  be  used  to  check  oozing  from  spongy 
parts,  or  bleeding  from  deep  organs  or  cavities.  If  they  are 
applied  locally,  and  act  primarily  by  causing  coagulation  of  the 
blood,  they  are  known  as  Styptics,  or  astringents.  Such  are  the 
liquor  ferri  perchloridi  or  pernitratis,  tincture  of  matico,  tannic  or 
gallic  acids,  alum,  nitrate  of  silver,  fibrin  ferment,  styptic  colloid, 
cocaine,  suprarenal  extract  (adrenalin),  etc.  If  the  drug  is 
administered  internally,  and  acts  by  increasing  the  coagulability 
of  the  blood,  or  by  causing  constriction  of  the  vessels,  it  is  termed 
a  Haemostatic — e.g.,  opium,  ergot,  turpentine,  hamamelis,  acetate 
of  lead,  chloride  of  calcium,  etc.  In  applying  a  styptic,  it  is 
essential  that  the  surface  of  the  wound  should  first  be  thoroughly 
cleansed,  and  all  coagula  removed.  A  portion  of  the  dressing 
dipped  in  the  solution  is  applied  to  the  surface,  or  the  drug  is 
sprinkled  or  sprayed  upon  it.  The  objection  to  most  of  these 
agents  is  that  healing  by  first  intention  is  often  hindered,  whilst 
in  the  case  of  perchloride  of  iron  extensive  sloughing  may  result. 
Probably  the  most  powerful  styptic  is  suprarenal  extract,  which, 
however,  loses  its  virtues  when  kept  in  solution  for  more  than  an 


HEMORRHAGE  231 


hour  or  two.  One  of  the  dried  tabloids  (grs.  5)  may  be  dissolved 
in  2  drachms  of  a  5  per  cent,  cocaine  solution,  and  this  is  sprayed 
over  the  part,  or  applied  on  a  piece  of  dressing. 

6.  Cauterization  is  not  very  largely  employed  for  the  arrest  of 
haemorrhage,  except  from  bones  and  from  tissues  thickened  by 
inflammation,  where  retraction  and  contraction  of  the  vessels  are 
difficult.  It  need  in  no  way  interfere  with  primary  union  if  the 
skin  is  not  touched,  for  the  minute  sloughs  formed,  are  quite 
aseptic,  and  will  either  be  absorbed  or  cast  off  in  the  discharges. 
The  chief  objection  to  this  method  is  the  risk  of  secondary 
haemorrhage  when  the  sloughs  separate.  The  cautery  is  some- 
times used  for  the  bloodless  removal  of  vascular  tumours,  either 
as  a  galvano-cautery,  or  a  Pacquelin's  knife,  or  the  ordinary  clamp 
and  cautery.  It  must  be  remembered  that,  in  order  to  effectually 
seal  the  mouths  of  the  vessels,  the  cautery  must  be  at  a  dull  red 
or  black  heat ;  a  bright  red-hot  iron  cuts  through  a  vessel  as 
cleanly  as  a  knife,  and  does  not  stop  the  haemorrhage. 

When  the  bleeding  is  more  serious,  mid  originates  from  some  definite 
vessel  or  vessels,  other  and  more  vigorous  measures  have  to  be 
adopted.  Digital  pressure  suffices  to  arrest  it  for  a  time,  whilst 
preparations  are  being  made  to  ligature  or  otherwise  treat  the 
wounded  vessel.  If  possible,  a  ligature  should  be  applied  with 
antiseptic  precautions,  but  other  means  are  used  : 

1.  Acupressure  was  introduced  by  the  late  Sir  James  Simpson 
in  order  to  obviate  the  use  of  ligatures.  The  introduction  of 
aseptic  absorbable  animal  ligatures  has  made  such  a  method  only 
necessary  in  exceptional  circumstances.  A  needle  is  passed 
either  under  the  vessel  from  the  skin,  or  over  the  vessel  from  the 
surface  of  the  wound,  and,  if  placed  accurately,  is  quite  sufficient 
to  stay  the  bleeding.  With  it,  however,  is  sometimes  combined 
the  pressure  of  a  loop  of  silk  or  wire  passed  figure-of-8  fashion 
around  the  ends  of  the  needle. 

2.  Forcipressure  is  a  plan  of  stopping  haemorrhage  by  crushing 
the  divided  end  of  the  vessel  between  the  strong  and  deeply 
serrated  blades  of  a  pair  of  forceps  with  scissor  handles  pro- 
vided with  a  catch  ;  those  known  by  the  name  of  Spencer  Wells 
are  the  most  convenient.  In  dealing  with  small  vessels,  it  is 
quite  sufficient  to  leave  the  forceps  applied  for  a  few  minutes, 
perhaps  twisting  them  before  removal  ;  but  with  the  larger  it  is 
advisable  to  apply  a  ligature.  In  deep  wounds  where  it  is 
difficult,  or  almost  impossible,  to  tie  the  vessel,  the  forceps  may 
be  incorporated  in  the  dressings,  and  not  removed  for  twenty-four 
hours. 

3.  Torsion  was  used  as  a  means  of  sealing  the  ends  of  divided 
vessels  before  aseptic  ligatures  were  introduced.  It  may  be  applied 
in  two  ways,  viz.,  (a)  Limited  Torsion,  which  is  employed  for  the 
larger  vessels.  The  artery  is  drawn  out  of  its  sheath  for  about 
half  an  inch  with  one  pair  of  forceps,  and  held  close  to  the  tissues 


232  A  MANUAL  OF  SURGERY 

by  another  pair  applied  transversely,  whilst  the  grasped  end  is 
twisted  sufficiently  to  thoroughly  close  it ;  it  should  not,  however, 
be  twisted  off.  (b)  Free  Torsion  is  used  for  the  smaller  vessels 
which  cannot  be  so  completely  isolated  from  surrounding  struc- 
tures ;  the  vessel  is  laid  hold  of  with  its  sheath  or  connective 
tissue  covering,  and  twisted  as  much  as  necessary. 

The  effect  of  torsion  is  that  the  inner  and  middle  coats  are 
ruptured  just  above  the  spot  grasped,  and  tend  to  curl  upwards 
into  the  lumen  of  the  vessel,  whilst  the  outer  coat  is  twisted  up 
beyond.  A  coagulum  forms  upon  the  injured  structures,  and  the 
subsequent  processes  to  secure  permanent  occlusion  are  similar 
to  those  described  above.  The  advantages  claimed  in  favour  of 
torsion  are  that  it  is  easier  to  twist  the  vessels  than  to  tie  them, 
that  there  is  less  liability  of  secondary  haemorrhage,  and  that  no 
foreign  body  is  left  in  the  wound.  As  to  the  ease  of  application, 
it  is  doubtful  whether  torsion  has  any  advantage  over  ligature, 
and  certainly  when  asepsis  is  maintained  the  two  last  statements 
do  not  hold  good,  for  secondary  haemorrhage  is  practically  un- 
known in  aseptic  surgery,  and  the  catgut  ligature  is  not  more  of 
a  foreign  body  than  the  damaged  end  of  a  twisted  vessel.  Torsion 
is,  however,  occasionally  useful  in  plastic  work. 

4.  Ligature  is  at  the  present  day  the  method  most  frequently 
employed  for  arresting  bleeding  from  a  definite  source. 

The  material  used  should  be  of  sufficient  strength  to  secure  the 
vessel,  of  sufficient  resistance  to  maintain  its  hold  in  spite  of 
being  soaked  in  the  body  fluids,  and  yet  of  such  quality  as  to  be 
finally  absorbed,  or  so  pure  and  unirritating  as  to  become  encap- 
suled  in  the  tissues.  Catgut  suitably  prepared  is  the  substance 
most  frequently  employed,  but  inasmuch  as  commercial  catgut, 
even  when  rendered  aseptic  by  immersion  in  carbolic  acid,  swells 
up  in  warm  blood  serum,  and  becomes  a  soft,  pulpy  mass  in  half 
an  hour,  it  is  necessary  to  harden  and  render  it  more  resistant  by 
steeping  it  for  twelve  hours  in  a  solution  of  chromic  acid  (5  parts 
of  gut  to  1  of  chromic  acid  in  100  parts  of  water),  and  subse- 
quently for  twelve  hours  in  100  parts  of  sulphurous  acid  solution. 
It  is  then  dried,  and  is  of  a  greenish  colour.  It  must  not  be 
forgotten  that  catgut  is  prepared  from  sheeps'  intestines,  by 
allowing  the  latter  to  putrefy  in  water  and  then  scraping  away  the 
mucous  and  muscular  coats,  leaving  only  the  submucous  tissue 
with  its  elastic  fibres,  which  is  twisted  up  into  long  strands.  It 
is  obvious  that  very  efficient  sterilization  is  necessary  to  make  a 
material  thus  prepared  fit  for  surgical  work  (p.  18). 

Sterilized  silk  is  another  agent  employed,  whilst  animal  tissues, 
such  as  kangaroo  tendon  and  strips  of  ox  aorta,  have  their  advocates. 
Ballance  and  Edmunds  advise  the  use  of  gold-beaters'  skin,  prepared 
from  the  peritoneum  of  the  ox,  as  a  material  for  tying  vessels  in 
their  continuity,  and  excellent  results  have  followed  its  employment. 
Recently  a  celluloid  ligature  has  been  introduced,  and  holds  out 


HEMORRHAGE 


233 


Reef  Knot 


prospects  of  replacing  by  a  safe  and  harmless  material  all  these 
more  dangerous  animal  preparations. 

Ligatures  may  be  applied  either  to  the  divided  end  of  an  artery 
in  an  open  wound,  or  to  an  artery  in  its  continuity,  the  effects  and 
final  means  of  occlusion  being  in  both  cases  very  similar. 

When  applied  to  the  open  cud  of  a  divided  vessel,  care  should 
be  taken  to  select  a  ligature  the  thickness  of  which  is  proportionate 
to  the  lumen  of  the  vessel  to  be  tied. 
The  artery  should  be  cleanly  picked  up 
with  forceps,  so  as  to  include  as  little 
surrounding  tissue  as  possible,  and 
where  a  sheath  exists,  should  be  with- 
drawn from  it.  The  ligature  is  then 
passed  round  it  and  tied  in  a  knot 
which  will  not  slip,  e.g.,  the  reef  knot 
(Fig.  60).  When  the  application  of  a 
ligature  is    difficult,  as    in   very   dense 

fibroid  tissue,  it  may  be  advisable  to  pass  it  under  the  vessel   by 
means  of  an  ordinary  curved  needle,  and  then  to  tie  it. 

For  ligation  in  continuity,  see  p.  280. 

Effects  of  Ligature — 1.  On  the  Vessel  Wall. — The  immediate 
result,  if  the  vessel  has  been  tied  in  the  usual  way,  is  to  divide 
the  inner  and  middle  coats,  which  are 
separated  from  the  outer  and  curl  up 
slightly,  whilst  the  outer  coat  is  con- 
stricted and  thrown  into  folds  within 
the  grasp  of  the  ligature  (Fig.  61).  If 
an  artery  is  tied  in  its  continuity,  the 
same  effect  is  produced  on  each  side  of 
the  ligature.  The  changes  already 
described,  by  means  of  which  the 
artery  is  obliterated  and  transformed 
into  a  fibro-cicatricial  cord,  then  mani- 
fest themselves  in  due  order.  An 
exudation  of  plastic  lymph  and  cells 
occurs  into  the  sheath  and  around  the 
ligature,  and  if  the  latter  is  aseptic,  the 
whole  is  embedded  in  this  plastic  mass, 
which  undergoes  the  ordinary  changes 
seen  in  repair.  If  the  ligature,  how- 
ever, is  septic  and  irritating,  it  has  to 
cut  its  way  out  through  the  vessel  wall 
by  an  ulcerative  process  akin  to  the 
separation  of  a  septic  slough,  thus  ex- 
posing the  patient  to  the  risk  of  secondary  haemorrhage  from  the 
disintegration  of  the  internal  coagulum.  The  period  at  which  a 
septic  ligature  is  separated  varies  with  the  size  of  the  vessel, 
from  a  week  or  eight  days  for  an  artery  the  size  of  the   radial 


Fig.  61. — Effect  of  Tying  a 
Ligature  firmly  around 
an  Artery. 

The  ligature  was  tied  at  two 
levels,  and  the  artery  then 
laid  open  longitudinally. 


234  A   MANUAL  OF  SURGERY 

or  ulnar  to  twelve  or  fourteen  clays  for  the  subclavian  or 
carotid. 

Of  late  years  an  old  idea  has  been  resuscitated,  and  has  gained 
a  considerable  amount  of  support  from  some  surgeons,  viz.,  that 
occlusion  of  a  vessel  is  satisfactorily  accomplished  by  merely 
bringing  the  walls  into  close  apposition  by  an  animal  ligature  of 
suitable  size,  and  that  division  of  the  inner  and  middle  coats  is 
not  only  unnecessary,  but  prejudicial,  and  favours  secondary 
haemorrhage.  Where  asepsis  is  fully  maintained,  satisfactory 
occlusion  follows  either  plan  ;  but  it  appears  to  us  that  the  division 
and  curling  up  of  the  inner  and  middle  coats  must  facilitate 
the  deposit  of  fibrin  and  process  of  repair.  At  any  rate,  it  would 
seem  safer  to  apply  a  ligature  to  a  main  vessel  on  the  face  of  a 
stump  with  sufficient  tightness  rather  than  to  err  on  the  other  side. 
In  cases  where,  perforce,  the  artery  must  be  tied  at  a  spot  where 
extensive  atheroma  or  calcareous  degeneration  is  present,  it  may 
be  advisable  to  use  broad  animal  ligatures,  such  as  strips  of  ox 
aorta  (Harwell),  or  prepared  portions  of  gold-beaters'  skin,  and 
only  to  tighten  the  knot  sufficiently  to  occlude  the  vessel  with  as 
little  damage  to  the  coats  as  possible.  The  same  plan  must  also 
be  adopted  in  dealing  with  arteries  of  great  size,  such  as  the 
innominate,  the  first  part  of  the  subclavian,  or  the  common  iliac  ; 
the  non-observance  of  this  precaution  results  in  aneurismal  dila- 
tion at  the  point  of  ligature,  and  this  to  secondary  haemorrhage 
and  death. 

It  is  a  well-known  fact  that  all  arteries  are  maintained  in  the 
body  more  or  less  upon  the  stretch,  as  evidenced  by  their  retrac- 
tion within  the  sheath  on  complete  division.  A  certain  amount 
of  longitudinal  tension  must  therefore  always  exist  upon  any 
part  of  an  artery  to  which  a  ligature  has  been  applied  in  its 
continuity,  a  condition  which  may  presumably  predispose  to 
secondary  haemorrhage.  To  obviate  this,  it  has  been  suggested 
that  two  ligatures  should  be  applied,  and  the  vessel  divided 
between  them.  This  plan  may  be  used  with  advantage  in  situa- 
tions where  the  artery  is  easily  accessible,  but  is  scarcely  feasible 
in  some  of  the  deeper  operations. 

2.  The  Ligature  itself  undergoes  changes,  which  result  in  its 
partial  or  total  absorption,  if  such  be  possible,  or  in  its  becoming 
encapsuled  if  absolutely  unabsorbent.  The  leucocytes  attack 
any  soft  material,  such  as  silk  or  catgut,  insinuating  themselves 
amongst  the  fibrillae,  and  finally  remove  them  by  a  similar  digestive 
process  to  that  which  leads  to  the  absorption  of  a  small  aseptic 
slough.  Multinucleated  giant-cells  are  often  present,  and  probably 
take  some  part  in  the  proceeding.  Finally  every  trace  of  the  liga- 
ture disappears,  and  its  place  is  taken  by  fibrous  tissue,  incor- 
porated with  that  arising  from  the  end  of  the  vessel.  Chromicized 
gut  usually  lasts  for  about  a  fortnight,  but  not  unfrequently  much 
longer  ;  silk  is  similarly  attacked  and  removed,  but  more  slowly. 


HEMORRHAGE  235 


Other  animal  substances  employed  are  dealt  with  in  the  same 
way,  and  even  silver  wire  is  not  unaffected,  its  surface  becoming 
roughened  after  a  time  and  slightly  eroded. 

3.  The  effect  on  the  Circulation  is  the  same  whether  ligature 
or  any  other  plan  of  occlusion  is  adopted.  The  passage  of  the 
blood  through  the  vessel  ceases,  and  its  proximal  end  as  far  as 
the  next  patent  branch,  though  remaining  somewhat  distended 
for  a  short  time  by  the  impact  of  the  blood-stream,  soon  begins 
to  contract,  and  is  ultimately  converted  into  a  fibrous  cord,  which 
may  or  may  not  be  pervious  for  a  short  distance.  Blood  is 
conveyed  to  the  vessels  of  the  limb  below  the  ligature  by  anasto- 
mosing branches  which  rapidly  undergo  dilatation,  and  establish 
a  collateral  circulation,  sufficiently  free  as  a  general  rule  to  main- 
tain the  vitality  of  the  part.  These  collateral  branches  become 
permanently  enlarged,  lengthened,  and  tortuous,  and  their  walls 
thickened.  If  for  any  reason  the  collateral  circulation  is  in- 
sufficient, gangrene  is  likely  to  supervene,  starting  in  the  parts 
furthest  away  from  the  centre  of  the  circulation,  or  in  the  structures 
of  least  vitality,  and  spreading  upwards  until  a  part  is  reached 
which  receives  enough  blood  to  keep  it  alive. 

Arterial  Haemorrhage. 

Three  forms  of  arterial  haemorrhage  are  described,  viz.,  primary, 
reactionary,  and  secondary. 

Primary  Arterial  Haemorrhage  is  met  with  under  two  conditions 
—  from  an  open  wound,  or  where  an  artery  is  ruptured  or 
punctured  subcutaneously,  so  that  extravasation  into  the  tissues 
occurs,  constituting  either  a  severe  bruise  if  the  artery  is  small, 
or  if  the  vessel  is  large  what  has  been  badly  termed  a  '  diffuse 
traumatic  aneurism.'  The  general  rules  for  the  surgical  treatment 
of  both  these  conditions  are  identical,  and  although  the  agent 
employed  to  finally  arrest  the  bleeding  varies  according  to  the 
surgeon's  personal  predilections,  yet  the  underlying  principles 
hold  good  in  all  cases.  We  shall  limit  ourselves  mainly  to 
speaking  of  the  ligature,  as  we  almost  always  employ  this  agent. 

A.  Primary  arterial  haemorrhage  from  an  open  wound.  The 
blood  is  here  poured  forth  upon  the  surface,  and  escapes  freely,  so 
that  the  full  constitutional  effects  are  experienced. 

The  principles  that  guide  us  in  the  Treatment  of  primary  arterial 
haemorrhage  were  first  recognised  by  the  late  Mr.  John  Bell,  but 
the  importance  of  acting  upon  them,  and  not  trusting  to  the 
Hunterian  plan  of  ligature  at  a  distance,  was  first  fully  insisted 
upon  by  Guthrie,  whose  large  experience,  confirmed  by  that  of 
later  surgeons,  demonstrated  their  accuracy.  They  may  be 
enunciated  as  follows  : 

1.  That  the  vessel  must  be  secured  at  the  bleeding-point,  an  operation 
to  expose  it  being  undertaken  if  necessary.     However  infiltrated 


236  A  MANUAL  OF  SURGERY 

the  part,  the  rule  of  cutting  down  to  expose  the  wounded  vessel  is 
to  be  adhered  to,  with  one  or  two  exceptions  noted  below,  and 
this  for  two  reasons  :  (a)  It  is  often  impossible  to  know  the  exact 
source  of  the  haemorrhage  unless  it  is  laid  bare.  Thus,  the 
bleeding  from  a  punctured  wound  of  the  front  of  the  leg,  which 
was  apparently  derived  from  the  anterior  tibial  artery,  was  proved 
on  incision  and  careful  dissection  to  come  from  the  peroneal,  the 
puncture  having  passed  between  the  bones.  In  the  axilla  and 
groin  such  uncertainty  often  exists,  (b)  Proximal  ligature  of  a 
vessel  at  some  distance  above  the  bleeding  spot  is  very  commonly 
insufficient  to  arrest  the  haemorrhage,  since  collateral  circulation 
is  quickly  established,  or,  though  apparently  effective  for  a  time, 
reactionary  haemorrhage  is  very  likely  to  ensue. 

2.  That  both  ends  of  the  wounded  vessel  must  be  secured  if  it  is 
completely  divided,  whilst  if  it  is  only  punctured,  a  ligature  must 
be  placed  on  each  side  of  the  puncture,  and  the  complete  division 
of  the  vessel  effected.  The  ease  with  which  collateral  circulation 
is  established  justifies  such  treatment  in  the  case  of  all  arteries 
of  large  size.  Thus,  where  the  facial  artery  is  divided,  jets  of 
blood  are  emitted  from  each  end  quite  freely,  and  with  nearly 
as  much  force  from  the  distal  as  from  the  proximal.  Occasionally 
the  distal  end  of  a  bleeding  vessel  retracts  amongst  the  infiltrated 
tissues  to  such  an  extent  as  to  render  its  isolation  impracticable. 
The  surgeon  must  then  trust  to  plugging  of  the  wound  from  the 
bottom,  but  not  until  every  effort  has  been  made  to  secure  it. 

It  is  only  needful  to  undertake  the  measures  detailed  above  in 
cases  where  primary  haemorrhage  is  actually  proceeding.  If  it 
has  been  once  arrested,  it  is  unnecessary  to  search  for  the  bleeding 
spot  unless  the  patient  is  very  faint  and  collapsed,  and  the  surgeon 
has  reason  to  anticipate  that  a  large  trunk  has  been  injured. 
Under  such  circumstances  it  may  be  needful  to  seek  for  and  tie 
it  at  once,  otherwise  recurrent  haemorrhage  is  likely  to  ensue 
when  the  heart's  action  becomes  more  vigorous. 

There  are  a  few  exceptions  to  the  general  rule  of  tying  a 
wounded  vessel  at  the  injured  spot,  e.g.,  where  the  depth  of  the 
dissection  needed  might  endanger  important  parts,  as  in  dealing 
with  the  deep  palmar  and  plantar  arches,  or  with  the  secondary 
branches  of  the  carotid. 

In  the  actual  treatment  of  any  particular  case,  temporary  arrest 
of  the  bleeding  may  usually  be  effected  by  digital  compression 
either  of  the  bleeding  point  or  of  the  main  trunk  at  a  favourable 
spot  nearer  to  the  heart,  against  some  resisting  structure,  such 
as  a  subjacent  bone.  The  common  carotid  is  controlled  by  grasping 
the  neck  from  behind,  and  compressing  the  artery  by  the  fingers 
placed  along  the  anterior  border  of  the  sterno-mastoid  against  the 
transverse  process  of  the  sixth  cervical  vertebra  (Chassaignac's 
tubercle).  Such  pressure  will  also  control  the  vertebral  and 
inferior  thyroid  vessels.     The  subclavian  is  to  be  compressed  in  the 


HEMORRHAGE  237 


third  part  of  its  course  against  the  first  rib  by  the  finger  or  thumb 
placed  immediately  behind  the  clavicle,  the  palm  of  the  hand 
resting  over  the  shoulder.  A  good  deal  of  force  is  required  in 
order  to  maintain  the  pressure,  and  this  may  be  gained  by  super- 
imposing the  fingers  or  thumb  of  the  other  hand.  Where  the 
pressure  is  to  be  kept  up  for  some  time,  the  handle  of  a  doorkey 
well  padded  may  be  employed  in  the  same  way,  or  an  incision 
may  be  made  and  the  vessel  exposed,  and  directly  controlled  by 
digital  pressure.  The  facial  artery  is  compressed  against  the 
lower  jaw  just  in  front  of  the  masseter  muscle.  Bleeding  from 
the  labial  and  coronary  arteries  is  commanded  by  inserting  the 
index-  finger  into  the  corner  of  the  mouth,  and  compressing  the 
lip  between  it  and  the  thumb  outside.  The  temporal  artery  should 
be  compressed  against  the  zygoma  just  in  front  of  the  ear, 
the  occipital  at  a  spot  about  i\  inches  from  the  occipital  pro- 
tuberance against  the  superior  curved  line.  To  control  the 
brachial  artery,  the  arm  should  be  grasped  from  behind,  and  the 
fingers  pressed  inwards  along  the  inner  margin  of  the  biceps 
against  the  humerus.  The  radial  and  ulnar  arteries  are  easily 
commanded  just  above  the  wrist  by  using  both  hands  to  grasp 
the  forearm,  one  for  each  vessel.  The  abdominal  aorta  is  tem- 
porarily controlled  in  slim  individuals  with  ease  by  pressure  through 
the  abdominal  wall  against  the  body  of  the  third  lumbar  vertebra 
at  a  point  a  little  above  and  to  the  left  of  the  umbilicus,  i.e.,  just 
above  its  bifurcation  ;  in  stout  persons  this  is  impossible.  The 
common  femoral  artery  is  best  compressed  just  below  Poupart's 
ligament.  The  surgeon  should  stand  on  the  same  side  of  the 
patient  as  the  artery  to  be  controlled,  and  use  either  the  finger- 
tips or  thumbs  to  press  the  vessel  upwards  and  backwards  against 
the  pubic  ramus.  The  fingers  of  one  hand  placed  over  the  other 
may  sometimes  be  necessary  to  maintain  sufficient  command,  or 
the  thigh  may  be  encircled  by  the  two  hands,  and  one  thumb  laid 
over  the  other.  Care  must  be  taken  not  to  let  the  vessel  roll  to 
one  side  or  the  other,  and  so  escape  compression.  When  the 
artery  has  to  be  controlled  for  some  time,  as  in  an  amputation, 
the  hands  may  be  used  alternately,  the  one  to  rest  the  other. 
Such  pressure  will  suffice  for  the  temporary  arrest  of  haemorrhage 
from  any  part  of  the  lower  limb.  If  it  is  desirable  to  control  the 
anterior  and  posterior  tibial  arteries  close  to  the  ankle  during  opera- 
tions upon  the  foot,  the  assistant  who  steadies  the  limb  accom- 
plishes this  by  grasping  the  toes  with  one  hand,  and  with  the 
other  compressing  the  vessels,  the  posterior  tibial  at  a  spot  a 
finger's  breadth  behind  the  internal  malleolus,  the  anterior  midway 
between  the  two  malleoli. 

As  digital  compression  cannot,  however,  be  comfortably  main- 
tained for  long,  mechanical  compression  of  a  limb  as  by  tourniquet 
or   elastic    bandage   must   be    resorted    to.     Possibly  the    screw , 
tourniquet  will  be  the  best  to  apply,  as  it  can  be  relaxed   and 


238  A   MANUAL  OF  SURGERY 

tightened  again  as  often  as  is  necessary  during  the  operation. 
In  some  cases  it  is  advisable  to  exsanguinate  the  limb  by  eleva- 
tion before  applying  the  tourniquet. 

The  wound  is  then,  if  need  be,  enlarged  by  incisions,  which 
whilst  freely  laying  the  parts  open  should  inflict  the  least  possible 
damage  on  surrounding  structures.  All  coagula  are  removed, 
and  the  wounded  vessel  looked  for.  It  may  be  needful  to  relax 
the  tourniquet,  and  allow  a  jet  or  two  to  escape,  in  order  to  ascer- 
tain its  position.  Both  ends  should  be  sought  for  and  tied,  a 
proceeding  easier  said  than  done.  This  especially  applies  to  the 
distal  end,  which  retracts,  and  often  does  not  bleed  at  the  time  of 
operation,  but  may  do  so  when  the  collateral  circulation  becomes 
established. 

B.  For  Subcutaneous  Rupture  of  an  Artery,  see  p.  247. 

Recurrent,  Intermediate,  or  Reactionary  Arterial  Haemorrhage. 

Such  are  the  terms  applied  to  bleeding  which  recurs  within 
twenty-four  hours  of  an  accident  or  operation.  Its  occurrence 
is  an  evidence  of  the  failure  of  the  means  employed  to  per- 
manently arrest  the  primary  loss  of  blood,  and  may  result  from 
two  chief  causes  :  (a)  Defective  application  of  a  ligature,  which 
comes  undone  from  being  badly  tied  (a  'granny'  knot),  or  slips 
off  from  including  within  its  grasp  other  structures  as  well  as  the 
arterial  wall;  or  (b)  the  coagula  lying  in  the  mouths  of  divided 
vessels  are  not  sufficiently  firm  to  withstand  the  increasing  blood- 
pressure  which  supervenes  after  the  shock  has  passed  away,  or 
which  may  be  due  to  excitement  or  the  injudicious  administration 
of  stimulants.  It  is  usually  due  to  the  second  of  these  causes, 
and  is  then  not  very  serious,  inasmuch  as  it  can  only  arise  from 
the  smaller  vessels,  all  the  larger  ones  having  probably  been 
recognised  and  tied  during  the  operation.  The  term  should  not 
be  applied  to  the  oozing  of  blood  or  blood-stained  serum  so 
common  after  operations,  but  only  used  for  those  cases  which 
demand  treatment,  and  where  considerable  pain  and  tension  are 
caused  by  the  accumulation  of  blood  in  the  wound. 

Treatment. — Elevation  and  the  pressure  of  a  firm  bandage  are 
often  quite  sufficient  to  arrest  this  form  of  bleeding;  but  if  un- 
successful, the  wound  must  be  opened  up,  washed  out  writh  hot 
or  cold  lotion,  and  any  bleeding  vessel  tied.  The  actual  cautery 
may  even  be  employed  to  check  oozing  from  cicatricial  surfaces, 
and  if  it  is  not  allowed  to  touch  the  skin,  and  the  wound  kept 
aseptic,  no  delay  in  its  healing  need  be  occasioned.  Should  the 
bleeding  persist,  antiseptic  plugging  must  be  resorted  to. 


HEMORRHAGE 


239 


Secondary  Haemorrhage. 

Under  this  title  are  included  all  forms  of  haemorrhage  from 
wounds  which  occur  after  the  lapse  of  twenty-four  hours.  It 
is  usually  due  to  sepsis,  and  was  formerly  very  common,  being  a 
frequent  cause  of  a  fatal  termination  ;  but  since  the  introduction 
of  antiseptic  surgery  it  is  but  seldom  seen.  Where  antisepsis, 
however,  cannot  be  efficiently  carried  out,  as  in  the  mouth, 
pharynx,  etc.,  it  is  still  occasionally  met  with. 

The  Fundamental  Cause  in  the  production  of  secondary  haemor- 
rhage is  without  doubt  a  septic  condition  of  the  wound.  This 
may  act  in  various  ways.  Thus,  in  a  vessel  entirely  divided, 
the  cocci  may  gain  entrance  through  the  open  mouth  to  the 
internal  coagulum,  and  by  causing  its  disintegration,  break 
down  the  barrier  which  Nature  had  raised  against  such  an 
occurrence.  This  process  is  assisted  by  an  ulcerative  form  of 
periarteritis,  which  leads  to  the  maceration  and  softening  of  an 
absorbent  ligature,  and  to  weakening  of  the  vessel  walls.  It  is 
in  this  latter  way  that  secondary  haemorrhage  is  induced  in 
vessels  ligatured  in  their  continuity,  the  loss  of  support  due  to 
the  opening  up  of  the  septic  wound  being  also  an  element  of 
danger.  We  desire  here  to  emphasize  the  marked  alterations 
in  all  the  conditions  existing  in  a  septic  as  opposed  to  an  aseptic 
wound.  In  the  latter  it  is  not  only  the  clot  in  the  lumen  of  the 
vessel  which  is  relied  on  to  prevent  accidents,  but  the  vital  action 
of  all  the  tissues  is  calculated  to  work  in  the  same  direction,  that 
of  ensuring  the  patient  against  haemorrhage  ;  in  fact,  the  occur- 
rence of  secondary  haemorrhage  in  an  aseptic  wound  is  almost 
impossible.  On  the  other  hand,  when  sepsis  supervenes,  a 
destructive  process  replaces  that  of  repair,  and  the  activity  of 
the  part  is  temporarily  paralyzed  by  the  toxic  influence  of  the 
micro-organisms  and  their  products. 

Various  other  conditions  may  be  mentioned,  however,  as  Con- 
tributory Causes  of  secondary  haemorrhage :  (i.)  The  ligature 
may  be  coarse,  irritating,  or  septic,  or  it  may  consist  of  material 
too  readily  absorbed.  (ii.)  Its  mode  of  application  may  be 
faulty.  Thus,  it  may  have  included  other  structures,  and  so 
becomes  loose,  offering  an  insufficient  bar  to  the  blood-pressure ; 
or  the  sheath  may  have  been  opened  too  freely,  and  thus  the 
vitality  of  the  vessel  wall  dependent  on  the  vasa  vasorum  is 
diminished.  In  large  vessels,  such  as  the  innominate  and  first 
part  of  the  subclavian,  the  mere  division  of  the  inner  and  middle 
coats  weakens  the  wall  to  such  an  extent  as  to  render  it  incapable 
of  withstanding  even  a  normal  blood-pressure,  so  that  aneurismal 
dilatation  and  secondary  haemorrhage  are  almost  certain  to  result, 
even  in  aseptic  cases,  (iii.)  The  ligature  may  have  been  placed 
too  near  a  branch  immediately  concerned  in  the  establishment  of 


240  A   MANUAL  OF  SURGERY 

the  collateral  circulation  (though  if  asepsis  is  maintained  this  is 
comparatively  unimportant),  or  where  there  is  a  considerable 
back-flow,  or  the  part  may  not  have  been  kept  absolutely  at  rest, 
(iv.)  The  condition  of  the  arterial  wall  at  the  site  of  ligature  may 
be  unhealthy,  being  possibly  the  seat  of  atheroma  or  fatty  de- 
generation, a  most  important  complication  if  the  wound  becomes 
septic,  (v.)  The  state  of  the  blood  may  be  unfavourable  to  the 
repair  of  any  wound,  whether  in  an  artery  or  not,  e.g.,  in  albu- 
minuria or  diabetes,  (vi.)  Increased  blood-pressure  after  the 
ligature  of  a  vessel  may  lead  to  secondary  haemorrhage,  as  in 
plethora,  Bright's  disease,  traumatic  fever,  or  from  injudicious 
excitement,  or  the  unwise  administration  of  stimulants. 

The  Phenomena  are  usually  preceded  by  those  of  septic  con- 
tamination of  the  wound,  to  which  a  slight  occasional  loss  of 
blood  is  added.  This  continues  with  more  or  less  frequency  and 
severity,  until  either  the  patient  is  worn  out  by  the  constant 
repetition  of  small  losses,  or  is  destroyed  by  one  or  two  severe 
gushes  from  the  larger  vessels.  The  earlier  the  bleeding  occurs, 
the  less  serious  it  is,  as  it  probably  comes  from  the  smaller 
vessels,  and  can  be  easily  dealt  with.  When,  however,  it  does 
not  supervene  till  late,  as  on  the  tenth  or  twelfth  day,  it  usually 
arises  from  the  larger  trunks,  and  is  increasingly  severe.  When 
originating  from  a  vessel  tied  in  its  continuity,  it  generally 
comes  from  the  distal  end,  and  that  for  the  following  reasons  : 
(a)  The  internal  coagulum  is  here  less  firm,  and  forms  later. than 
at  the  proximal  end  ;  (b)  the  pressure  at  the  distal  side  of  the 
ligature,  which  is  at  first  nil,  is  continually  increasing  as  the 
collateral  circulation  is  established,  whilst  proximally  it  gradually 
diminishes  as  the  vessel  contracts,  and  the  blood-flow  is  deflected 
into  other  channels ;  and  (c)  the  main  vasa  vasorum  always  run 
into  and  along  the  vessel  wall  in  the  same  direction  as  the  blood- 
stream. Hence  the  effect  of  isolating  the  artery  in  its  sheath  and 
ligating  it  is  to  diminish  the  vitality  of  the  arterial  tunics  and  to 
impede  repair  just  below  the  point  of  ligature. 

The  Treatment  is  a  matter  of  grave  anxiety  until  the  wound 
gets  into  a  healthy  state,  inasmuch  as  the  surgeon  can  never  be 
certain  that  the  bleeding  will  not  break  out  again,  although  it 
may  have  been  temporarily  stayed  ;  hence  such  a  case  must  be 
most  carefully  watched.  If  the  wound  is  in  a  limb,  a  tourniquet 
should  be  lightly  adjusted  above  it  as  a  precautionary  measure, 
so  that  at  a  moment's  notice  it  may  be  tightened. 

When  arising  from  an  artery  entirely  divided  across,  as  in  an 
amputation  stump,  elevation  of  the  part,  exposure  to  the  external 
air,  bathing  it  with  cold  lotion,  and  then  redressing  and  firmly 
bandaging  it,  may  be  all  that  is  needed  in  the  early  and  mild  cases. 
A  recurrence  will  necessitate  the  reopening  of  the  wound,  and 
the  application  of  ligatures  to  the  bleeding  points,  if  practicable. 
The  actual  cautery  may  be  employed  where  the  tissues  are  too 


HEMORRHAGE 


241 


rotten  to  hold  a  ligature.  Means  should  be  adopted  to  remove 
septic  sloughs,  as  by  a  Volkmann's  spoon,  and  if  possible  to  render 
the  wound  aseptic  by  swabbing  it  out  with  strong  carbolic  lotion 
(1  in  20),  or  with  a  solution  of  chloride  of  zinc.  The  wound 
should  then  be  powdered  with  iodoform,  packed  with  cyanide 
gauze,  and  firmly  bandaged.  If  occurring  later  in  the  case,  the 
wound  should  be  freely  opened  up,  and  an  attempt  made  to  secure 
the  bleeding  vessel  by  isolating  it  for  some  little  distance  from 
surrounding  structures.  If  this  fails,  owing  to  the  sloughy  or 
septic  state  of  the  tissues,  the  artery  must  be  tied  just  above,  or 
re-amputation  performed.  When  the  bleeding  comes  from  the 
main  vessel  near  the  trunk,  as  after  amputation  at  the  shoulder 
or  hip,  proximal  ligature  can  alone  be  depended  on,  should  local 
treatment  be  unsuccessful. 

When  coming  from  an  artery  tied  in  its  continuity,  the  means 
indicated  above  should  be  adopted  in  the  early  stages.  Later  on, 
the  treatment  varies  a  little  according  to  the  situation.  If  from 
a  vessel  of  the  trunk,  such  as  the  carotid  or  iliac,  the  wound  must 
be  freely  opened  up,  and  the  artery  secured  again  above  and 
below,  whilst  every  effort  is  made  to  combat  the  septic  condition 
by  plugging  with  antiseptic  materials.  Failing  this,  if  proximal 
ligature  is  impossible,  one  can  only  trust  to  pressure.  In  the 
arm,  after  using  cold,  pressure,  and  elevation,  one  would  re-tie 
above  and  below  through  the  original  wound.  If  this  fails,  a 
ligature  should  be  applied  higher  up  through  a  separate  incision, 
or  finally  amputation  be  performed.  In  the  leg,  however,  it  is 
scarcely  wise  to  attempt  re-ligature  at  a  higher  spot,  owing  to 
the  less  abundant  collateral  circulation.  If  the  haemorrhage 
ceases,  gangrene  is  very  likely  to  ensue  ;  whilst  if  the  latter  does 
not  supervene,  haemostasis  will  probably  not  be  effected.  Under 
such  circumstances  amputation  must  be  undertaken  without 
delay. 

Venous  Haemorrhage. 

Bleeding  from  the  smaller  veins  rarely  requires  much  attention, 
in  that  the  walls,  when  once  divided,  rapidly  collapse,  and  this 
effectually  checks  further  loss  of  blood  ;  but  if  the  larger  veins  are 
involved,  or  if  the  walls  are  thickened  and  rigid,  as  in  varix,  a 
very  considerable  amount  may  be  lost,  the  blood  welling  up  in  a 
dark,  purplish  stream  from  the  wound,  and  rendering  its  arrest  the 
more  difficult  from  the  fact  that,  except  in  veins  of  the  largest  size, 
there  is  no  definite  jet  or  gush  to  guide  one  to  the  wounded  spot. 

Treatment  of  Venous  Haemorrhage. —The  same  means  to  a  large 
extent  must  be  employed  as  for  arterial  haemorrhage,  but  it  is 
less  frequently  required,  since  the  smaller  veins  collapse  naturally, 
and  thus  the  bleeding  stops.  It  is  never  advisable  to  occlude  the 
whole  circumference  of  a  large  vein  if  it  can  be  avoided,  since  a 
puncture  or  tear  can  often  be  secured  without  seriously  encroach- 

16 


242  A  MANUAL  OF  SURGERY 


ing  upon  the  calibre  of  the  tube.  In  amputations  it  is  usual  to 
tie  both  the  main  artery  and  vein.  Where  it  is  difficult  to  reach 
a  vein  in  order  to  tie  it,  the  wound  may  be  stuffed. 

The  dangers  of  venous  haemorrhage  are  fourfold  :  (i)  The  con- 
stitutional symptoms  arising  from  the  actual  loss  of  blood,  details 
of  which  have  been  given  above ;  (2)  the  thrombus  which  forms 
may  become  displaced  as  an  embolus ;  (3)  septic  infection  of  the 
thrombus  lying  in  the  mouth  of  the  vessel  may  lead  to  pyaemia  ; 
and  (4)  the  entrance  of  air  into  veins,  which,  though  rarely  met 
with,  is  fraught  with  the  most  urgent  danger  to  the  patient.  The 
air  becomes  churned  up  in  the  cavities  of  the  right  side  of  the 
heart,  forming  a  spumous,  frothy  mixture  amongst  the  columnar 
carneae,  which  the  heart  can  only  with  difficulty  eject ;  thus  the 
circulation  is  brought  to  a  standstill  in  spite  of  forcible  cardiac 
contractions,  and  the  patient  dies  from  anaemia  of  the  lungs  and 
brain. 

The  Cause  of  the  entry  of  air  is  usually  a  wound  of  some  vein 
in  what  is  known  as  the  '  dangerous  region '  of  the  neck  or  axilla, 
but  it  may  occur  in  other  positions.  There  is  but  little  blood- 
pressure  within  the  veins  at  any  time,  but  during  inspiration  the 
movements  of  the  thorax  exercise  an  aspiratory  or  suction  effect 
upon  the  blood  in  the  veins  of  the  neck,  a  most  important  element 
in  the  maintenance  of  the  venous  flow.  Any  condition  which 
tends  to  prevent  the  collapsing  of  the  walls  of  the  veins,  or 
brings  about  what  is  termed  their  canalization,  predisposes  to  this 
accident.  Thus  they  may  be  held  open  at  spots  where  they 
pierce  the  deep  fascia  or  the  platysma ;  if  the  coats  are  thick  and 
rigid  from  inflammation,  or  surrounded  by  indurated  tissue,  or 
button-holed  as  by  excision  of  a  portion  of  the  walls  or  division 
of  a  branch  close  to  the  main  trunk,  or  if  undue  traction  is  exer- 
cised upon  the  pedicle  of  a  tumour  containing  a  wounded  vein, 
then  the  orifice  may  remain  patent,  and  air  can  be  sucked  in. 
If,  however,  the  veins  are  very  distended,  and  the  intravenous 
pressure  high,  as  is  often  seen  in  the  operation  of  tracheotomy, 
then  the  wound  of  a  vein,  even  in  the  dangerous  area,  usually 
results  in  loss  of  blood  rather  than  entrance  of  air. 

Signs. — The  entrance  of  air  into  a  wounded  vein  is  accompanied 
by  a  hissing,  gurgling,  or  sucking  sound,  which  is  quite  charac- 
teristic. A  few  bubbles  of  air  may  also  be  seen  clinging  about 
the  aperture  in  the  vessel.  If  only  a  small  amount  has  entered, 
no  bad  results  may  follow ;  but  the  usual  effect  of  this  accident  is 
to  produce  sudden  and  severe  faintness,  and  if  the  patient  is  con- 
scious, a  feeling  of  dyspnoea  and  distress,  which  is  partly  cardiac 
in  origin,  partly  due  to  obstruction  to  the  flow  of  blood  through 
the  lungs.  The  pulse  becomes  rapid  and  almost  imperceptible, 
the  pupils  widely  dilated,  and  death  usually  follows,  preceded 
perhaps  by  convulsions,  although  the  fatal  issue  may  be  postponed 
for  a  few  hours.     If  the  patient  survives,  no  after-effects  remain. 


HEMORRHAGE 


243 


Treatment.— This  accident  can  usually  be  avoided  by  dealing 
cautiously  with  all  veins  in  operations  about  the  neck.  Should  it 
occur,  any  fresh  entrance  must  be  at  once  checked  by  placing  a 
finger  over  the  bleeding  point  or  pouring  lotion  into  the  wound. 
The  vein  should  be  secured  by  ligature  as  soon  as  possible.  Com- 
pression of  the  chest  has  been  recommended  by  some  authorities  in 
order  to  squeeze  out  the  air  that  has  entered  ;  but  there  is  little 
chance  of  attaining  this  end.  To  combat  the  general  symptoms,  it 
is  essential  to  maintain  a  good  supply  of  blood  to  the  brain.  The 
head  is  lowered,  and,  if  need  be,  the  limbs  raised  and  bandaged, 
or  the  abdominal  aorta  compressed.  Stimulants  and  artificial 
respiration  are  used  in  order  to  maintain  the  heart's  action  and  to 
overcome  the  pulmonary  obstruction.  Warmth  and  friction  are 
also  applied  to  the  extremities. 

Capillary  Haemorrhage. 

This  is  usually  of  little  significance.  It  is  characterized  by  a 
general  oozing  from  the  wounded  surface,  the  blood  trickling 
down  to  fill  the  cavity  from  the  bottom.  It  is  often  very  abun- 
dant from  inflamed  parts,  and  especially  from  fibro-cicatricial 
tissue,  which  prevents  the  closure  of  the  vessel  mouths.  It  can 
usually  be  arrested  by  a  little  pressure,  or  by  the  application  of 
cold  or  hot  water,  by  styptics,  cauterization,  or  plugging. 

Methods  of  dealing  with  Haemorrhage  from  Special  Sources. 

Carotid  Artery. — Treatment  is  impossible  unless  the  surgeon  is  on  the  spot, 
when  both  ends  should  be  tied. 

Jugular  Vein. — Tie,  or  stitch,  if  possible,  without  occluding  the  whole 
lumen. 

Secondary  Branches  of  the  Carotid. — It  may  be  difficult  to  secure  the  divided 
ends  of  these  vessels  either  in  the  neck  or  head,  e.g.,  in  a  cut  throat  or  a  punc- 
tured wound  of  the  pterygoid  region.  Under  such  circumstances,  ligature 
of  the  external  carotid  between  the  superior  thyroid  and  lingual  has  been 
recommended  as  more  satisfactory  than  tying  the  common  carotid,  since  the 
cerebral  circulation  is  not  thereby  affected. 

Vertebral  Artery. — The  source  of  such  bleeding  may  be  difficult  to  ascertain, 
as  it  is  scarcely  possible  to  compress  this  vessel  without  also  including  the 
carotid  ;  and  hence  mistakes  in  diagnosis  have  often  arisen.  It  may  be  feasible, 
however,  to  control  the  carotid  alone  by  pinching  it  up  by  the  fingers  placed 
on  either  side  of  the  sterno-mastoid,  without  interfering  with  the  vertebral. 
Treatment  must  follow  the  usual  course  of  cutting  down  and  tying  at  the 
bleeding  point,  if  possible.  To  do  this  the  incision  must  be  enlarged,  or  a 
new  one  made  along  the  posterior  border  of  the  sterno-mastoid  in  order  to 
define  the  transverse  processes  of  the  vertebrae.  In  the  upper  part  of  its 
course  the  vessel  may  be  secured  by  clipping  away  a  transverse  process  if 
necessary,  due  care  being  taken  of  the  nerve  roots  ;  otherwise,  plugging  of  the 
vertebral  canal  or  the  use  of  styptics  must  be  depended  on.  It  is  most  essen- 
tial that  the  carotid  should  not  be  tied  by  mistake  in  these  cases,  as  therebv 
more  blood  is  directed  to  the  vertebral  trunk,  and  the  bleeding  is  correspond- 
ingly increased. 

The  Internal  Mammary  Artery  rarely  calls  for  treatment,  since  a  punctured 
wound  of  this  vessel  is  usually  complicated  with  some  graver  mischief  to  heart, 

16 — 2 


244 


A   MANUAL  OF  SURGERY 


liver  or  lungs.  If  recognised,  tie  at  the  bleeding  spot,  possibly  removing  a 
costal  cartilage  to  gain  access.  The  vessel  lies  about  \  inch  outside  the  border 
of  the  sternum. 

Intercostal  Haemorrhage  usually  results  from  penetrating  wounds  also  in- 
volving the  rib,  and  is  not  easily  stopped,  on  account  of  the  position  of  the 
vessels  in  the  groove.  Treatment. — Incise  the  periosteum  longitudinally  along 
the  lower  border  of  the  rib,  and  detach  it  and  the  vessels  from  the  groove ;  or 
remove  a  portion  of  the  bone,  and  thus  expose  the  bleeding  point ;  or  in  some 
cases  a  suture  passed  round  the  rib  a  little  above  the  injury  has  sufficed  ;  or 
again,  pressure  may  be  employed  by  pushing  a  piece  of  aseptic  gauze,  like  a 
pocket,  through  the  wound  into  the  pleural  cavity,  and  then  stuffing  it  tightly 
with  wool  or  strips  of  gauze,  so  that  on  pulling  upon  it  the  vessel  may  be 
effectually  compressed. 

Wounds  of  the  Vessels  of  the  Extremities  need  treatment  according  to  the 
principles  enunciated  above.     Only  one  or  two  require  special  mention. 

Wounds  of  the  Palmar  Arches  were  formerly  much  more  dreaded  than 
they  are  at  present,  when  thorough  antisepsis  and  the  use  of  the  elastic 
tourniquet  allow  us  to  explore  the  depths  of  a 
wound  without  much  danger  or  difficulty.  The 
position  of  the  wound  will  usually  indicate 
whether  the  bleeding  comes  from  the  superficial 
or  deep  arch,  but  in  case  of  doubt  it  is  well 
to  remember  that  pressure  on  the  ulnar  trunk 
mainly  affects  the  superficial  arch,  whilst  pres- 
sure on  the  radial  will  chiefly  influence  the  deep. 
A  wound  of  the  superficial  arch  presents  little 
trouble  in  treatment,  as  it  can  be  readily  secured 
by  catch  forceps  and  ligature  ;  but  the  deep  arch 
is  not  so  easily  dealt  with.  It  lies  just  over  the 
bases  of  the  metacarpal  bones  (Fig.  62,  d),  and 
to  expose  it  the  wound  must  be  freely  enlarged 
by  a  longitudinal  incision,  and  the  tendons 
turned  on  one  side  or  separated.  It  may  be 
possible  to  secure  the  vessel  by  forcipressure 
forceps,  and  these  may  be  left  on  for  twenty-four 
hours  if  a  ligature  cannot  be  applied.  Of  course 
the  strictest  asepsis  is  needful  in  such  cases,  and 
passive  movement  of  the  fingers  must  be  early 
undertaken,  in  order  to  prevent  troublesome 
adhesions.  Failing  such  means,  or  in  septic 
wounds,  a  modification  of  the  old  graduated 
compress  may  be  employed  ;  the  wound  is  care- 
fully and  thoroughly  plugged  with  gauze,  and  over  this  the  fingers  are  firmly 
bandaged.  The  patient  is  kept  in  bed  for  a  few  days,  and  the  arm  elevated. 
Pressure  on  the  main  vessels  above  is  scarcely  necessary  if  the  compress  is 
accurately  applied.  The  bandages  may  be  relaxed  at  the  end  of  twenty-four 
hours,  but  the  deep  dressing  should,  if  possible,  not  be  touched  for  three  or 
four  days.  If,  in  spite  of  this,  bleeding  recurs,  the  main  vessel  or  vessels 
of  the  limb  must  be  tied.  Ligature  of  the  ulnar  and  radial  at  the  wrist  is 
generally  insufficient  to  control  it,  as  there  is  often  a  communicating  branch 
of  some  size  passing  from  the  anterior  interosseous  to  the  deep  arch,  and 
hence  it  may  be  needful  to  secure  the  brachial  artery,  ascertaining  first,  how- 
ever, by  pressure  that  such  would  be  efficacious ;  for  occasionally  there  is  a 
high  division  of  the  brachial,  or  a  vas  aberrans  may  exist,  which  would  compel 
the  surgeon  to  tie  the  third  part  of  the  axillary. 

Bleeding  from  the  Plantar  Arch  must  be  conducted  on  exactly  similar  lines. 

The  Gluteal,   Sciatic,  or  Pudic  arteries  may  be  wounded  by  stabs  in  the 

buttock.     Treatment. — Enlarge  the  wound  in  the  direction  of  the  fibres  of  the 

gluteus  maximus,   i.e.,  downwards  and  outwards,   and   secure  the   bleeding 


Fig.  62. — Hand,  to  show 
position  of  Palmar 
Arches. 

A,  Radial  artery ;  B,  Ulnar 
artery  ;  C,  Superficial 
arch  ;   D,  Deep  arch. 


HEMORRHAGE  245 

vessel.  The  gluteal  trunk  emerges  from  the  pelvis  at  the  junction  of  the 
middle  and  inner  thirds  of  a  line  from  the  posterior  superior  iliac  spine  to  the 
great  trochanter ;  the  pudic  crosses  the  ischial  spine  at  the  junction  of  the 
middle  and  lower  thirds  of  a  line  from  the  posterior  superior  iliac  spine  to 
the  tuber  ischii.  The  sciatic  emerges  from  the  pelvis  just  above  and  a  little 
external  to  the  latter  spot.  The  pudic  may  also  be  divided  in  the  perineum  by 
a  penetrating  wound.  Failing  ligature  of  any  of  these  arteries  at  the  seat  of 
bleeding,  the  internal  iliac  may  need  to  be  secured. 

Haemophilia. 

By  haemophilia,  or  the  hemorrhagic  diathesis,  is  meant  a  congenital  and 
hereditary  disease  characterized  by  a  tendency  to  persistent  and  uncon- 
trollable bleeding  from  slight  wounds,  whether  open  or  subcutaneous.  This 
condition  is  often  associated  with  extravasation  of  blood  into  the  joints,  and 
certain  consecutive  phenomena  (Chap.  XX.).  The  family  history  is  always 
interesting,  the  disease  being  usually  transmitted  through  the  females  to  the 
males  of  a  succeeding  generation,  whilst  the  former  often  escape  entirely. 
The  pathological  cause  of  this  affection  has  not  yet  been  ascertained,  no 
change  in  the  vessels  or  constitution  of  the  blood  having  been  discovered. 
Unless  haemorrhage  is  actually  occurring,  nothing  abnormal  is  noticed,  but 
any  injury  is  sure  to  be  followed  by  excessive  bleeding  ;  spontaneous  sub- 
cutaneous ecchymoses  frequently  occur,  as  also  bleeding  from  the  mucous 
membranes.  Hence  no  operations  must  be  undertaken  on  such  patients 
unless  absolutely  urgent,  even  such  a  small  matter  as  the  extraction  of  a  tooth 
having  proved  fatal. 

The  Treatment  of  haemophilia  should  be  directed  more  to  correcting  the 
constitutional  defect  than  to  pursuing  the  usual  practice  in  dealing  with 
haemorrhage.  The  application  or  administration  of  haemostatics,  and  sub- 
stances which  tend  to  promote  coagulation  and  the  formation  of  fibrin,  should 
be  resorted  to.  Calcium  chloride,  1  drachm  to  i  pint  of  water,  given  by 
enema,  or  30  grs.  by  the  mouth,  repeated  several  times  a  day,  has  been 
recommended,  whilst  fibrin  ferment,  suprarenal  extract,  and  cocaine  should 
be  employed  locally.  Position  and  pressure  are  attended  to,  and  in  severe 
cases  the  actual  cautery  may  prove  useful,  or  the  prolonged  application  of 
cold. 


CHAPTER   X. 

INJURIES    AND    DISEASES    OF     ARTERIES— ANEURISM- 
LIGATURE  OF  ARTERIES. 

Injuries  of  Arteries. 

Contusion  of  an  artery  is  the  result  of  violence  applied  directly  to 
the  vessel  wall.  The  effects  vary  with  the  severity  of  the  injury 
and  with  the  condition  of  the  arterial  tunics.  If  atheroma  or 
calcification  exists,  thrombosis  often  follows  slight  injuries,  and 
dry  or  senile  gangrene  may  ensue  ;  but  in  healthy  arteries  a  good 
deal  of  violence  is  needed  to  produce  such  an  effect,  as  their 
natural  elasticity  enables  them  to  yield  or  slip  aside,  and  thus  the 
consequences  are  usually  insignificant. 

Rupture  or  Laceration  may  follow  more  severe  blows  or  strains, 
weakness  or  disease  of  the  arterial  wall  predisposing  to  it.  It 
occasionally  results  from  attempts  to  reduce  old-standing  disloca- 
tions, or  to  break  down  intra-articular  adhesions  when  the  vessel 
has  become  fixed  in  some  abnormal  position.  If  the  rupture  is 
partial,  the  inner  and  middle  coats  are  usually  torn  through,  and 
by  projecting  into  the  lumen  of  the  vessel  constitute  a  valve  which 
prevents  the  passage  of  blood,  and  leads  to  subsequent  thrombosis 
and  occlusion.  In  other  cases,  where  the  injury  to  the  coats  is 
slight,  a  thrombus  may  form,  which  leads  to  obliteration  ;  or,  if 
the  lesion  is  limited  to  one  side,  the  clot  may  become  organized 
over  that  spot,  narrowing,  but  not  interfering  with  the  lumen  of  the 
vessel,  and  leaving  an  area  of  weakness  from  which  an  aneurism 
may  subsequently  develop.  Again,  when  complicated  with  a  septic 
wound,  an  ulcerative  form  of  peri-arteritis  may  ensue,  giving  rise 
later  on  to  secondary  haemorrhage.  It  is  also  stated  that  the 
adventitia  is  occasionally  torn  without  injury  to  the  tunica  intima, 
and  that  an  aneurism  may  result  from  a  protrusion  of  the  latter 
coat  through  the  wound  in  the  former ;  such  an  occurrence  must 
be  exceedingly  rare.  A  dissecting  aneurism  (p.  259)  may  also 
result  under  special  circumstances  from  such  an  accident. 

Complete  Rupture  of  an  artery  often  leads  to  but  little  haemor- 
rhage in  a  severe  lacerated  wound,  such  as  is  produced  when  a 


INJURIES  AND  DISEASES  OF  ARTERIES  247 


limb  is  torn  off:  the  inner  and  middle  coats  give  way  at  a  higher 
level  than  the  adventitia,  and  curl  up  within  it,  whilst  the  outer 
coat  and  sheath  contract  over  them,  and  thus  prevent  bleeding. 
If,  however,  the  artery  is  ruptured  in  a  subcutaneous  injury,  such 
as  a  fracture  or  dislocation,  extensive  extravasation  often  ensues, 
constituting  the  condition  badly  termed  a  Diffuse  Traumatic 
Aneurism.  The  objection  to  this  name  lies  in  the  fact  that  there 
is  no  true  sac  wall  as  in  an  aneurism,  the  only  boundary  con- 
sisting of  an  ill-defined  mass,  partly  coagulum,  partly  inflammatory 
exudation,  and  in  part  thickened  and  infiltrated  tissues.  A  similar 
condition  may  ensue  from  a  punctured  wound  dividing  a  vessel, 
where  the  track  leading  to  it  is  valvular  or  becomes  closed  by 
clot  or  some  external  application. 

Symptoms. — The  patient  usually  feels  a  snap,  as  though  some- 
thing had  given  way,  accompanied  by  a  sudden  pain,  localized  to 
the  part  injured,  and  often  shooting  down  the  limb  in  the  line  of 
the  vessel.     These  are  succeeded  by  the  following  phenomena  : 

(a)  Locally,  the  formation  of  a  diffuse,  rapidly  increasing  swelling, 
the  skin  over  which  is  at  first  normal,  but  soon  becomes  dis- 
tended and  bluish,  and  finally  bright  red  and  cedematous,  when 
the  tumour  is  threatening  to  give  way.  There  is  no  increased 
local  heat  except  in  the  later  stages.  Distinct  pulsation  is  usually 
present,  and  some  amount  of  bruit,  synchronous  with  the 
heart's  action,  although  these  subsequently  become  less  obvious. 

(b)  Distally,  diminished  sensibility  in  the  limb  quickly  follows, 
together  with  loss  of  pulsation  in  the  vessels  and  a  fall  of 
temperature.  It  lies  more  or  less  useless  and  flaccid,  and  in 
colour  is  either  white  and  blanched,  or  may  be  congested  and 
cedematous  if  the  extravasated  blood  presses  upon  the  venous 
trunks,  (c)  Generally,  the  signs  of  haemorrhage  and  shock  manifest 
themselves  in  varying  degree,  according  to  the  amount  of  blood 
lost  and  the  character  of  the  violence. 

Results. — (1)  The  swelling  may  increase  steadily  in  size  until 
the  skin  becomes  so  distended  as  to  rupture  or  slough,  and  then,  if 
help  is  not  at  hand,  the  patient  dies  of  haemorrhage.  Occasionally 
the  bleeding  continues  into  an  internal  cavity,  or  into  the  tissues 
of  a  limb,  to  such  an  extent  as  to  cause  death  without  any  external 
loss  of  blood.  (2)  Suppuration,  accompanied  by  the  general  signs 
of  fever,  may  result  from  auto-infection,  or  from  the  entrance  of 
bacteria  through  the  small  valve-like  wound.  The  whole  swelling 
becomes  red,  hot,  cedematous,  and  excessively  tender,  looking  like 
a  large  abscess.  Rupture  and  external  haemorrhage  will  probably 
conclude  the  case  if  surgical  assistance  cannot  be  obtained.  (3) 
The  pressure  of  the  extravasated  blood  upon  the  veins  or  on  the 
arteries  needed  for  the  collateral  circulation  may  determine  gangrene 
of  the  extremity,  which  is  almost  always  of  the  moist  type.  (4) 
The  process  may  become  more  or  less  limited  after  a  time  by 
coagulation  occurring  in  the  divided  mouth  of  the  vessel,  which  is 


248  A  MANUAL  OF  SURGERY 

thus  occluded.  Collateral  circulation  may  be  established,  and 
thereby  the  health  and  vitality  of  the  limb  are  maintained,  whilst 
the  blood-clot  is  absorbed  or  organized. 

The  Treatment  is  necessarily  the  same  as  for  a  divided  artery 
communicating  with  an  open  wound,  viz.,  to  cut  down  and  tie 
both  ends.  The  circulation  is  first  temporarily  arrested  by  an 
elastic  tourniquet,  a  free  incision  made,  and  all  coagula  removed. 
The  bleeding  points  are  then  sought  for  and  tied,  the  tourniquet 
being  relaxed  to  allow  them  to  become  evident.  If  the  distal 
end  cannot  be  found,  the  wound  is  not  closed,  but  should  be 
stuffed  with  gauze,  and  allowed  to  granulate,  a  tourniquet 
being  kept  loosely  about  the  limb  ready  to  be  tightened  at 
any  moment,  if  necessary.  When  suppuration  is  threatening, 
the  same  plan  must  be  adopted,  viz.,  free  incision  and  tying  the 
ends  of  the  vessel  if  they  can  be  found ;  but  in  cases  where 
from  the  cedematous  and  unhealthy  state  of  the  surrounding 
parts  this  is  impracticable,  it  will  be  necessary  either  to  tie  the 
main  trunk  on  the  cardiac  side  of  the  rupture,  or  to  trust  to  the 
pressure  of  a  graduated  compress.  If  gangrene  is  imminent, 
or  if  secondary  haemorrhage  occurs,  amputation  is  the  only 
resource. 

Penetrating  Wounds  of  arteries,  if  completely  dividing  the 
vessel,  are  always  followed  by  haemorrhage,  although  the  blood 
may  be  unable  to  escape  if  the  wound  in  the  skin  is  small  or 
valvular,  or  if  the  opening  is  closed  by  blood-clot  or  dressing  ; 
under  these  circumstances,  the  signs  due  to  subcutaneous  rupture 
of  a  vessel  are  produced.  The  amount  of  bleeding  in  open  wounds 
varies  according  to  the  character,  direction,  and  extent  of  the 
lesion,  and  with  the  size  of  the  vessel.  If  a  large  artery  is  cleanly 
cut  across,  the  bleeding  is  copious,  whilst  from  a  small  vessel  it 
soon  ceases,  owing  to  the  contraction  and  retraction  of  the  coats. 
When  an  artery  is  buttonholed — i.e.,  when  a  small  segment  of  the 
wall  is  cut  through — the  haemorrhage  is  often  continuous  and 
prolonged,  since  retraction  cannot  take  place.  The  treatment  of 
this  condition  consists  in  completing  the  division  of  the  injured 
trunk,  if  it  is  a  small  one,  thus  allowing  of  contraction  and  re- 
traction, or,  if  the  vessel  is  of  large  size,  in  tying  it  above  and 
below  the  opening,  and  dividing  it  between  the  ligatures. 

If  the  wound  is  in  the  long  axis  of  the  vessel,  it  gapes  but  little, 
and  the  loss  of  blood  is  often  slight,  whilst  if  transverse  or  oblique, 
both  contraction  and  retraction  tend  to  increase  the  size  of  the 
opening,  rendering  it  more  nearly  circular,  and  therefore  the 
haemorrhage  in  such  cases  is  considerable. 

If  a  small  artery  is  divided  close  to  its  origin  from  a  large  main 
trunk,  the  blood  escapes  with  a  jet,  the  strength  of  which  is 
proportionate  to  the  blood-pressure  in  the  main  trunk,  and  not 
to  the  size  of  the  vessel  divided.  In  such  a  case  the  main 
trunk  must  be  tied  above  and  below  the   wound,    and    divided 


INJURIES  AND  DISEASES  OF  ARTERIES  249 


between  the  ligatures,  and  the  distal  end  of  the  divided  branch 
also  secured. 

A  good  many  attempts  have  been  made  of  late  to  effect  the 
union  of  wounds  in  the  walls  of  arteries  without  causing  their 
obliteration,  and  with  some  success.  Small  longitudinal  wounds 
may  certainly  be  sutured,  the  stitches  being  of  the  finest  silk  and 
applied  so  that  the  edges  of  the  tunica  intima  are  brought  accur- 
ately into  apposition  ;  Heidenhain  reports  a  case  where  a  wound 
1-5  cms.  long  in  the  axillary  artery  was  successfully  sutured  in 
this  way.  End-to-end  union  of  a  divided  artery  has  also  been 
obtained  in  one  case,"  the  upper  end  being  invaginated  into  the 
lower ;  such  a  procedure  can,  however,  only  be  required  under 
very  exceptional  circumstances. 

In  punctured  wounds  of  arteries  the  size  of  the  penetrating 
body  is  all-important.  A  vessel  may  be  traversed  by  a  needle 
without  haemorrhage  or  any  subsequent  ill  effect,  but  a  larger 
puncture  results  in  extravasation.  If  it  ceases  after  a  time,  the 
blood-clot  is  absorbed,  and  the  wound  in  the  vessel  closed  by  a 
cicatrix,  which  may  subsequently  yield  to  the  blood-pressure,  and 
give  rise  to  a  circumscribed  aneurism.  This  occurrence  is  not 
unfrequent  in  the  neighbourhood  of  the  wrist  from  glass  wounds, 
involving  the  radial  or  ulnar  trunks,  and  hence  is  not  uncommon 
among  window-cleaners  or  mineral-water  bottlers. 

Arterio-Venous  Wounds  are  not  so  frequent  in  the  present 
day  as  formerly,  when  venesection  was  in  vogue.  They  follow 
penetrating  wounds  which  involve  an  artery  and  vein  lying  in 
close  contact,  e.g.,  at  the  bend  of  the  elbow  between  the  median 
basilic  vein  and  the  brachial  artery,  in  the  neck  between  the 
internal  jugular  and  carotid,  in  the  groin  between  the  femoral 
vessels,  and  occasionally  in  the  orbit.    Two  conditions  may  result. 

An  Aneurismal  Varix  is  produced  by  a  direct  communication 
between  an  artery  and  a  vein,  no  dilated  passage  intervening 
between  the  vessels  (Fig.  63,  A).  The  venous  walls,  unfitted  to 
withstand  arterial  pressure,  are  thereby  dilated  and  rendered 
varicose.  A  pulsating  venous  tumour  results,  the  dilatation 
extending  for  a  variable  distance  above  and  below  the  opening, 
and  at  each  beat  of  the  heart  a  loud  whizzing  sound  can  be 
heard,  likened  by  some  authors  to  that  caused  by  an  imprisoned 
bluebottle  buzzing  in  a  thin  paper  bag. 

Treatment. — Nothing  is  usually  required  beyond  the  application 
of  an  elastic  bandage  or  support  to  prevent  further  enlargement. 
Should  pain  or  inconvenience  arise,  the  artery  should  be  secured 
above  and  below  the  abnormal  communication  with  the  vein. 
Occasionally  the  latter  is  so  distended  that  it  has  to  be  removed 
before  the  artery  can  be  reached.  This  operation  should  not  be 
undertaken    in    the    neck    for    the    carotid-jugular   varix    unless 

*  J.  B.  Murphy,  Medical  Record,  January  16,  1897. 


250 


A  MANUAL  OF  SURGERY 


absolutely  essential.     In  the  orbit  electrolysis  may  be  used  with 
advantage. 

A  Varicose  Aneurism,  though  brought  about  by  the  same  cause, 
differs  from  the  above  in  that  an  aneurismal  sac  exists  between 
the  artery  and  the  dilated  vein  (Fig.  63,  B).  It  is  produced  when 
the  vessels  are  placed  at  a  short  distance  from  each  other,  or 
when  extravasation  of  blood  has  separated  them.  The  aneurism 
is  of  the  false  type,  its  walls  being  composed  entirely  of  newly- 
formed  organized  clot  and  cicatricial  tissue  ;  it  is  almost  certain 
to  become  diffuse.  The  physical  signs  are  similar  to  those  of 
aneurismal  varix,  except  that  the  aneurism  can   be   sometimes 


A  B 

Fig.  63. — Diagrams  of  Aneurismal  Varix  and  Varicose  Aneurism. 

A,  Artery;   V,  Vein;  AN,  Aneurism. 

detected  by  palpation,  whilst  a  soft  bruit  may  be  heard  over  it, 
and  the  distension  of  the  veins  is  not  quite  so  marked. 

Surgical  Treatment  is  always  required  in  these  cases.  Simple 
ligature  of  the  artery  above  and  below  the  abnormal  communi- 
cation will  sometimes  suffice,  allowing  the  blood  in  the  sac  to 
coagulate  ;  the  veins  will  subsequently  diminish  in  size,  when 
the  arterial  blood-pressure  is  removed.  Occasionally,  however, 
the  vein  overlaps  the  artery,  and  has  to  be  tied  and  removed 
before  the  sac  of  the  aneurism  is  reached  ;  it  is  then  better  to 
excise  the  sac  and  tie  the  artery  above  and  below.  In  the  less 
urgent  cases  digital  pressure  to  the  artery  above  the  sac  is  some- 
times successful. 

Inflammation  of  Arteries. 

Various  forms  of  inflammation  of  the  arterial  wall  are  met 
with,  which  are  usually  named  from  the  cause  producing  them — 
Traumatic,  Infective,  or  Embolic  arteritis.  The  terms  Endarteritis 
and  Periarteritis  are  used  to  distinguish  inflammatory  conditions 
which  respectively  start  from  the  tunica  intima,  or  reach  the  vessel 
from  without ;  in  both  cases,  however,  the  middle  coat  is  generally 


INJURIES  AND  DISEASES  OF  ARTERIES  251 

involved,  and  the  process  may  even  finally  spread  beyond  it,  so 
that  the  whole  thickness  of  the  arterial  wall  is  attacked. 

1.  Traumatic  or  Plastic  Arteritis  is  the  result  of  some  injury, 
such  as  total  or  partial  division  of  the  vessel,  laceration,  bruising, 
etc.  The  phenomena  are  merely  those  of  repair,  resulting  in 
occlusion  of  the  vessel,  viz.,  congestion  of  and  exudation  into  the 
vessel  walls  from  the  vasa  vasorum,  together  with  proliferation  of 
the  tunica  intima ;  they  have  been  already  described  at  p.  227. 

2.  Infective  Arteritis  is  a  condition  in  which  the  arterial  wall 
becomes  invaded  and  softened  by  bacteria.  It  frequently  results 
from  inflammation  advancing  inwards  from  the  exterior  (peri- 
arteritis), and  is  usually  seen  in  connection  with  septic  wounds 
and  spreading  ulceration.  The  vasa  vasorum  are  dilated,  and  an 
exudation  of  leucocytes  occurs,  as  a  result  of  the  bacterial  in- 
vasion ;  the  peptonizing  action  of  the  toxins  thereby  produced 
leads  to  softening  of  the  vessel  walls,  the  fibres  of  which  lose  their 
cohesion  with  each  other.  Finally,  their  resisting  power  may  be 
so  impaired  that  they  yield  before  the  blood-pressure  and  cause 
haemorrhage,  unless  thrombosis  has  previously  sealed  the  vessel. 
In  the  smaller  arteries  this  is  usually  the  case,  but  in  those  larger 
than  the  radial  there  is  considerable  danger  of  bleeding,  especially 
if  the  irritation  is  confined  to  one  side  of  the  vessel.  Secondary 
haemorrhage  from  arteries  tied  in  their  continuity  is  generally  due 
to  this  cause,  as  also  bleeding  from  phthisical  cavities,  the  vessels 
having  previously  lost  the  support  of  surrounding  tissues,  and 
being  more  or  less  dilated  or  aneurismal.  Acute  abscesses,  septic 
ligatures,  and  malignant  tumours  may  weaken  an  arterial  wall 
and  lead  to  haemorrhage,  whilst  the  infective  agent  sometimes 
reaches  the  walls  from  within,  as  from  an  infective  embolus. 

3.  Embolic  Arteritis. — When  a  vessel  is  blocked  by  a  simple 
embolus,  obliteration  as  a  result  of  a  simple  plastic  arteritis  is 
the  usual  consequence.  If  the  embolus  contains  some  irritating 
or  infective  material,  as  in  a  case  of  infective  endocarditis  or 
pyaemia,  an  abscess  may  result ;  but  if  the  irritant  is  less  intense, 
the  process  may  stop  shore  of  suppuration,  and  yet  an  aneurismal 
dilatation  of  the  softened  wall  takes  place.  The  latter  process  is 
the  most  common  cause  of  spontaneous  aneurism  in  children. 

4.  Acute  Endarteritis  is  met  with  rather  as  a  pathological 
curiosity  than  as  a  condition  of  any  clinical  import.  It  is  usually 
associated  with  acute  endocarditis,  however  produced,  or  may 
accompany  some  of  the  chronic  forms  described  below.  It  is 
evidenced  by  the  presence  on  the  inner  aspect  of  the  vessel  of 
more  or  less  raised  patches,  somewhat  pinkish  and  gelatinous  in 
appearance,  soft  and  elastic  in  consistency,  and  although  the 
polish  is  lost,  the  endothelium  is  usually  intact.  It  is  found  in  the 
aorta,  or  in  smaller  vessels,  especially  near  inflamed  wounds. 

5.  Chronic  Endarteritis  is  an  exceedingly  common  affection, 
and  the  following  forms  may  be  described : 


252 


A   MANUAL  OF  SURGERY 


(a)  Simple  Chronic  Endarteritis,  resulting  in  Atheroma  (Gr. 
d#?//»7,  'gruel'  or  'pap').  This  condition  is  constantly  found  in 
elderly  people,  but  especially  in  drinkers  and  those  who  have 
suffered  from  chronic  Bright's  disease,  gout,  or  syphilis ;  it  arises 
from  continual  strain  and  increased  blood-pressure,  and  hence 
often  starts  in  the  convexity  of  the  aortic  arch,  at  the  spot  where 
the  impact  of  the  blood-stream  is  most  felt  as  it  is  ejected  from 
the  ventricle,  or  in  places  where  a  vessel  passes  over  or  around 
some  bony  projection,  or  at  the  bifurcation  of  a  main  artery,  or 
where  a  large  branch  is  given  off,  thus  causing  a  sudden  decrease 


Fig.  64. — Section  of  Atheromatous  Cerebral  Artery,     x  50.    (Ziegler.) 

a,  Intima  considerably  thickened;  b,  bounding  elastic  lamella  of  intima  ; 
c,  media;  d,  adventitia  ;  e,  necrosed  denucleated  tissue  with  masses  of  fatty 
detritus  ;  /,  and  flt  detritus  with  cholesterine  tablets  ;  g,  intima  infiltrated 
with  leucocytes;  h,  infiltration  of  adventitia  with  leucocytes. 

in  its  lumen.     It  is  rarely  found  in  the  smaller  arteries,  except 
those  of  the  heart  or  brain. 

The  pathological  phenomena  consist  at  first  of  a  proliferation 
of  the  deeper  parts  of  the  tunica  intima,  giving  rise  to  opaque, 
milky-looking,  non-vascular  patches  (Fig.  64,  g),  which  may 
organize  into  fibroid  tissue,  or  undergo  fatty  degeneration  (e  and 
/).  They  are  arranged  longitudinally  or  around  the  mouths  of 
large  branches.  The  tunica  media  is  more  or  less  involved  in  the 
process,  and  the  adventitia  is  often  thickened  externally.  As 
soon  as  the  fatty  changes  have  commenced,  the  patches  become 


INJURIES  AND  DISEASES  OF  ARTERIES  253 


yellowish  in  colour,  somewhat  elevated  from  the  inner  surface, 
and  irregular  in  outline  ;  they  are  small  at  first,  but  increase  in 
size,  and  coalesce  one  with  another.  The  contents  are  now  fluid 
or  cheesy  in  consistency,  constituting  the  so-called  '  atheromatous 
abscess,'  although  no  true  pus  exists,  the  pultaceous  material 
consisting  of  fatty  granules  and  debris,  with  oil  globules  and 
plates  of  cholesterine  (Fig.  64, /j).  It  maybe  absorbed  entirely, 
leaving  a  weakened  spot  in  the  wall  of  the  vessel,  from  which  an 
aneurism  may  arise  ;  or  the  tunica  intima  may  give  way  over  it, 
allowing  the  contents  to  be  swept  into  the  general  circulation, 
where  it  probably  does  no  harm,  and  the  raw  surface  left  behind 


Fig.  65. — Syphilitic  Arteritis,      x  150.     (Ziegler  ) 

a,  Intima  greatly  thickened  by  newly-formed  fibro-cellular  tissue ;  b,  fenes- 
trated elastic  lamina  of  Henle  ;  c,  muscle  fibres  of  media,  infiltrated 
towards  the  left ;  d,  adventitia  thickened  by  cell  infiltration  and  hyperplasia. 

is  known  as  an  '  atheromatous  ulcer.'  The  outer  coat  has  by  this 
time  become  thickened,  and  hence  no  immediate  ill  result  follows 
the  breach  in  the  inner  coats,  although  subsequently  dilatation 
may  take  place,  even  though  cicatrization  of  the  ulcer  has 
occurred.  Again,  the  blood  may  find  its  way  through  the  open- 
ing into  the  substance  of  the  wall  and  strip  up  the  inner  from  the 
outer  layers,  constituting  a  '  dissecting  aneurism  ' ;  or  a  localized 
thrombus  may  form,  causing  occlusion  of  the  vessel. 

Not  uncommonly  the  cheesy  contents  of  the  abscess  become 
inspissated,  and  later  on  infiltrated  with  lime  salts,  resulting  in 
the  formation  of  calcareous  plates,  which  are  either  covered  with 
endothelium,  or  exposed  to  the  blood  stream,  and  hence  may  cause 


254  A   MANUAL  OF  SURGERY 


thrombosis,  or  become  detached  as  an  embolus,  or  the  blood  may 
get  in  under  the  plate  and  form  a  dissecting  aneurism. 

A  condition  of  endarteritis  evidenced  by  proliferation  of  the 
tunica  intima  is  always  met  with  in  chronically  inflamed  tissues, 
as  also  in  diabetes  ;  such  does  not,  however,  run  on  to  atheroma. 

(b)  Chronic  Syphilitic  Endarteritis  is  chiefly  met  with  in  the 
tertiary  stage  of  the  disease,  and  is  characterized  by  an  over- 
growth of  the  tunica  intima  (Fig.  65,  a),  which  is  at  first  limited 
by  Henle's  elastic  lamina  (b),  but  is  subsequently  associated  with 
infiltration  of  the  media  (c),  and  much  more  so  of  the  adven- 
titia  (d).  The  change  occurs  in  the  smaller  arteries,  especially 
those  of  the  brain  or  kidneys,  or  in  the  neighbourhood  of  gummata, 
and  but  rarely  in  the  larger  vessels,  although  a  considerable  per- 
centage of  individuals  affected  with  internal  aneurism  have 
suffered  from  syphilis.  It  differs  from  simple  atheroma  (1)  in 
attacking  small  arteries  ;  (2)  in  affecting  the  whole  circumfer- 
ence of  the  vessel,  and  not  merely  patches  ;  (3)  the  newly- 
formed  tissue  becomes  vascular,  and  does  not  undergo  fatty 
degeneration  ;  and  (4)  it  leads  to  narrowing  or  occlusion  of  the 
vessel  rather  than  to  weakening  and  dilatation.  When  involving 
the  cerebral  arteries,  various  forms  of  monoplegia,  or  even  hemi- 
plegia, may  result. 

(c)  It  is  still  more  or  less  an  open  question  whether  the  so- 
called  Endarteritis  obliterans  or  proliferans  is  truly  syphilitic  or 
not.  In  some  cases  a  syphilitic  history  has  been  present,  but  in 
other  marked  instances  it  has  been  entirely  absent.  The  main 
arteries  are  gradually  obliterated  in  persons  apparently  sound  in 
health,  as  a  result  of  which  the  peripheral  parts  become  anaemic, 
diminished  in  vitality,  or  even  gangrenous.  The  tunica  intima  is 
converted  into  a  thickened  and  vascular  mass,  which  narrows  and 
finally  occludes  the  lumen.  This  disease,  which  is  by  no  means 
common,  is  associated  with  considerable  local  pain. 

(d)  Chronic  Tuberculous  Endarteritis  is  met  with  as  a  prolifera- 
tion of  the  tunica  intima,  with  or  without  thickening  of  the 
adventitia,  in  all  places  in  which  tubercle  is  actively  developing  ; 
in  fact,  tubercles  are  usually  formed  around  arterioles,  and  as  the 
mass  grows  the  vessel  is  slowly  occluded  and  replaced  by  the 
typical  anatomical  structure  of  the  miliary  tubercle.  The  tuber- 
culous endarteritis  may,  however,  spread  widely  beyond  the  focus 
of  the  mischief,  and  in  almost  any  portion  of  pulpy  granulation 
tissue  this  change  can  be  seen. 

Degeneration  of  Arteries. 

Fatty  Degeneration  occurs  independently  of  atheroma,  involving 
merely  the  tunica  intima,  and  manifesting  itself  in  small  patches, 
yellowish  in  colour  and  stellate  in  shape.  As  a  rule,  it  is  of  but 
little  significance  ;  but  occasionally  the  infiltration  is  deeper,  and 


INJURIES  AND  DISEASES  OF  ARTERIES 


255 


the  tunica  intima  gives  way,  causing  the  so-called  fatty  evasion, 
and  then  an  aneurism,  possibly  of  the  dissecting  type,  may  arise. 
The  most  usual  seat  of  this  trouble  is  the  aorta. 

Primary  Calcareous  Degeneration  (Fig.  66)  is  chiefly  met  with 
in  the  smaller  arteries  of  the  extremities.  It  occurs  in  elderly 
people  at  the  same  time  of  life  as  the  calcification  of  cartilages, 
etc.,  and  commences  by  the  deposit  of  lime  salts  in  the  muscular 
fibres  of  the  tunica  media,  constituting  a  series  of  calcareous 
rings  which  transform  the  elastic  expansile  vessels  into  rigid 
tubes  like  gas-pipes,  through  which  can  alone  pass  a  fixed  and 
unchangeable  minimal  supply  of  blood. 


Fig.  66. 


-Primary  Calcareous  Degeneration  of  Arteries. 
College  of  Surgeons'  Museum.) 


(From 


The  affected  limb  passes  into  a  condition  of  chronic  anaemia 
and  impaired  nutrition,  resulting  in  coldness  of  the  feet  or  hands, 
cramps  and  spasms  of  muscles,  sensations  of  pins  and  needles, 
etc.  The  endothelium  is  not  removed  except  in  the  later  stages, 
and  then  thrombosis  may  be  produced,  or  a  similar  result  may 
arise  from  the  lodgment  of  an  embolus.  Senile  gangrene  is  a 
common  termination  of  such  arterial  changes.  From  the  general 
rigidity  of  the  vessel,  and  the  method  of  deposit  of  the  lime-salts, 
it  follows  that  aneurism  is  not  likely  to  occur. 

Amyloid  Degeneration  of  the  viscera  commences  in  the  arterial 
walls,  but  is  described  elsewhere  (p.  53). 

The  Effects  of  Arterial  Inflammation  and  Degeneration  are 
both  local  and  peripheral.  Locally,  Thrombosis  may  be  produced 
whenever  the  lining  endothelium  is  removed  and  a  raw  surface 


256  A  MANUAL  OF  SURGERY 

exposed,  upon  which  fibrin  can  collect.  Under  this  fibrinous 
coating  repair  is  often  effected  without  further  complication  ;  but 
if  the  blood-stream  is  retarded,  or  the  lumen  of  the  tube  narrowed, 
complete  thrombosis  is  likely  to  follow,  the  clot  extending  some 
distance  up  or  down  the  vessel,  or  even  from  a  branch  into  the 
main  trunk,  which  may  be  blocked  by  this  means.  Aneurism 
is  also  a  result  of  any  weakening  of  the  arterial  tunics.  Oblitera- 
tion of  the  artery  may  follow,  either  in  consequence  of  thrombosis, 
or  from  excessive  proliferation  of  the  tunica  intima  (as  in  syphilitic 
or  tuberculous  disease),  or  from  gradually  increasing  pressure  from 
without.  Lastly,  Spontaneous  Rupture  is  another  local  effect 
occasionally  met  with. 

Peripherally,  defective  blood-supply  and  consequent  lowered 
vitality  are  the  most  marked  results  of  arterial  disease,  leading 
to  various  forms  of  ulceration  and  gangrene.  Thus,  senile  gan- 
grene is  due  to  calcareous  changes  in  the  arteries,  fatty  degenera- 
tion of  the  heart  follows  atheroma  of  the  coronary  arteries,  whilst 
softening  of  the  brain  may  ensue  from  various  affections  of  the 
cerebral  vessels.  Similar  results  may  also  arise  from  emboli 
detached  from  areas  of  local  disease. 


Aneurism. 

An  Aneurism  is  a  tumour  filled  with  blood  communicating  with 
the  interior  of  an  artery,  and  due  to  dilatation  of  part  or  the  whole 
of  the  vessel  walls. 

Causes. — Aneurisms  have  been  divided  into  the  spontaneous 
and  the  traumatic,  the  distinction  between  them  being  that  in  the 
former  the  coats  of  the  artery  are  primarily  diseased,  whereas 
in  the  latter  they  may  be  previously  healthy.  However,  it  must 
not  be  forgotten  that  persons  with  diseased  arteries  are  just  as 
liable  to  injury  as,  and  even  more  so  than,  those  with  healthy 
vessels,  and  thus  no  strict  line  of  separation  can  be  drawn  between 
the  two  forms.  The  causes  of  aneurism  may  be  conveniently 
grouped  under  two  headings  : 

i.  Changes  in  the  Vessel  Walls,  by  which  their  resistance  to 
the  intravascular  pressure  is  diminished.  Many  varieties  of 
disease,  e.g.,  atheroma,  whether  starting  from  within  or  without, 
predispose  to  aneurismal  dilatation,  especially  if  occurring  in 
syphilitic  or  gouty  men  about  middle  life,  in  whom,  although  the 
arterial  tunics  may  be  weakened,  the  power  of  the  heart  and  the 
resulting  blood-pressure  are  by  no  means  diminished.  Calcifica- 
tion, on  the  other  hand,  is  antagonistic  to  aneurismal  dilatation. 
Any  injury,  a  contusion,  a  penetrating  wound,  or  a  strain,  may  so 
interfere  with  the  integrity  of  the  vascular  coats  as  to  result 
in  aneurism,  and,  indeed,  a  cicatrix  in  an  arterial  wall  must 
always  be  looked  on  as  a  weak  spot  predisposing  to  dilatation. 
The   lodgment    of  an   embolus   in    the    smaller  arteries  is  stated 


ANEURISM 


257 


to  be  one  of  the  most  common  causes  of  spontaneous  dilatation 
of  these  vessels  in  the  brain  and  extremities  of  young  people. 

2.  Increase  in  the  Blood-Pressure  is  another  factor,  especially 
when  due  to  heavy  strain  or  exertion,  which  leads  to  irregular 
excitement  and  increased  action  of  the  heart.  Steady  laborious 
employment,  such  as  is  seen  amongst  artisans  and  mechanics,  or 
regular  exercise,  does  not  appear  to  predispose  to  this  condition  ; 
but  irregular  intermittent  efforts,  in  which  for  the  time  being 
every  power  is  strained  to  its  utmost,  are  very  liable  to  determine 
its  occurrence.  A  day's  exertion  in  the  hunting  or  shooting  field 
by  an  elderly  man,  accustomed  to  sedentary  occupations,  is  often 
the  cause  of  some  vascular  lesion,  such  as  aneurism,  apoplexy, 
etc.  Hence  aneurisms  are  more  frequently  seen  amongst  men 
than  in  women,  in  the  proportion  of  seven  to  one;  whilst  they  are 
much  more  common  among  the  dwellers  in  Northern  climates 
than  in  the  more  lethargic  and  ease-loving  inhabitants  of  the 
South.  The  energy  and  activity  of  the  Anglo-Saxon  race  espec- 
ially predispose  them  to  this  disease. 

Structure  of  an  Aneurism. — Formerly  much  stress  was  placed 
on  the  terms  true  and  false,  the  word  '  true  '  meaning  that  all  the 
coats  of  the  vessel  were  present,  whilst  the  '  false  '  were  those 
in  which  the  sac  wall  comprised  little  or  none  of  the  original 
arterial  tunics.  This  distinction  is  of  comparatively  little  value, 
since  no  aneurism  which  has  attained  to  any  size  is  in  reality  true. 
The  sac  consists  more  or  less  evidently  of  a  distension  of  all 
or  part  of  the  original  walls  of  the  vessel  whilst  it  is  small  ;  but 
as  the  aneurism  increases,  the  original  structure  is  replaced 
by  a  mass  of  newly-formed  fibrous  tissue,  due  to  a  condensation 
and  matting  together  of  the  surrounding  structures,  with  or 
without  an  internal  lining  of  laminated  fibrin  deposited  on  parts 
where  the  endothelium  of  the  tunica  intima  has  disappeared. 
The  contents  of  the  sac  depend  on  the  character,  age  and  size  of 
the  aneurism.  Whilst  still  small  and  with  a  complete  endothelial 
lining,  it  merely  contains  fluid  blood,  the  amount  of  which  varies 
with  each  beat  of  the  heart  ;  but  as  the  tumour  grows,  and 
especially  if  of  the  sacculated  type,  the  whole  or  part  of  the 
interior  becomes  lined  with  a  deposit  of  fibrin,  upon  which,  again, 
other  layers  form,  until  possibly  in  rare  cases  the  entire  cavity  is 
filled,  and  a  spontaneous  cure  results.  The  oldest  laminae  are 
dry  and  yellowish-white  in  colour  (the  so-called  active  clot  of  Broca) ; 
those  more  recently  deposited  are  softer  and  more  reddish,  whilst 
the  last  formed  is  merely  like  ordinary  blood  coagulum  (the  passive 
clot  of  Broca).  No  single  lamina  covers  the  whole  area,  but  layer 
is  arranged  over  layer  (Fig.  67)  in  such  a  manner  that  the  oldest 
and  necessarily  the  smallest  laminae  are  nearest  to  the  sac  wall. 

Three  chief  varieties  of  aneurism  have  been  described  :  ■  the 
fusiform,  sacculated,  and  dissecting. 

1 .  The  Fusiform  Aneurism  (Fig.  68,  A)  is  one  in  which  the  whole 

r7 


258 


A   MANUAL  OF  SURGERY 


lumen  of  the  vessel  is  more  or  less  equally  expanded,  so  that  the 
swelling  is  tubular  in  character.  It  is  due  rather  to  a  general 
increase  of  blood-pressure,  or  to  a  widely  extended  disease  of  the 
arterial  walls,  than  to  any  localized  lesion  or  injury,  and  hence  is 
more  commonly  met  with  in  the  larger  internal  vessels  than  in 
those  of  the  extremities.  The  tunica  intima  is  usually  represented 
throughout  the  whole  extent  of  the  sac,  but  is  thickened  and 
atheromatous  in  patches,  the  margins  and  surfaces  of  calcareous 
plates  being  indicated  by  flocculi  of  fibrin,  which  are  attached  to 
them,   although   no  regular  laminated  deposit  is  present.     The 


Fig.  67. — Sacculated  Aneurism.     (Museum  of  Royal  College  of 

Surgeons.) 

The  small  mouth  of  the  saccule  is  clearly  seen,  and  the  cavity  is  nearly  filled 

with  laminated  clot. 

tunica  media  is  stretched,  atrophied,  and  in  the  later  stages 
practically  non-existent,  whilst  the  adventitia  is  much  thickened 
by  inflammatory  new  formation  and  by  incorporation  with  the 
surrounding  tissues.  The  progress  of  fusiform  aneurisms  is 
generally  slow,  so  that  in  some  situations,  e.g.,  the  thorax,  they 
may  attain  enormous  dimensions,  and  cause  grave  symptoms  by 
their  pressure.  A  natural  cure  is  almost  impossible,  and  hence, 
if  unchecked  by  treatment,  a  fatal  termination  is  caused  by 
rupture  or  by  implication  of  important  neighbouring  structures. 
Frequently   one   portion    of    the    aneurysmal   wall    yields    more 


ANEURISM 


259 


than  another,  and  thus  to  the  fusiform  swelling  is  superadded  a 
localized  sacculation,  which  by  its  rapid  increase  in  size  may 
quickly  destroy  life 

2.  A  Sacculated  Aneurism  (Figs.  67  and  68,  B)  is  due  to  the 
yielding  of  some  weak  patch  in  the  vessel  wall  which  does  not 
involve  the  whole  circumference,  or,  as  just  mentioned,  it  may 
spring  from  a  fusiform  aneurism.  It  communicates  with  the 
interior  of  the  artery  by  an  opening  of  variable  size.  All  trau- 
matic aneurisms  are  of  this  type,  whether  they  are  due  to  the 
yielding  of  a  cicatrix,  or  to  the  partial  division  of  the  coats  of  the 
vessel,  and  hence  they  are  most  commonly  met  with  in  the  ex- 
tremities.    It  is  possible  that  in  some  very  early  specimens  all 


Fig.  68. — Diagrams  of  Fusiform,  Sacculated,  and  Dissecting 

Aneurisms. 

In  the  first  the  walls  are  expanded,  but  more  or  less  normal  in  texture  ;  in  the 
sacculated,  the  normal  structure  of  the  arterial  wall  ceases  abruptly  at  the 
commencement  of  the  saccule ;  in  the  dissecting,  the  arterial  wall  is  split 
into  two  lamellae. 

The  interrupted  fine  line  is  supposed  to  represent  the  intima ;  the  continuous 
dark  line,  the  media ;  and  the  continuous  fine  line,  the  adventitia. 

the  vascular  tunics  may  be  present,  but  such  an  occurrence 
must  be  extremely  rare.  Generally  one  can  trace  the  inner 
and  middle  coats  to  the  mouth  of  the  saccule,  and  there  they  are 
suddenly  lost,  the  wall  being  constituted  by  a  mass  of  ribro- 
cicatricial  tissue,  upon  which  laminated  fibrin  readily  forms,  thus 
increasing  its  thickness  and  power  of  resistance.  Their  progress 
is,  however,  much  more  rapid  than  that  of  the  fusiform,  and  they 
generally  rupture  or  become  diffuse,  although  occasionally  a 
natural  cure  results.  The  blood  as  it  enters  the  sac  impinges 
against  the  wall  furthest  removed  from  the  heart,  and  thence 
eddies  back  in  circles,  coagulation  being  thereby  favoured. 

3.  A  Dissecting  Aneurism  (Fig.  68,  C)  is  one  in  which  the  blood 

17 — 2 


260  A   MANUAL  OF  SURGERY 

forms  a  cavity  within  the  wall  of  the  vessel  by  stripping  up  the 
inner  from  the  outer  half,  the  line  of  cleavage  being  within  the 
middle  coat,  half  going  with  the  adventitia,  half  with  the  intima. 
It  is  usually  the  result  of  extensively  diffused  atheroma.  The 
blood  thus  driven  into  a  cul-de-sac  may  remain  limited  to  this 
cavity  for  some  time,  or  it  may  find  its  way  outwards,  and  become 
diffused,  or  burst  back  through  another  atheromatous  spot  into 
the  interior  of  the  vessel.  The  condition  occurs  chiefly  in  the 
thoracic  aorta,  but  cannot  be  recognised  ante-mortem. 

Symptoms  and  signs  of  a  Circumscribed  Aneurism. — These  may 
be  divided  into  two  groups  :  the  intrinsic  and  extrinsic. 

Intrinsic  Signs. — A  tumour,  pulsating  synchronously  with  the 
heart's  beat,  is  present  in  the  course  of  a  vessel.  The  pulsations 
are  distensile  or  expansile  in  character,  i.e.,  the  whole  tumour 
increases  in  size  at  each  systole,  and  that  evenly  in  all  directions, 
so  that  if  the  tumour  is  lightly  grasped  in  any  position  the  fingers 
are  separated.  If  the  supplying  vessel  is  compressed  on  the 
proximal  side,  the  pulsation  ceases,  and  the  tumour  diminishes 
in  size  and  becomes  softer  ;  this  is  more  marked  in  fusiform  than 
in  sacculated  aneurisms.  The  application  of  pressure  to  the  sac 
itself,  whilst  the  afferent  trunk  is  compressed  above,  will  still 
further  diminish  its  size.  On  removing  the  pressure,  the  swelling 
regains  its  old  dimensions  in  a  certain  definite  number  of  beats, 
usually  not  more  than  two  or  three.  Pressure  on  the  distal  side 
of  the  sac  makes  it  more  tense  and  the  pulsation  more  marked, 
unless  such  compression  is  very  prolonged.  On  auscultating  the 
tumour,  a  bruit  of  variable  character  may  be  heard.  Usually  it 
is  loud,  harsh,  and  systolic,  but  sometimes  quiet  and  musical.  It 
is  occasionally  double  in  some  forms  of  sacculated  aneurism,  and 
in  the  aorta  when  regurgitation  through  the  aortic  valves  is  also 
present.  The  bruit  is  loudest  and  most  rasping  in  the  fusiform 
variety,  and  may  be  absent  in  the  sacculated  form,  where  the 
mouth  is  small  and  the  cavity  nearly  full  of  clot.  Great  dis- 
tension of  the  sac  is  unfavourable  to  the  production  of  the  bruit. 

The  Extrinsic  Signs  of  aneurism  are  those  occurring  in  neigh- 
bouring or  distal  structures  from  its  constantly  increasing  size 
and  pressure,  and  the  interference  produced  by  it  with  the 
circulation.  The  pulse  in  the  vessels  below  is  diminished  and 
delayed,  its  diminution  being  caused  partly  by  the  obstruction 
experienced,  but  also  in  some  cases  by  the  pressure  of  the  sac 
upon  the  trunk  above  or  below  the  tumour.  The  delay  is  due  to 
the  interference  with  the  transmission  of  the  heart's  impulse  by 
the  intervention  of  the  aneurismal  sac.  The  dicrotic  notch  is 
usually  absent.  The  smaller  vessels  engaged  in  establishing 
collateral  circulation  may  be  compressed,  and  thus  the  vitality  of 
the  limb  considerably  impaired.  Pressure  on  the  accompanying 
vein  or  veins  results  in  diminution  of  their  calibre,  and  possibly  a 
localized  thrombosis,  together  with  congestion  and  cedema  distally, 


ANEURISM  261 


whilst  gangrene  may  be  the  final  outcome  if  the  case  is  not 
efficiently  treated.  Compression  of  nerves  occasions  neuralgia, 
spasm,  or  paralysis.  Muscles  are  displaced,  expanded,  and  attenu- 
ated ;  bones  may  be  eroded,  as  evidenced  by  a  deep,  constant, 
boring  pain,  and  even  spontaneous  fracture  may  ensue ;  whilst 
joints  are  encroached  upon  and  disorganized.  Tubes,  such  as  the 
trachea  or  oesophagus,  are  often  injuriously  constricted  and  laid 
open  by  ulceration.  It  is  an  interesting  fact  to  note  that  resisting 
tissues,  like  bone,  are  much  more  liable  to  be  eroded  than  elastic, 
yielding  structures,  such  as  cartilage,  and  in  cases  where  the 
vertebral  column  is  encroached  upon  by  an  abdominal  or  thoracic 
aneurism,  the  bones  always  manifest  greater  destructive  changes 
than  the  intervertebral  discs. 

The  increased  difficulty  in  propelling  the  blood  through  the 
sac  usually  induces  a  certain  amount  of  compensatory  hyper- 
trophy of  the  heart.  Emboli  consisting  of  fragments  of  fibrin 
occasionally  become  detached,  and  lead  either  to  a  spontaneous 
cure,  or  to  gangrene  of  the  parts  supplied  by  the  vessel,  or  to 
death  if  the  brain  is  involved.  Gangrene  may  also  be  induced  as 
a  result  of  the  diminished  blood  supply  to  peripheral  parts, 
especially  if  associated  with  interference  with  the  venous  return. 
It  is  usually  of  the  dry  type,  involving  merely  one  or  two  fingers 
or  toes  ;  but  when  attacking  more  fleshy  parts,  or  if  due  to  venous 
congestion,  it  is  moist  in  character. 

The  Differential  Diagnosis  of  a  circumscribed  aneurism  is  not 
difficult,  if  due  weight  is  given  to  the  above  symptoms  and  signs, 
but  the  following  conditions  may  simulate  it  somewhat  closely  : 
1.  A  tumour  or  chronic  abscess  situated  near  an  artery,  and  deriving 
transmitted  pulsation  from  it,  is  recognised  by  the  impulse  being 
merely  heaving  in  character,  and  not  expansile ;  by  the  pulsation 
ceasing  entirely  if  the  tumour  is  lifted  from  the  vessel,  or  allowed 
to  fall  away  from  it  by  assuming  a  suitable  position  ;  by  the  size 
of  the  tumour  not  diminishing  if  the  pulsation  is  stopped  by 
pressure  on  the  vessel  above ;  and  by  the  fact  that  after  stoppage 
of  the  pulsation  the  first  beat  is  equal  to  the  subsequent  ones, 
whereas  in  an  aneurism  it  almost  always  requires  more  than  one 
beat  to  re-establish  the  strength  and  force  of  the  impulse.  More- 
over, the  pulse  below  is  not  affected  in  the  same  way  or  to  the 
same  extent  as  when  an  aneurism  is  present.  2.  A  pulsating 
sarcoma  or  navus  is  known  by  being  rarely  limited  exactly  to  the 
line  of  the  artery,  pulsation  being  present  in  situations  where  an 
aneurismal  dilatation  could  not  be  felt,  and  being  less  forcible  and 
regular  in  its  character.  The  consistency  of  the  swelling  is  more 
variable,  and  pressure  over  the  afferent  trunk  does  not  diminish 
its  size  to  any  marked  extent.  Moreover,  a  sarcoma  is  usually 
more  adherent  to  the  deeper  structures,  and  its  limits  are  not  so 
accurately  defined.  3.  The  pain  caused  by  an  aneurism  may 
lead  it  to  be  mistaken  for  rheumatism  or  neuralgia  (e.g.,  for  sciatica 


262  A   MANUAL  OF  SURGERY 


in  popliteal  aneurism),  and  in  every  case  of  obstinate  pain  of  this 
kind  the  arteries  should  always  be  carefully  examined  with  the 
intention  of  eliminating  such  a  possible  cause  of  the  trouble. 

Natural  Terminations  and  Results. — i.  Spontaneous  Cure,  though 
of  unusual  occurrence,  may  arise  in  sacculated  aneurisms  from  a 
variety  of  circumstances,  and  is  a  well-recognised  phenomenon. 
(a)  It  may  be  due  to  the  gradual  deposit  within  the  sac  of  fibrin, 
which,  in  the  first  place,  limits  the  expansion  and  extension  of  the 
aneurism,  but  may  finally  increase  to  such  an  extent  as  to  cause 
obliteration  of  its  cavity.  Such  a  termination  can  only  occur  in 
saccules  with  small  mouths,  and  that  also  in  vessels  of  the  second 
magnitude,  hardly  ever  in  the  aorta  or  larger  trunks,  the  impetus 
of  the  blood  stream  being  too  great  to  permit  of  the  necessary 
deposit  of  fibrin,  (b)  It  may  arise  as  the  result  of  the  sudden 
coagulation  of  all  the  blood  in  the  sac  from  the  stoppage  of  the 
circulation,  owing  to  the  lodgment  of  an  embolus  either  at  the 
mouth  of  the  aneurism  or  in  the  trunk  immediately  below,  (c)  The 
aneurism  may  become  so  large  as  to  compress  the  main  vessel, 
either  going  to  or  coming  from  it,  thus  bringing  about  its  own 
cure,  (d)  Again,  if  the  sac  becomes  inflamed,  consolidation  may 
occur  with  or  without  suppuration,  although  the  latter  process,  as 
will  be  seen  anon,  is  attended  with  serious  danger  to  life  and  limb. 

In  the  non-inflammatory  conditions  the  sac  becomes  more  and 
more  firm,  the  pulsation  less  forcible  and  distinct,  the  bruit 
diminishes,  and  finally  consolidation  is  effected,  a  firm  fibroid 
tumour  alone  remaining,  which  gradually  shrinks,  whilst  the 
collateral  circulation  is  opened  up  so  as  to  supply  the  limb  below. 
It  is  sometimes  by  no  means  easy  to  recognise  the  fibroid  mass 
resulting  from  the  spontaneous  consolidation  of  an  aneurism,  and 
in  making  a  diagnosis  the  history  has  mainly  to  be  depended  on. 
The  existence  of  a  tumour  in  the  line  of  an  artery,  the  probable 
occlusion  of  the  main  trunk,  and  the  fact  that  the  circulation  is 
carried  on  by  means  of  collateral  branches,  are  the  chief  points 
which  can  be  ascertained  by  a  physical  examination. 

2.  Diffusion  and  Rupture  result  from  yielding  of  the  walls  of  an 
aneurism,  as  an  outcome  of  some  mechanical  injury  or  from  simple 
over-distension. 

When  an  internal  aneurism  gives  way,  the  patient  usually 
experiences  a  sensation  of  pain  in  the  part,  and  becomes  pale, 
cold,  and  faint,  possibly  dying  within  a  few  minutes  or,  at  most, 
hours ;  or  there  may  be  a  sudden  gush  of  blood  from  the  mouth 
if  the  trachea  or  oesophagus  has  been  opened.  Sometimes  internal 
aneurisms  leak  slowly,  and  the  final  stage  lasts  some  days. 

When  an  external  aneurism  yields,  it  may  do  so  slowly  or 
quickly.  If  the  blood  becomes  effused  slowly  (constituting  what 
is  sometimes  called  a  leaking  aneurism),  the  tumour  gradually 
increases  in  size,  and  its  outline  is  less  clearly  limited  ;  the  pulsa- 
tion diminishes  in  force  and  distinctness,  and  the  signs  of  pressure 


ANEURISM  263 


upon  the  veins  or  nerves  become  more  urgent,  until,  perhaps, 
gangrene  supervenes.  If  the  aneurism  ruptures  suddenly  the 
patient  experiences  severe  pain  in  the  part,  which  becomes  tense, 
swollen,  and  brawny  ;  all  pulsation  ceases,  both  in  the  aneurism 
and  below  it,  and  gangrene  of  the  limb  follows,  or  even  death  from 
syncope,  arising  from  the  amount  of  blood  extravasated,  either 
externally  if  the  skin  gives  way,  or  into  the  tissues  and  under  the 
fascia?.  Suppuration  may  also  occur  in  these  cases,  the  skin  be- 
coming red  and  inflamed,  and  finally  external  rupture  may  follow. 
In  the  absence  of  history  the  recognition  of  diffuse  aneurisms  is  by 
no  means  simple,  especially  when  they  become  inflamed,  and  then 
only  the  most  careful  attention  to  the  facts  to  be  made  out  by 
digital  examination  can  determine  the  nature  of  the  case. 

3.  Suppuration  is  an  exceedingly  serious,  but  by  no  means  a 
usual,  complication.  It  may  arise  in  the  following  ways  :  (a)  After 
ligature  of  the  main  vessel  above,  especially  when  the  wound 
becomes  septic,  and  there  is  a  good  deal  of  loose  cellular  tissue 
around  the  sac,  as  in  the  axilla  ;  (b)  after  diffusion,  partial  or 
complete,  of  an  aneurism,  where  there  is  great  tension  upon  sur- 
rounding parts.  Auto-infection  or  the  presence  of  an  infective 
embolus  may  finally  determine  the  suppurative  process.  The 
tumour  shows  signs  of  inflammation,  becoming  hot,  red,  painful, 
and  swollen,  and  the  skin  over  it  may  pit  on  pressure  ;  whilst  fever 
and  general  constitutional  disturbance  are  also  present.  Sooner 
or  later,  if  left  to  itself,  the  tumour  points  at  one  spot  and  bursts, 
giving  exit  to  a  mixture  of  blood  clot,  pus,  and  a  greater  or  less 
amount  of  bright  red  blood.  The  patient  either  dies  at  once  from 
syncope,  or  a  little  later  from  secondary  haemorrhage  and  septic 
poisoning,  unless  efficient  treatment  is  adopted.  Occasionally,  but 
very  rarely,  the  afferent  trunk  becomes  plugged  by  a  thrombus, 
and  spontaneous  cure  may  thereby  be  induced. 

Treatment  of  Aneurisms. 

I.  General  Treatment  is  employed  as  an  accessory  to  surgical 
measures,  or  must  be  depended  on  entirely  in  cases  where  local 
means  are  impracticable  or  contra-indicated,  such  as  in  internal 
aneurisms  ;  it  is  then  to  be  looked  on  rather  as  palliative  in  nature 
than  curative.  The  general  condition  of  the  patient  must  be  care- 
fully investigated,  since  aneurisms  are  associated  either  with 
plethora  or  with  an  enfeebled  and  cachectic  state  of  the  system. 

In  plethoric  individuals,  where  the  disease  often  runs  a  rapid 
course,  absolute  rest,  both  mental  and  physical,  must  be  enjoined, 
with  the  removal  of  all  sources  of  irritation  and  worry.  The 
bowels  are  freely  opened  by  a  calomel  purge  at  the  commencement 
of  treatment,  and  watery  stools  should  be  subsequently  induced 
by  20  grain  doses  of  pulv.  jalapae  co.  two  or  three  times  a  week, 
so  as  to  increase  the  plasticity  of  the  blood.     The  heart's  impulse 


264  A   MANUAL  OF  SURGERY 

may  be  diminished  by  the  use  of  aconite,  or  even  by  venesection 
when  it  is  very  forcible.  Iodide  of  potassium  is  useful  both  for 
reducing  blood-pressure  and  in  cases  where  a  syphilitic  history  is 
present.  The  diet  must  be  diminished,  all  stimulating  articles 
being  eliminated,  and  only  highly  nutritious  material  allowed, 
and  that  mainly  of  the  nitrogenous  type,  with  as  little  fluid  as 
possible.  Various  special  methods,  £.g\,Tufnell's,  Valsalva's,  etc., 
have  been  recommended,  but  it  usually  suffices  to  limit  the  dietary 
as  much  as  is  in  conformity  with  the  patient's  comfort  and  well- 
being,  and  not  to  allow  more  than  about  a  pint  of  fluid  in 
the  day. 

In  weakly  individuals,  whilst  enjoining  strictly  a  recumbent 
posture,  the  surgeon  should  prescribe  iron  and  a  somewhat  more 
liberal  diet,  in  order  to  improve  the  quality  of  the  blood. 

II.  Surgical  Treatment. — Whichever  of  the  plans  described 
below  is  selected  in  any  particular  case,  the  general  health  must 
be  carefully  attended  to,  and  the  condition  of  internal  organs  fully 
investigated  beforehand,  as  great  harm  may  follow  injudicious 
interference,  if  internal  aneurisms  co-exist. 

i.  Compression  may  be  continuous  or  intermittent.  If  inter- 
mittent, it  is  applied  over  the  main  vessel  leading  to  the  aneurism 
by  means  of  fingers  (digital  compression),  or  by  mechanical  con- 
trivances, for  as  long  a  period  as  the  patient  can  bear,  which 
usually  does  not  exceed  thirty  minutes,  especially  if  there  is  any 
nerve  in  the  immediate  neighbourhood.  There  seems  to  be  no 
necessity  to  completely  arrest  the  flow  of  blood  through  the  sac, 
so  long  as  the  blood-pressure  is  sufficiently  diminished  to  permit 
of  coagulation  within  it.  Continuous  pressure  can,  as  a  rule,  only 
be  maintained  under  an  anaesthetic,  and  in  such  cases  the  circula- 
tion through  the  sac  is  entirely  stopped,  so  as  to  allow  not  only  of 
its  contraction,  but  also  in  some  instances  of  the  rapid  coagulation 
of  its  contents.  Such  pressure  may  be  effected  by  the  fingers  of 
relays  of  dressers,  taking  shifts  of  ten  to  fifteen  minutes  at  a  time  ; 
but  inasmuch  as  this  is  excessively  tiring  and  difficult  to  maintain 
efficiently,  arrangements  should  be  made  whereby  some  weight, 
such  as  a  conical  shot-bag,  rests  upon  the  thumb  or  finger  em- 
ployed, thereby  relieving  muscular  strain.  Tourniquets  may  be 
similarly  utilized,  but  are  less  satisfactory,  since  they  require 
more  skilful  and  accurate  adaptation,  and  are  liable  not  only  to 
slip  out  of  place,  but  also  to  bruise  the  coats  of  the  vessels.  The 
best  appliance  of  this  nature  is  probably  Petit's  tourniquet. 
Esmarch's  elastic  bandage  has  been  used  with  success,  principally 
for  aneurisms  of  the  lower  extremities,  notably  the  popliteal. 
The  limb  is  first  elevated  for  some  moments,  and  then  the  elastic 
bandage  applied  from  the  toes  to  the  upper  part  of  the  limb, 
passing  loosely  over  the  aneurism.  An  indiarubber  tourniquet 
is  then  placed  round  the  thigh,  so  as  to  arrest  the  circulation 
completely  (Reid's  method).     The  limb  has  in  this  way  been  left 


ANEURISM  265 


bloodless  for  an  hour  and  a  half,  but  we  cannot  recommend  the 
proceeding. 

Although  in  suitable  cases  compression  certainly  has  been 
successful,  especially  in  the  hands  of  the  Dublin  surgeons,  and 
may  be  given  a  trial  before  ligature,  yet  it  is  unwise  to  per- 
severe with  it  for  too  long  if  signs  of  improvement  are  not  quickly 
observed,  lest  the  collateral  circulation  be  increased  to  an  unde- 
sirable extent,  and  the  success  of  the  subsequent  operation 
jeopardized.  Especially  is  this  the  case  in  plethoric  individuals 
with  high  arterial  tension.  On  the  other  hand,  in  feeble,  weakly 
patients,  where  gangrene  of  the  limb  might  be  anticipated,  the 
opening  up  of  the  collateral  circulation  by  compression,  even  if 
the  aneurism  is  not  thereby  cured,  is  by  no  means  a  disadvantage. 

Necessarily  the  part  of  the  skin  to  which  pressure  is  applied 
must  be  carefully  protected  from  local  irritation  by  shaving  and 
removal  of  hairs,  by  the  use  of  dry  aseptic  dusting-powders,  and 
by  the  surface  of  any  pad  employed  being  perfectly  smooth,  and 
the  skin  not  wrinkled  beneath  it. 

2.  Ligature  of  the  main  vessels  leading  to  or  coming  from  the 
aneurismal  sac  must  next  be  considered.  The  oldest  procedure, 
the  Operation  of  Antyllus,  consisted  in  laying  open  the  sac, 
turning  out  the  clots,  securing  the  vessel  above -and  below,  and 
allowing  the  wound  to  heal  by  granulation  (Fig.  69,  A).  Per- 
formed, as  it  was  originally,  without  anaesthetics  or  antiseptics, 
it  was  naturally  attended  with  great  mortality,  since,  even  if 
secondary  haemorrhage  did  not  occur  from  the  main  trunk,  it  was 
liable  to  follow  from  any  of  the  branches  which  arose  from  the 
dilated  portion  of  the  vessel. 

In  Anel's  Method  (Fig.  69,  B)  the  artery  was  tied  just  above 
the  sac  on  the  cardiac  side,  with  no  branch  intervening ;  this  also 
proved  dangerous,  since  secondary  haemorrhage  frequently  re- 
sulted, either  from  suppuration  within  the  sac,  or  from  injury  to 
the  sac  during  the  operation,  or  from  yielding  of  the  arterial  wall 
at  the  site  of  ligature  from  septic  periarteritis. 

Hunter's  Operation  (Fig.  69,  C),  which  consists  of  ligature  of 
the  main  vessel  on  the  cardiac  side  at  some  distance  from  the 
aneurism,  was  first  performed  by  him  in  1785.  The  object  to 
be  attained  is  not  to  absolutely  cut  off  the  blood-supply  to  the 
sac,  but  to  allow  the  blood  to  enter  it  with  a  greatly  diminished 
impulse,  and  in  small  amount  at  first,  thus  permitting  of  the 
contraction  of  the  sac  wall  and  of  the  gradual  deposit  of  fibrinous 
clot  within  it.  The  sac  thus  becomes  consolidated,  and  finally 
transformed  into  a  mass  of  firm  fibroid  tissue.  The  operation  is 
most  likely  to  succeed  in  cases  where  the  aneurism  is  well  defined 
and  not  large  enough  to  exercise  injurious  pressure  on  surround- 
ing parts,  whilst  it  is  desirable,  though  not  essential,  that  no 
branch  of  large  size  should  intervene  between  the  point  of  ligature 
and  the  sac.     The  operation  is  contra-indicated  (1)  in  cases  where 


266 


A   MANUAL  OF  SURGERY 


serious  cardiac  disease  co-exists,  or  when  an  internal  aneurism  is 
also  present,  rendering  undesirable  any  sudden  increase  of  the 
blood-pressure,  as  by  occlusion  of  a  main  vessel ;  (2)  where 
pressure  over  the  vessel  does  not  control  the  circulation  through 
the  sac  ;  (3)  where  the  peripheral  vessels  are  extensively  calcified  ; 

(4)  where  gangrene  of  the  limb  is  threatening  or  present ;    or 

(5)  where  bones  or  joints  have  been  seriously  involved. 

Distal  Ligature  is  only  practised  for  aneurisms  situated  in 
positions  where  it  is  impractible  to  deal  with  the  artery  on  the 
cardiac  side  of  the  sac,  such  as  the  innominate,  lower  part  of 
the  carotid,  or  first  part  of  the  subclavian.  Brasdor's  Operation 
consists  in  tying  the  main  trunk  beyond  the  sac,  so  as  to  totally 
cut   off  the  circulation  through  it  (Fig.  69,  D).     In  Wardrop's 


Fig.  69. — Methods  of  applying  Ligatures  for  Aneurisms. 

A,  Method  of  Antyllus  ;  B,  Anel's  operation  ;   C,  the  Hunterian  operation  ; 
D,  Brasdor's  operation  ;  E,  Wardrop's  method. 

Operation  a  ligature  is  placed  on  one  or  more  of  the  distal  branches 
(Fig.  69,  E).  In  the  former  the  sac  gradually  contracts,  and 
thus  allows  of  the  deposit  of  fibrin  ;  in  the  latter  proceeding, 
where  the  circulation  is  only  partially  controlled,  the  diminution 
of  the  size  of  the  aneurism  goes  on  much  more  slowly,  and  the 
chances  of  the  deposition  of  clot  in  the  sac  are  correspondingly 
lessened. 

It  is  not  unusual,  after  the  application  of  a  ligature  to  a  main 
artery  for  aneurism,  to  observe  a  return  of  pulsation  in  the  sac 
after  a  few  days.  In  the  majority  of  cases  this  only  continues  for 
a  short  time,  and  is  by  no  means  an  unfavourable  sign,  indicating 
the  re-establishment  of  the  collateral  circulation  ;  but  if  it  com- 
mences a  week  or  ten  days  after  the  operation,  it  is  more  likely 
to  persist.  It  is  most  frequently  seen  in  cases  where  the  main 
vessel  has  been  tied  at   some  distance  from  the  sac,  as  in  the 


ANEURISM  267 


superficial  femoral  for  popliteal  aneurism,  and  where  one  or  more 
large  and  important  collateral  branches  carry  blood  into  the 
artery  below  the  ligature  or  directly  into  the  sac.  The  early 
recurrence  of  pulsation  needs  no  treatment  in  most  instances,  since 
it  disappears  spontaneously  ;  but  when  it  comes  on  at  a  later 
stage,  it  demands  serious  attention.  Rest,  elevation  of  the  limb 
and  judicious  pressure  over  the  trunk  above  the  site  of  ligature, 
should  first  be  tried.  These  failing,  the  following  courses  are 
open  :  (a)  The  artery  may  be  again  tied,  either  nearer  the  sac 
when  feasible,  or  further  away  from  it ;  (b)  where  the  aneurism 
can  be  reached,  it  may  be  cut  down  on  and  dissected  out,  the  best 
course  to  adopt  if  it  be  practicable  ;  or  (c)  amputation  just  above 
the  aneurism  may  be  called  for  as  a  last  resource,  when  the  tumour 
is  rapidly  increasing  or  threatening  to  become  diffuse,  or  if  gan- 
grene is  impending. 

3.  Complete  Extirpation  of  the  aneurismal  sac  may  be  looked 
on  as  the  best  and  most  satisfactory  method  of  treatment.  The 
sac  is  thus  dealt  with  as  if  it  were  a  tumour,  although,  owing  to 
the  adhesions  always  present,  complete  separation  of  the  wall 
from  surrounding  parts  is  often  difficult.  The  limb  is  exsan- 
guinated by  elevation,  and  in  suitable  cases  the  aneurism  is 
removed  without  opening  it,  and  the  vessel  secured  by  ligature 
above  and  below,  as  also  any  branches  which  may  arise  from  it. 
When,  however,  a  large  saccule  obscures  the  main  trunk,  it  may 
be  necessary  to  open  it  and  turn  out  its  contents  before  attempting 
its  extirpation.  Not  unfrequently  the  vein  will  be  encroached  on 
in  this  dissection,  and  it  may  have  to  be  removed ;  bad  results  are 
not  likely  to  follow,  since  probably  its  lumen  has  been  already 
diminished  by  the  pressure  of  the  sac,  and  an  efficient  collateral 
venous  circulation  established.  This  method  has  hitherto  been 
chiefly  applied  to  small  aneurisms  of  the  peripheral  vessels,  and, 
indeed,  in  the  majority  of  such  cases  no  other  plan  need  be  con- 
sidered ;  surgeons  are  now,  however,  extending  its  scope  to  the 
larger  trunks,  such  as  the  popliteal,  carotid,  external  iliac  and 
subclavian,  from  each  of  which  aneurisms  have  been  successfully 
extirpated,  whilst  as  far  back  as  1883  one  of  us  removed  in  this 
way  a  recurrent  femoral  aneurism,  involving  the  vein,  with  a  good 
result.'1  It  is  also  attempted  as  an  alternative  to  amputation  for 
recurrent,  diffused,  and  suppurating  aneurisms.  The  results  of 
this  operation  which  have  been  recently  recorded  are  most 
encouraging  :  primary  union  of  the  wound  is  often  obtained,  and 
hence  the  length  of  treatment  is  curtailed,  whilst  all  chances  of 
recurrence  are  removed.  Statistics  also  show  that  there  is  less 
danger  of  gangrene,  and  this  depends,  as  Pearce  Gould  has 
pointed  out,  on  the  fact  that  only  one  set  of  collateral  circulation 
is  called  upon,  viz.,  that  required  to  bridge  the  gap  made  by 
removing  the  aneurism,  whereas  in  the   Hunterian  operation  a 

*  Lancet,  1883,  ii.,  p.  1082. 


268  A  MANUAL  OF  SURGERY 

double  set  is  needed,  viz.,  at  the  site  of  the  ligature,  and  round 
the  consolidated  aneurism.  It  is  obvious  that  the  nutrition  of 
the  limb  is  best  secured  when  what  Gould  calls  the  '  irreducible 
minimum  '  of  operative  treatment,  viz.,  the  occlusion  of  the  vessel 
only  at  the  site  of  the  aneurism,  is  undertaken.  Secondary 
haemorrhage  is  also  less  likely  to  occur. 

4.  Electrolysis  has  been  occasionally  employed  in  dealing  with 
thoracic  aneurisms  when  a  saccule  has  developed  in  an  accessible 
position.  The  clot  thus  formed  is  soft  and  liable  to  break  up, 
and  the  results  have  not  been  very  satisfactory.  For  details  of 
the  methods  of  employing  electrolysis,  see  p.  309. 

5.  The  Introduction  of  Foreign  Bodies  into  the  Sac  (Moore's 
Method)  has  not  been  followed  by  much  success,  although  a  few 
cases  of  abdominal  aneurism  seem  to  have  derived  temporary 
benefit  from  it.  Steel  wire  has  been  usually  employed  ;  it  is 
firmly  wound  round  a  cotton  reel  to  give  it  a  spiral  coil,  and 
inserted  into  the  sac  through  a  very  fine  cannula.  Varying 
lengths  from  10  feet  to  26  yards  have  been  introduced. 

6.  The  combination  of  the  last  two  methods  (as  originally 
suggested  and  practised  by  an  Italian,  Corradi,  in  1879)  has  been 
attended  by  some  very  happy  results,  especially  in  the  hands  of 
Stewart  of  Philadelphia."  He  introduces  a  variable  length  of 
gold  or  silver  wire  (No.  30  gauge),  preferably  the  former,  through 
a  small  cannula,  and  then  electrolyses  through  the  wire  which  is 
attached  to  the  positive  electrode,  whilst  the  negative  electrode  is 
placed  on  the  back.  The  current  is  gradually  increased  up  to 
60  or  80  milliamperes,  and  the  whole  proceeding  lasts  about 
thirty  minutes.  Finally,  the  wire  is  cut  short  and  pushed  into 
the  sac.  Several  most  brilliant  results  have  followed  this  plan 
of  treatment,  including  the  cure  of  an  innominate  aneurism,  the 
patient  living  for  three  and  a  half  years,  and  of  an  aneurism  of 
the  abdominal  aorta,  dealt  with  by  transperitoneal  operation. 
We  ourselves  have  treated  a  subclavian  aneurism  in  this  way 
with  considerable  temporary  benefit. 

7.  Acupuncture  has  been  occasionally  tried  for  many  years,  but 
without  much  advantage.  Macewen,  however,  has  again  drawn 
attention  to  the  method,  and  suggested  some  modifications  in  the 
technique.  He  passes  fine  needles  into  the  interior  of  the  sac, 
and  leaves  them  for  a  time  to  be  played  upon  by  the  blood- 
stream, so  as  to  scratch  and  irritate  the  posterior  wall,  and  thus 
cause  inflammatory  thickening.  The  principle  involved  is  entirely 
at  variance  with  all  the  other  methods  of  cure ;  in  these  an 
attempt  is  made  to  fill  the  sac  with  blood  clot,  which  is  subse- 
quently organized  ;  Macewen  looks  on  blood  clot  as  undesirable 
material  to  work  with,  and  directs  his  attention  to  thickening  the 
walls  to  such  an  extent  as  to  occlude  the  sac  or  to  prevent  subse- 

*  British  Medical  journal,  August  14,  1897  '•  Philadelphia  Medical  Journal, 
June  25,  1898. 


ANEURISM  269 


quent  dilatation.  In  his  own  hands  excellent  results  have  been 
obtained  ;  but  whilst  admitting  its  value  for  internal  aneurisms, 
we  cannot  but  think  that  for  those  involving  peripheral  vessels 
other  methods  would  be  more  rapid  and  equally  effective. 

8.  Amputation  may  be  required  in  the  treatment  of  aneurisms 
under  a  variety  of  circumstances  :  (a)  When  gangrene  of  the  limb 
has  occurred  or  is  imminent ;  (b)  for  diffusion  or  suppuration  of 
an  aneurism  when  everything  else  has  failed ;  (c)  for  secondary 
haemorrhage  as  a  last  resource  ;  (d)  in  some  cases  of  recurrent 
aneurism  ;  (e)  when  joints  have  been  opened  or  bones  eroded  to 
such  an  extent  as  to  impair  the  utility  of  the  limb ;  and,  finally, 
(/)  in  a  few  cases  of  subclavian  aneurism  amputation  at  the 
shoulder-joint  has  been  practised  in  order  to  diminish  the  amount 
of  blood  flowing  through  the  sac. 

The  Treatment  of  a  Diffuse  Aneurism  varies  somewhat  according 
to  whether  the  diffusion  is  slow  or  rapid.  In  the  leaking  aneurism, 
which  increases  in  size  somewhat  slowly,  the  main  vessel  leading 
to  the  swelling  may  be  tied,  if  this  has  not  already  been  under- 
taken, and  the  influence  of  this  measure,  combined  with  rest, 
elevation,  and  careful  general  treatment,  observed.  Should  the 
process  not  be  stayed,  the  case  is  treated  as  a  diffuse  or  ruptured 
aneurism  by  laying  open  the  sac,  after  exsanguinating  the  limb  by 
elevation  and  the  use  of  an  elastic  band,  and  securing,  if  possible, 
the  main  vessel  above  and  below,  as  also  any  branches  which  may 
open  into  the  sac,  if  they  can  be  found.  If  there  is  any  evidence 
of  incipient  gangrene,  or  if  secondary  haemorrhage  supervenes, 
amputation  must  be  undertaken.  In  such  cases  everything  will 
depend  on  the  efficient  maintenance  of  asepsis. 

The  Treatment  of  an  Inflamed  Aneurism  is  always  a  matter  of 
anxiety  from  the  risk  of  recurrent  and  fatal  haemorrhage.  If  the 
artery  above  the  aneurism  has  not  been  previously  ligatured,  it  would 
certainly  be  correct  practice  to  tie  it,  and  watch  the  effect  produced 
by  that  measure,  together  with  rest,  elevation,  and  the  local 
application  of  an  icebag.  If  the  inflammatory  symptoms  still 
continue,  the  aneurism  should  be  laid  freely  open  after  applying 
an  elastic  tourniquet,  the  coagula  turned  out,  and  the  main  trunk 
secured  above  and  below.  If  bleeding  still  continues  from  smaller 
branches  opening  into  the  sac,  the  cavity  is  carefully  plugged  with 
strips  of  aseptic  gauze,  but  a  strict  watch  must  be  kept  over  the 
case,  for  fear  of  a  return  of  the  bleeding.  Should  this  happen,  or 
should  gangrene  threaten,  amputation  alone  remains.  //  the  main 
vessel  of  supply  has  been  previously  tied,  the  sac  should  still  be  laid  open 
and  cleared  of  coagula,  all  bleeding  points  secured  if  possible,  and 
the  cavity  stuffed  ;  amputation  is,  however,  likely  to  be  required. 


270  A  MANUAL  OF  SURGERY 


Special  Aneurisms. 

Aneurism  of  the  Thoracic  Aorta  is  dealt  with  rather  in  medical 
than  in  surgical  text-books ;  it  is,  however,  of  such  importance  as 
to  demand  a  short  notice  here.  Any  part  of  the  thoracic  aorta 
may  be  affected,  and  the  symptoms  arising  therefrom  are  very 
variable.  The  fusiform  type  is  most  commonly  met  with  in  the 
early  stages,  a  limited  sacculation  often  supervening  as  the  disease 
advances.  In  the  ascending  part  of  the  arch  the  swelling  rarely 
reaches  a  great  size,  especially  if  it  is  intra-pericardial,  the  sac 
usually  rupturing  before  marked  pressure  signs  are  evident. 
When  arising  from  the  transverse  part  of  the  arch,  the  symptoms 
vary  with  the  direction  taken  by  the  enlargement.  If  it  projects 
upwards,  a  pulsating  tumour  may  appear  at  the  episternal  notch, 
and  cerebral  effects  may  then  ensue  from  interference  with  the 
circulation  through  the  carotids,  or  from  pressure  on  the  venous 
trunks.  If  it  extends  anteriorly,  it  may  form  a  large  tumour  with 
comparatively  slight  pressure  effects,  except  the  pain  arising  from 
its  erosion  of  the  thoracic  wall ;  it  then  appears  as  a  pulsating 
swelling  to  the  right  of  the  sternum.  If  the  enlargement  takes 
place  either  posteriorly  or  downwards  within  the  concavity  of  the 
arch,  symptoms  in  the  shape  of  dyspnoea  and  dysphagia  are  early 
produced  from  the  close  contiguity  of  the  trachea,  oesophagus, 
and  pulmonary  vessels.  Dyspnoea  may  also  be  due  to  pressure 
upon  the  left  recurrent  laryngeal  nerve,  causing  paresis  of  the 
crico-arytenoideus  posticus  muscle  and  difficulty  in  opening  the 
glottis  ;  the  voice,  moreover,  becomes  harsh  and  the  cough  hard, 
with  what  has  been  described  as  a  '  metallic  ring '  about  it,  which 
is  extremely  characteristic.  Laryngeal  or  tracheal  stridor  may 
be  noticed  in  these  cases,  and  a  dragging  of  the  trachea  synchronous 
with  the  heart's  action  (the  so-called  'tracheal  tug'). 

Aneurisms  of  the  descending  arch  and  thoracic  aorta  often  attain 
considerable  dimensions,  and  may  project  posteriorly  to  the  left 
of  the  vertebral  column,  causing  a  pulsating  swelling.  The  only 
prominent  symptoms  are  pain  due  to  erosion  of  ribs  or  vertebrae 
and  interference  with  deglutition,  which  may  be  so  great  as  to 
suggest  the  presence  of  an  oesophageal  constriction  ;  in  fact,  before 
a  bougie  is  passed  in  any  case  of  dysphagia,  it  is  always  advisable 
to  make  certain,  if  possible,  that  an  aneurism  is  not  present. 
Auscultation  in  the  left  vertebral  groove  may  reveal  the  existence 
of  a  systolic  bruit  where  such  a  condition  exists. 

Treatment.  —  Little  can  be  done  beyond  ordinary  medical 
measures,  such  as  rest,  diet,  and  the  administration  of  iodide  of 
potassium.  Where  the  tumour  could  be  felt  in  front,  the  intro- 
duction of  coils  of  iron  wire  or  horsehair  has  been  attempted,  and 
in  one  or  two  cases  with  partial  or  temporary  success  ;  whilst 
Stewart's  method  of  electrolysis  and  Macewen's  plan  of  acupunc- 
ture have  been   used  with  some  benefit  for  supposed  cases  of 


ANEURISM  271 


sacculated  aneurism.  Dyspnoea  may  be  at  times  severe,  but 
tracheotomy  should  never  be  undertaken,  death  seldom  resulting 
from  this  cause. 

Surgical  treatment,  such  as  ligature  of  the  right  carotid  and  right 
subclavian,  or  of  the  left  carotid  alone,  has  been  adopted  in  cases 
of  aneurism  of  the  ascending  aorta  or  of  the  arch.  A  certain 
amount  of  improvement  has  followed  some  of  the  operations,  but 
of  eleven  cases  reported  by  Kiister  five  died  within  the  first  ten 
days.  The  principles  underlying  such  proceedings  are  certainly 
at  variance  with  those  guiding  our  usual  treatment  of  an  aneurism, 
and  it  is  quite  possible  that  the  improvement  was  as  much  due  to 
the  enforced  rest  in  bed  as  to  the  operation.  Of  course,  if  the 
lower  end  of  the  carotid  is  involved  in  the  aneuiismal  swelling, 
distal  ligature  may  do  some  good,  as  in  a  case  of  our  own,"  where 
the  left  carotid  and  subclavian  were  tied,  with  a  short  interval 
between  the  operations.  The  patient's  condition  improved  greatly 
for  a  time,  and  she  was  able  to  return  to  work,  but  the  aneurism 
finally  burst  into  the  left  pleura  about  three  years  after  the  first 
operation. 

Innominate  Aneurism  is  usually  of  the  tubular  variety,  and 
frequently  associated  with  a  similar  enlargement  of  the  aorta.  It 
presents  a  pulsating  tumour  behind  the  right  sterno-clavicular 
articulation — i.e.,  between  the  heads  of  origin  of  the  sterno-mastoid 
— projecting  either  into  the  episternal  notch  or  outwards  into  the 
subclavian  triangle,  and  perhaps  pushing  the  clavicle  forwards. 
The  effects  produced  by  its  pressure  are  very  variable.  The  pulse 
in  both  the  right  temporal  and  radial  arteries  is  diminished ; 
oedema  of  a  brawny  character  of  the  right  side  of  the  head  and 
neck,  and  of  the  right  arm,  is  caused  by  pressure  on  the  right 
innominate  vein,  whilst  less  commonly  similar  changes  on  the  left 
side  may  follow  compression  of  the  left  vein  or  of  the  superior  vena 
cava  ;  pain  shooting  into  the  neck  and  arm  is  often  a  marked 
symptom,  arising  from  implication  of  the  cervical  and  brachial 
nerves,  whilst  hyperemia  of  the  right  side  of  the  face  and  dilata- 
tion of  the  right  pupil  may  result  from  irritation  of  the  sympathetic 
trunk.  Dyspnoea  is  induced  by  direct  pressure  on  the  trachea, 
which  may  be  displaced  or  flattened,  or  by  irritation  of  the  right 
recurrent  laryngeal  nerve,  causing  partial  or  complete  paralysis 
of  the  right  vocal  cord.  Dysphagia  occurs  from  pressure  on  the 
oesophagus. 

The  course  of  the  case  is  slowly  progressive,  and  death  most 
commonly  results  from  asphyxia  or  from  rupture  of  the  sac. 

Treatment. — Rest  and  the  administration  of  large  doses  of 
iodide  of  potassium  may  cause  improvement,  but  distal  ligature  is 
the  most  hopeful  proceeding.  It  is  obviously  impossible  to  cut 
off  all  the  blood  passing  through  the  sac  to  the  three  main  divisions 
— viz.,  the  carotid,  subclavian,  and  vertebral — with  safety  to  the 

*  British  Medical  Journal,  December  3,  1898. 


272 


A  MANUAL  OF  SURGERY 


patient  (Fig.  70).     Ligature  of  any  one  of  these  alone  offers  but 
little  prospect  of  improvement  ;  thus,  the  only  case  benefited  by 

ligature  of  the  subclavian  was 
one  treated  by  Wardrop,  in 
which  the  carotid  also  had  been 
independently  and  by  accident 
blocked  ;  whilst  the  only  cure 
recorded  after  tying  the  carotid 
was  probably  due  to  subse- 
quent suppuration  within  the 
sac  (Evans).  Ligature  of  both 
carotid  and  subclavian,  with  an 
interval  of  more  than  a  week 
between  the  two  operations, 
has  practically  the  same  effect 
as  a  single  ligature,  for  by  that 
time  the  collateral  circulation 

Fig.  7o-Application   of  Ligatures    ™U     have,    bef„   established. 

for  Innominate  Aneurism.    (After     1  he  _  results     following     such 

Erichsen.)  practice  are  better  than  those 

IA,    innominate    aneurism;    S,    sub-    gained     by     ligating     a     single 

clavian  artery  ;  C,  carotid  ;  V,  vertebral    vessel,  but  not  SO  good  as  those 

artei7-  from  tying  both  vessels  at  the 

same  time.  Simultaneous  liga- 
ture is  doubtless  the  best  plan  of  treatment  to  adopt ;  it  places 
the  sac  in  the  best  possible  condition  for  the  deposit  of  fibrin, 
whilst  the  additional  step  of  tying  the  third  part  of  the  subclavian 
does  not  materially  add  to  the  risk  of  the  operation,  which  is 
mainly  due  to  the  effect  on  the  cerebral  circulation.  Should 
operative  measures  seem  undesirable,  recourse  must  be  had  to 
Stewart's  or  Macewen's  methods. 

Aneurism  of  the  Common  Carotid  is  usually  situated  at  the 
upper  part  of  the  trunk  near  the  bifurcation,  and  more  often  on 
the  right  than  on  the  left  side.  The  root  of  the  right  carotid  as  it 
springs  from  the  innominate  is  also  not  unfrequently  dilated,  but 
the  intra-thoracic  portion  of  the  left  carotid  is  rarely  affected, 
except  in  conjunction  with  aneurism  of  the  aorta.  No  other 
external  vessel  is  so  frequently  the  seat  of  aneurism  in  women. 

The  ordinary  intrinsic  signs  of  an  aneurism  are  present,  and  the 
pressure  symptoms  are  mainly  referable  to  interference  with  the 
cerebral  circulation,  to  irritation  of  the  cervical  sympathetic  trunk, 
or  to  pressure  upon  the  larynx,  pharynx,  or  trachea.  The  progress 
of  these  cases  is  usually  slow. 

Diagnosis. — (1)  From  similar  disease  at  the  root  of  the  neck  the  dis- 
tinction is  often  made  with  difficulty,  since  either  an  aortic, 
innominate,  or  subclavian  aneurism  may  push  upwards  so  as 
to  simulate  it  somewhat  closely.  Percussion  and  auscultation  of 
the  upper  part  of  the  chest,  together  with  a  careful  investigation 


ANEURISM  273 


into  the  history  of  the  case,  and  a  digital  examination  of  the  limits 
of  the  pulsating  mass,  may  suffice  to  determine  the  point.  Holmes 
suggests  trying  the  effect  of  carefully  applied  distal  pressure  for  a 
few  hours  ;  in  a  carotid  aneurism  the  tension  becomes  distinctly 
less  as  the  collateral  circulation  commences  to  enlarge,  whilst 
in  an  aortic  aneurism  no  difference  is  observed.  The  pressure 
effects  must  also  be  carefully  considered.  '  Pressure  on  the  left 
recurrent  laryngeal  nerve  would  distinguish  an  aortic  aneurism 
from  one  on  the  right  vessels  ;  pressure  on  the  right  nerve  in  like 
manner  excludes  an  aortic  aneurism.  Pressure  on  the  left  innom- 
inate vein  indicates  aortic  aneurism  rather  than  innominate  ;  com- 
pression of  the  internal  jugular  or  subclavian  vein  only  points  to 
carotid  or  subclavian  aneurism.  A  "  tracheal  tug  "  indicates  an 
aneurism  of  the  aorta'  (P.  Gould).  The  differences  in  the  peri- 
pheral pulses  may  also  give  useful  information.  The  two  radial 
pulses  should  be  first  examined  ;  if  they  are  equally  affected,  an 
aneurism  of  the  aorta  on  the  cardiac  side  of  the  innominate  is 
indicated  ;  if  they  are  equal  and  normal,  an  aneurism  on  the  distal 
side  of  the  origin  of  the  left  subclavian.  If  the  left  radial  pulse  is 
alone  aneurismal,  the  root  of  the  left  subclavian  is  diseased,  whilst 
if  the  left  temporal  is  also  affected,  it  suggests  an  aneurism  of  the 
transverse  part  of  the  arch  beyond  the  innominate.  When  both 
radial  and  temporal  vessels  on  the  right  side  show  signs  of  inter- 
ference with  the  pulse,  innominate  aneurism  is  probably  present, 
whilst  an  affection  of  only  one  of  these  branches  indicates  that  the 
corresponding  carotid  or  subclavian  is  dilated.  One  source  of 
fallacy  must  not  be  forgotten,  viz.,  that  any  one  of  these  trunks 
may  be  occluded  or  compressed  by  a  neighbouring  aneurism  with- 
out being  dilated,  and  hence  the  quality  of  the  pulse  must  be 
taken  into  consideration  rather  than  its  actual  volume,  and  to  this 
end  the  sphygmograph  is  a  useful  adjunct  in  diagnosis.  (2)  From 
abscess,  tumours,  or  enlarged  glands  with  a  transmitted  impulse,  a 
carotid  aneurism  is  recognised  by  an  application  of  the  general 
principles  detailed  above  (p.  261).  (3)  Pulsating  or  cystic  goitre 
may  be  distinguished  from  a  carotid  aneurism  by  noting  that  the 
goitre  is  not,  as  a  rule,  limited  to  one  side  of  the  neck,  the  isthmus 
being  also  involved ;  that  the  most  fixed  part  of  the  tumour  is  in 
the  median  line,  and  not  under  the  sterno-mastoid  muscle,  and 
that  the  swelling  moves  up  and  down  during  deglutition,  an 
aneurism  remaining  fixed.  (4)  An  aneurism  close  to  the  bifurca- 
tion may  be  simulated  by  an  abnormal  arrangement  of  the  terminal 
branches,  the  external  carotid  crossing  the  internal  from  behind 
forwards,  and  being  pushed  outwards  sufficiently  to  cause  a 
pulsating  swelling  beneath  the  skin.  This  condition  is  usually 
symmetrica],  and  can  be  recognised  by  careful  palpation. 

Treatment. — Ligature  of  the  carotid  above  or  below  the  omo- 
hyoid is  the  treatment  usually  adopted,  and  generally  with  great 
success.     If  the  aneurism  is  near  the  root  of  the  neck,  proximal 

18 


274  A   MANUAL  OF  SURGERY 


ligature  becomes  impracticable,  and  the  distal  operation  (Brasdor's) 
must  be  undertaken. 

Aneurism  of  the  External  Carotid  is  seldom  met  with,  except  as 
an  extension  of  one  involving  the  bifurcation.  The  usual  pheno- 
mena are  presented  near  the  angle  of  the  jaw,  and  well  above  the 
thyroid  cartilage.  Pressure  results  are  early  experienced,  e.g., 
paralysis  of  one  side  of  the  tongue  through  implication  of  the 
hypoglossal  nerve,  aphonia,  or  dysphagia.  In  suitable  cases,  the 
sac  may  be  dissected  out  after  securing  the  branches  arising  from 
it,  as  recently  recommended  by  Walsham.*  Failing  this,  the 
common  trunk  must  be  tied. 

Aneurism  of  the  Internal  Carotid  (extracranial  portion). — There 
is  but  little  difference  between  the  symptoms  arising  from  this 
condition  and  those  caused  by  an  aneurism  of  the  bifurcation  or 
of  the  external  carotid,  except  that  the  swelling  projects  more 
into  the  pharynx,  from  which  it  is  separated  merely  by  the 
pharyngeal  wall.  It  appears  as  a  tense  pulsating  tumour,  placed 
immediately  under  the  mucous  membrane,  and  looking  danger- 
ously like  an  abscess  of  the  tonsil.  The  Treatment  consists  in 
tying  the  common  carotid. 

Intracranial  Aneurism. — Any  of  the  arteries  within  the  skull 
may  become  the  site  of  an  aneurism,  but  this  condition  occurs 
more  commonly  upon  the  internal  carotid  and  its  branches  than 
upon  those  arising  from  the  vertebrals,  although  the  basilar  artery 
is  more  often  affected  than  any  other  single  vessel.  The  aneurisms 
are  generally  fusiform  in  character,  and  their  origin  is  often 
extremely  obscure,  a  blow  or  fall  being  sometimes  adduced  to 
explain  them  ;  in  children  they  are  stated  to  result  from  the 
lodgment  of  septic  emboli.  They  sometimes  grow  to  a  con- 
siderable size  before  causing  obvious  symptoms ;  the  patient  may, 
in  fact,  have  continued  without  any  manifestation  of  the  disease, 
until  suddenly  seized  with  a  rapidly  fatal  apoplexy  from  rupture 
of  the  sac.  If  there  are  any  symptoms,  they  are  due  rather  to 
compression  of  the  brain  than  to  erosion  of  the  more  resistant 
bony  structures.  Pain  which  is  more  or  less  fixed  and  continuous 
may  be  complained  of,  or  there  may  be  a  feeling  of  pulsation, 
or  of  opening  and  shutting  the  top  of  the  skull.  Sight,  hearing, 
and  other  functions  of  the  brain,  may  also  be  interfered  with,  but 
physical  changes  in  the  eyes,  such  as  optic  neuritis  or  atrophy,  are 
not  induced,  unless  there  is  direct  pressure  on  some  part  of  the 
optic  tract.  Occasionally  a  loud  whizzing  bruit  may  be  heard 
on  auscultating  the  skull.  The  only  Treatment  possible,  if  a 
diagnosis  can  be  established,  is  ligature  of  the  common  carotid 
artery,  and  even  this  will  be  of  little  use  if  the  basilar  is  affected. 

*  Trans.  Med   Chiv.  Soc,  February  28,  1899. 


ANEURISM  275 


An  Intra-orbital  Aneurism  is  recognised  by  the  existence  of  a 
pulsating  swelling  of  the  orbit,  causing  protrusion  of  the  eyeball 
(exophthalmos)  and  congestion  of  the  conjunctival  and  deeper 
vessels.  A  feeling  of  pain  or  tension  in  the  orbit  may  exist, 
and  gradually  vision  is  impaired,  whilst  the  cornea  may  become 
opaque  from  exposure,  due  to  the  inability  of  the  lids  to  cover 
it ;  finally,  the  whole  globe  may  be  disorganized.  The  symptoms 
sometimes  commence  with  a  definite  snap  or  crack,  as  though 
something  had  given  way  in  the  orbit ;  or  they  may  follow  a 
penetrating  injury  or  a  blow.  Occasionally  the  condition  is  con- 
genital, or  arises  soon  after  birth. 

Several  pathological  lesions  are  included  under  the  title  '  intra- 
orbital aneurism':  (a)  If  congenital,  it  is  probably  a  case  of 
aneurism  by  anastomosis  ;  this,  however,  is  not  common,  being 
present  only  in  two  out  of  seventy-three  cases  collected  by 
Rivington  ;  (b)  if  traumatic  in  origin,  whether  due  to  a  pene- 
trating injury  or  not,  the  case  is  probably  an  aneurismal  varix 
between  the  internal  carotid  and  cavernous  sinus,  or  a  genuine 
traumatic  aneurism  of  the  ophthalmic  artery  ;  (c)  if  idiopathic,  it 
is  possibly  due  to  thrombosis  of  the  cavernous  sinus,  or  to  spon- 
taneous aneurism  of  the  internal  carotid  or  ophthalmic  arteries. 

Diagnosis. — To  determine  the  precise  cause  of  a  pulsating 
tumour  of  the  orbit  is  by  no  means  an  easy  matter,  inasmuch  as 
sarcomata  are  occasionally  met  with  exhibiting  many  of  the 
characters  of  intra-orbital  aneurism.  Careful  palpation  will,  how- 
ever, generally  demonstrate  the  existence  of  a  more  definite 
tumour,  and  a  less-marked  expansile  pulsation  in  the  sarcoma, 
whilst  the  bruit  is  less  distinct.  The  distortion  of  the  eyeball 
and  ocular  axis  is  often  considerable  in  malignant  tumours,  but 
vision  is  not  so  early  aftected. 

Treatment. — Electrolysis  and  ligature  of  the  common  carotid 
are  the  only  means  which  hold  out  any  prospect  of  success, 
and  of  these  the  former  should  always  be  first  tried.  In  the 
congenital  cases  its  application  has  been  very  successful,  but  in 
those  due  to  trauma  it  is  very  likely  to  fail. 

Subclavian  Aneurism  is  most  frequently  seen  in  men,  and 
particularly  those  who  use  their  arms  much  in  lifting,  such  as 
soldiers  and  sailors  ;  the  right  vessel  is  more  often  affected  than 
the  left.  Any  part  of  the  artery  may  be  involved,  but  the  greatest 
dilatation  naturally  occurs  in  the  third  portion.  A  pulsating 
tumour  develops  in  the  subclavian  triangle,  which  may  reach 
above  the  clavicle,  but  chiefly  extends  backwards,  outwards,  and 
downwards,  causing  pressure  effects  upon  the  veins  and  nerves 
of  the  arm,  and  also  hiccough  by  irritation  of  the  phrenic. 
Occasionally  it  encroaches  on  the  dome  of  the  pleura  and  apex 
of  the  lung,  and  has  been  known  to  burst  into  the  pleural  cavity. 
It  does  not  increase  in  size  very  rapidly,  being  surrounded   by 

18—2 


276  A  MANUAL  OF  SURGERY 


dense  unyielding  structures,  and  never  compresses  the  trachea  or 
oesophagus. 

No  difficulty  presents  itself  in  Diagnosis  as  a  rule,  although  in 
the  early  stages  it  may  be  somewhat  simulated  by  a  normal 
artery  pushed  forwards  by  an  exostosis  of  the  first  rib,  or  by  a 
supernumerary  cervical  rib.  A  pulsating  sarcoma  growing  from 
any  of  the  neighbouring  structures  may  also  resemble  it  some- 
what closely,  but  the  pulsation  is  then  rarely  so  limited  in  extent 
as  in  an  aneurism,  and  a  definite  tumour  can  usually  be  felt. 

The  Treatment  of  subclavian  aneurism  is  surrounded  with 
difficulties,  and  the  results  hitherto  obtained  have  been  most 
unsatisfactory.  Extirpation  has  been  undertaken  in  one  case" 
with  success  after  turning  up  the  middle  third  of  the  clavicle,  but 
the  aneurism  is  seldom  sufficiently  limited  to  allow  of  the  applica- 
tion of  this  ideal  proceeding.  Should  any  undilated  portion  of 
the  artery  be  available  outside  the  thorax,  digital  compression  on  the 
cardiac  side  may  be  attempted.  Direct  pressure,  manipulation, 
galvano-puncture  and  needling  the  sac  according  to  Macewen's 
method,  have  been  adopted  with  occasional  success,  but  cannot 
be  relied  on.  Stewart's  method  proved  of  benefit  in  a  case  we 
recently  had  under  treatment,  the  aneurism  becoming  much  firmer, 
and  the  patient  being  freed  from  pain  and  able  to  return  home. 
Unfortunately  he  died  three  months  later  from  haemorrhage,  but  no 
post-mortem  examination  was  obtainable.  About  10  feet  of  gold 
wire  were  introduced.  Ligature  of  the  innominate  trunk  suggests  itself 
as  the  operation  to  be  adopted  for  cure  by  the  Hunterian  method, 
and  recent  records  would  certainly  encourage  one  to  repeat  it  in  any 
suitable  case,  since  most  of  the  fatal  results  occurred  prior  to  the 
introduction  of  antiseptic  surgery,  death  resulting  from  sepsis  or 
secondary  haemorrhage.  It  would  appear  that  the  simultaneous 
ligature  of  the  carotid  or  vertebral  trunks  with  the  innominate  is 
essential  to  success,  in  order  to  prevent  the  rapid  backflow  on  the 
distal  side  of  the  ligature  which  otherwise  occurs  ;  in  addition, 
the  coats  of  the  vessel  must  be  approximated  by  a  broad  animal 
ligature,  e.g.,  of  gold-beater's  skin,  and  not  divided. 

Ligature  of  the  first  part  of  the  subclavian  has  also  been  attempted 
for  the  cure  of  aneurisms  involving  the  lower  part  of  the  vessel, 
but  until  recently  it  was  so  uniformly  fatal  that  it  was  con- 
sidered quite  an  unjustifiable  proceeding,  the  first  nineteen  cases 
all  dying.  Clutton,t  however,  has  reported  a  successful  case, 
the  ligature  being  applied  (without  dividing  the  coats)  on  the 
proximal  side  of  the  thyroid  axis  and  internal  mammary  vessels, 
which  were  also  secured.  The  first  part  of  the  axillary  and  the 
superior  intercostal  had  also  to  be  tied  before  pulsation  in  the 
aneurism  ceased.  Halsted|  has  since  reported  a  second  successful 
case  of  this  operation.    Ligature  of  the  second  part  of  the  subclavian 

*  Moynihan,  Annals  of  Surgery ,  July,  1898. 

t  Trans.  Med.  Chir.  Soc,  vol.  lxxx.,  p.  391.        J  Annals  of  Surgery,  May,  1900. 


ANEURISM  277 


has  been  advantageously  employed  in  suitable  cases  where  the 
aneurism  was  situated  below  it.  Distal  ligature  of  the  third  part 
has  also  been  attempted,  but  without  much  success. 

As  a  last  resource,  where  the  above  measures  are  impracticable 
or  have  failed,  the  plan  suggested  by  the  late  Sir  William  Fer- 
gusson  may  be  followed,  viz.,  amputation  at  the  shoulder-joint  and 
distal  ligature  as  near  the  sac  as  possible.  Distal  ligature  alone  is 
usually  unsuccessful,  owing  to  the  fact  that  the  great  bulk  of  the 
blood  needed  for  the  nutrition  of  the  arm  still  passes  through  the 
sac,  and  there  is  no  means  of  checking  this  except  by  the  removal 
of  the  limb.  A  few  successful  results  of  such  heroic  treatment 
have  been  reported. 

Axillary  Aneurisms  is  usually  the  result  of  falls  on  the  out- 
stretched arm.  or  injuries  to  the  shoulder,  such  as  fractures  or 
dislocations,  or  of  attempts  to  reduce  them.  The  Symptoms  are 
merely  those  due  to  the  presence  of  a  pulsating  tumour  and  its 
pressure,  which  may  cause  pain,  local  and  neuralgic,  or  oedema 
of  the  arm.  When  the  upper  part  of  the  vessel  is  affected,  a 
pulsating  swelling  is  felt  immediately  below  the  clavicle,  whilst 
if  placed  lower  down  it  projects  more  into  the  axilla,  and  may 
totally  fill  up  the  hollow.  Occasionally  the  clavicle  is  displaced 
upwards,  or  the  aneurism  may  extend  beneath  it  into  the  neck, 
conditions  of  serious  import  as  regards  treatment. 

Treatment. — Compression  (digital)  or  ligature  of  the  third  part 
of  the  subclavian  artery  is  required,  but  if  the  aneurismal  sac 
extends  under  the  clavicle,  it  may  be  necessary  to  secure  the 
second  part  of  the  artery,  due  care  being  taken  of  the  phrenic  nerve. 

Aneurisms  of  the  brachial  artery,  or  of  any  of  the  vessels  of  the 
forearm,  require  no  special  notice.  They  are  almost  invariably 
traumatic  in  origin,  and  should  be  treated  by  extirpation. 

Abdominal  Aneurism. — The  abdominal  aorta  may  become  the 
seat  of  aneurism,  either  at  the  upper  part  near  the  cceliac  axis, 
or  at  the  bifurcation  ;  in  the  former  case,  some  of  the  branches 
arising  at  that  spot  are  also  usually  involved,  and  the  disease  is  of 
the  sacculated  type.  Occasionally  aneurisms  form  independently 
on  the  splenic  or  mesenteric  vessels.  A  pulsating  tumour  is 
observed,  usually  near  the  middle  line,  and  either  close  to  the 
umbilicus  or  in  the  epigastric  notch  ;  the  pulsation  is  expansile  in 
type,  and  remains  the  same  in  character  whatever  the  position  of 
the  patient.  Pressure  signs  are  mainly  confined  to  pain,  localized 
in  the  back  from  erosion  of  the  vertebrae,  or  neuralgic  from 
pressure  on  the  solar  plexus  or  lumbar  nerves,  whilst  oedema 
of  the  lower  extremities  may  arise  from  compression  of  the  vena 
cava.  There  may  be  some  concurrent  derangement  of  the  intes- 
tinal functions. 


278  A  MANUAL  OF  SURGERY 

Diagnosis. — Many  conditions  give  rise  to  epigastric  pulsation, 
but  the  majority  of  them  can  be  readily  distinguished  from 
abdominal  aneurism  by  careful  examination,  if  necessary,  under 
an  anaesthetic.  Cardiac  pulsations  may  be  felt  in  the  epigastrium 
when  the  heart  is  dilated,  but  should  be  easily  recognised  ;  as  also 
an  impulse  transmitted  from  the  aorta  through  a  collection  of 
fasces,  or  a  cancerous  growth.  The  examination  of  such  a  case 
should  be  conducted  not  only  in  the  dorsal  decubitus,  but  also 
in  the  genu-pectoral  position  so  as  to  remove  the  weight  of  the 
viscera  from  the  aorta,  when  the  pulsation  will  cease,  or  become 
much  diminished.  A  large  accumulation  of  abdominal  fat  will 
seriously  interfere  with  any  satisfactory  investigation. 

Treatment. — Ligature  of  the  aorta  even  on  the  distal  side  has 
has  never  yet  been  attempted  for  this  condition,  and  hence, 
failing  medical  treatment  by  rest  and  diet,  compression  was  formerly 
relied  on,  being  applied  either  on  the  distal  or  proximal  sides  of 
the  sac.  The  method  is,  however,  clumsy  and  liable  to  cause 
serious  mischief  to  the  abdominal  viscera.  More  recently  treat- 
ment by  needling  the  sac  has  been  employed,  and  certainly  in 
Macewen's  hands  at  least  one  case  has  been  brilliantly  success- 
ful. There  is  also  one  instance  on  record  where  the  introduction 
of  wire  into  the  sac,  combined  with  electrolysis  through  the  wire 
by  Stewart's  method,  cured  an  aneurism  as  large  as  an  orange  ; 
the  abdomen  was  opened,  and  electrolysis  was  maintained  for 
thirty-seven  minutes. 

Iliac  or  Inguinal  Aneurism  arises  from  either  the  common  or 
external  iliac,  or  from  the  common  femoral,  and  usually  tends  to 
spread  upwards  towards  the  abdominal  cavity.  It  is  frequently 
sacculated  in  type,  and  is  certain  sooner  or  later  to  become  diffuse. 
Its  shape  is  determined  by  the  unequal  pressure  exercised  by 
fascial  or  other  structures,  sometimes  leading  to  lobulation.  The 
symptoms  are  very  typical,  and  pressure  effects  are  mainly  ex- 
perienced in  the  veins  and  nerves  of  the  leg.  The  Diagnosis 
cannot  be  well  mistaken  in  the  early  stages,  but  later  on,  and 
specially  when  situated  high  in  the  iliac  fossa,  it  may  be  difficult 
to  distinguish  from  a  pulsating  sarcoma. 

Treatment.  — Medical  treatment  alone  is  of  little  avail  in  curing 
inguinal  aneurisms;  but  proximal  compression  of  the  aorta  or 
common  iliac,  where  the  situation  of  the  swelling  and  the  thickness 
of  the  abdominal  parietes  permitted  it,  has  had  a  certain  amount 
of  success.  It  is  carried  out  by  means  of  a  tourniquet,  shot-bag, 
or  the  fingers,  and  may  be  advantageously  combined  with  distal 
pressure.  Ligature  of  the  external  iliac  has  been  frequently  per- 
formed for  inguinal  aneurism,  and  with  such  success  as  to  warrant 
its  being  employed  in  all  suitable  cases.  Ligature  of  the  common 
iliac  is  sometimes  needed  for  aneurisms  in  the  iliac  fossa.  The 
results  of  the  retro-peritoneal  operation  were  by  no  means  satisfac- 


ANEURISM  279 


tory,  but  the  introduction  of  the  trans-peritoneal  method  of  ligature 
and  the  recognition  of  the  importance  of  not  dividing  the  inner  and 
middle  coats  in  such  a  large  vessel,  combined  with  the  use  of 
aseptic  animal  ligatures,  are  certain  to  lead  to  better  results.  In 
ten  instances  ligature  of  the  abdominal  aorta  has  been  undertaken  for 
iliac  or  inguinal  aneurism,  and  in  all  a  fatal  issue  followed,  seven  of 
the  patients  dying  within  forty-eight  hours ;  one  survived  as  long  as 
the  tenth  day,  and  two  lived  for  forty-eight  and  thirty-nine  days 
respectively.  Of  course,  wherever  practicable,  extirpation  should 
be  resorted  to,  and  at  least  one  most  successful  case  has  been 
published. 

Aneurisms  of  the  Gluteal  and  Sciatic  Arteries  are  usually 
traumatic  in  origin,  and  present  as  pulsating  swellings  of  variable 
size  in  the  buttock,  the  gluteal  situated  at  the  upper  part  of  the 
sciatic  notch,  whilst  the  sciatic  lies  more  deeply,  and  may  be 
partly  intrapelvic.  Pulsation  is  well  marked,  and  murmurs  are 
heard  on  auscultation.  Pain  in  the  limb  from  pressure  on  the 
sciatic  nerve  is  a  prominent  sympton,  especially  in  the  sciatic 
variety.  The  Diagnosis  is  by  no  means  simple,  especially  from  a 
pulsating  sarcoma,  and  many  instances  of  mistakes  have  occurred 
even  in  the  practice  of  eminent  surgeons.  Treatment. — The  best 
results  hitherto  obtained  have  followed  the  laying  open  of  the  sac, 
turning  out  the  clot,  and  tying  the  affected  trunk — a  proceeding 
requiring  operative  dexterity  and  skill  of  the  highest  order. 
Ligature  of  the  internal  iliac  has  also  been  performed,  and  with 
a  creditable  degree  of  success,  even  where  the  old  extra-peritoneal 
method  was  employed.  The  use  of  the  trans-peritoneal  route 
greatly  simplifies  the  operation,  and  the  more  recent  records  of 
this  proceeding  are  most  satisfactory.  At  the  present  time  it 
should  certainly  be  undertaken  in  preference  to  the  plan  of  laying 
open  the  sac. 

Femoral  Aneurism  is  the  title  given  to  one  forming  in  the  course 
of  the  superficial  femoral  artery.  It  is  not  uncommonly  tubular, 
and  occurs  almost  invariably  in  males,  and  as  often  on  one  side  of 
the  body  as  the  other.  The  Diagnosis  needs  no  discussion,  as  the 
disease  runs  a  typical  course,  and  the  Treatment  consists  either  in 
extirpation,  compression  at  the  groin,  or  ligature  of  the  common 
or  superficial  femoral  trunk. 

Aneurism  of  the  Profunda  Femoris  Artery  is  a  very  rare  con- 
dition, presenting  the  ordinary  features  of  a  pulsating  tumour 
situated  amongst  the  muscles  on  the  inner  side  of  the  thigh,  but 
causing  no  diminution  of  the  pulse  in  the  popliteal  or  tibial 
vessels.  The  superficial  femoral  may  be  felt  coursing  over  it, 
but  quite  distinct.  Compression  by  a  shot  bag  in  the  groin, 
or   by   a  tourniquet,    may   be  sufficient  to  effect  a  cure,  whilst 


2SO 


A   MANUAL  OF  SURGERY 


ligature  of  the  common  femoral  or  external  iliac  may  be  resorted 
to,  if  neceessary. 

Popliteal  Aneurism  (Fig.  71)  occurs  almost  invariably  in  men, 
constituting  a  pulsating  tumour  in  the  ham,  rendering  the  knee 
painful  and  stiff,  and  so  much  do  the  symp- 
toms resemble  those  of  chronic  rheumatism 
that  in  every  such  case  the  popliteal  space 
should  be  examined.  The  limb  is  usually 
semiflexed,  and  the  aneurism,  which  is  of  a 
sacculated  type,  often  increases  rapidly  in 
size.  If  the  main  swelling  is  situated  to  the 
front  of  the  vessel,  there  is  some  likelihood 
of  the  knee-joint  becoming  implicated,  and 
neighbouring  bones  carious ;  when  it  extends 
posteriorly,  diffusion  is  not  uncommonly 
followed  by  gangrene,  on  account  of  the 
pressure  exercised  not  only  upon  the  vein, 
but  also  upon  the  articular  branches  of  the 
popliteal  artery,  which  are  most  important 
factors  in  maintaining  the  collateral  circula- 
tion. The  diagnosis  has  to  be  made  from 
chronic  enlargement  and  abscess  of  the 
glands  in  the  ham,  but  in  these  there  is  less 
disturbance  of  the  circulation  in  the  foot ; 
from  bursal  tumours,  by  their  want  of  mobility 
and  pulsation  ;  or  from  solid  tumours,  e.g., 
pulsating  sarcoma  of  the  femur  or  tibia,  from 
which  it  can  be  recognised  by  attention  to  the  general  principles 
already  enunciated.  In  a  few  instances  spontaneous  cure  has 
resulted  from  the  pressure  of  the  sac  upon  the  artery  above. 

Treatment. — Compression  is  eminently  successful  in  many  of 
these  cases,  whether  applied  in  the  groin  or  by  Reid's  method. 
Ligature  of  the  femoral  artery  at  the  apex  of  Scarpa's  triangle  is, 
however,  the  plan  most  commonly  adopted,  and  with  the  greatest 
success.  In  cases  where  either  of  these  methods  has  failed,  or 
where  the  aneurism  has  become  diffuse  or  recurred,  extirpation  of 
the  sac  is  the  best  course  to  adopt. 


Fig. 


71. — Popliteal 

Aneurism. 


Ligature  of  Vessels. 

Ligation  in  continuity  is  an  operation  performed  to  arrest  the 
flow  of  blood  to  the  periphery,  in  order  either  to  check  haemor- 
rhage, or  to  promote  the  cure  of  an  aneurism,  or  to  diminish  the 
rate  of  growth  of  some  tumour,  or  to  beneficially  influence  some 
peripheral  organ  by  reducing  its  blood-supply  (as  in  tying  the 
internal  iliac  for  enlarged  prostate),  or  as  a  preliminary  to  remov- 
ing some  vascular  structure,  such  as  the  tongue. 


LIGATURE  OF  VESSELS  281 

The  Instruments  needed  are  as  follows :  scalpels,  dissecting 
forceps,  director  or  blunt  dissector,  forcipressure  or  artery  forceps, 
blunt  hooks,  retractors  for  deep  wounds,  aneurism  needle,  ligature, 
needles,  and  sutures. 

The  Material  to  be  employed  for  the  ligature  has  been  discussed 
elsewhere  (p.  18).  Sulphuro-chromicised  catgut  is  that  most 
commonly  employed  for  all  but  the  largest  trunks,  and  for  its 
application  to  an  artery  in  its  continuity  the  following  plan  may 
be  adopted  :  A  fine  loop  of  catgut  having  been  passed  under  the 
vessel  by  means  of  an  aneurism  needle,  a  prepared  ligature,  con- 
sisting of  three  strands  of  catgut  about  10  inches  long,  knotted 
together  at  each  end,  is  threaded  through  the  loop,  which  is  then 
withdrawn,  carrying  the  ligature  under  the  vessel.  The  advan- 
tages of  this  method  are,  that  the  aneurism  needle,  being  threaded 
with  such  fine  gut,  passes  easily  and  without  friction,  whilst  the 
use  of  the  loop  to  draw  the  ligature  back  obviates  the  difficulty, 
where  the  artery  is  deeply  placed,  of  threading  the  needle  if 
passed  unarmed,  as  is  sometimes  advised.  The  substitution  of 
three  strands  for  a  single  ligature  distributes  the  pressure  over  a 
larger  area,  and  is  considered  more  certainly  to  effect  occlusion. 

As  to  the  Operation  itself,  the  strictest  asepsis  must  be  main- 
tained, the  skin  and  instruments  being  thoroughly  purified  pre- 
viously. The  artery  is  examined,  as  far  as  is  possible,  so  that  a 
healthy  portion  may  be  selected  for  applying  the  ligature.  The 
various  structures  met  with  on  the  way  to  the  artery  are  recog- 
nised, and  drawn,  if  need  be,  to  one  or  the  other  side,  so  as  to  lay 
bare  the  sheath  of  the  vessel.  It  is  most  important  that  these 
anatomical  landmarks  or  rallying  points  should  each  be  seen  or  felt 
in  order,  so  that  the  operator  may  not  be  led  astray  or  miss  the 
vessel.  Naturally  it  is  easier  to  find  the  artery  in  the  living 
subject  than  in  the  dead,  the  pulsation  being  of  the  greatest 
assistance.  The  sheath,  having  been  exposed,  must  now  be 
opened  over  the  situation  of  the  artery  by  a  few  delicate  strokes 
of  the  knife ;  a  portion  of  the  sheath  should  be  picked  up  between 
the  blades  of  the  forceps,  incised  along  the  longitudinal  axis,  and 
stripped  off  the  artery,  taking  care  to  keep  the  back  of  the  knife 
towards  the  vessel.  This  incision  should  be  about  f  inch  in 
length,  and  should  open  not  only  the  general,  but  also  the  special, 
sheath  of  the  artery,  if  such  exist.  The  sheath  is  then  steadied 
with  forceps,  whilst  the  aneurism  needle  is  inserted  unarmed,  and 
gently  manipulated  up  and  down,  so  as  to  free  the  vessel  all  round, 
a  matter  of  no  great  difficulty,  if  the  sheath  has  been  sufficiently 
opened,  and  the  actual  arterial  wall  fairly  exposed.  The  ligature 
may  then  be  passed  through  the  eye  of  the  needle,  and  carried 
round  the  vessel.  It  is  tied  in  a  direction  exactly  at  right  angles 
to  the  longitudinal  axis,  and  in  doing  so  the  artery  must  not  be 
dragged  out  of  its  sheath,  but  the  ligature  should  be  tightened  by 
the  tips  of  the  forefingers  meeting  upon  it.     A  reef-knot  is  all  that 


282  A  MANUAL  OF  SURGERY 

is  necessary  for  security  in  the  smaller  vessels,  but  in  the  largest 
trunks  it  may  be  advisable  to  employ  what  has  been  termed  the 
stay-knot.  Two  strands  of  ligature  material  are  passed  round  the 
vessel  side  and  half  knotted  ;  the  two  ends  on  each  side  are  then 
taken  up  together  and  tied  across  in  one  knot. 

The  rule  usually  followed  is  to  pass  the  needle  from  important  struc- 
tures, such  as  the  vein,  but  really  this  is  a  matter  of  little  importance 
when  the  above  directions  have  been  carefully  carried  out,  and 
especially  in  superficial  vessels.  Should  the  vein  be  accidentally 
punctured,  the  needle  must  be  at  once  withdrawn,  and  the  punc- 
ture in  the  vein  secured  by  ligature,  whilst  the  artery  is  tied 
a  little  higher  or  lower.  In  dealing,  however,  with  the  smaller 
vessels,  where  the  venae  comites  are  in  close  contact  with  the 
artery,  no  harm  will  attend  their  inclusion  in  the  ligature. 

After  -  Treatment.  —  The  ordinary  antiseptic  precautions  are 
taken  in  regard  to  the  wound,  which  should  be  healed  and  all 
stitches  removed  in  eight  days ;  but  the  patient  must  be  kept  at 
rest  for  some  time  longer  to  allow  the  tissues  to  consolidate, 
especially  in  dealing  with  the  larger  vessels  and  in  elderly  people. 
When  the  main  artery  to  one  of  the  extremities  has  been  tied,  the 
limb  should  be  wrapped  in  cotton-wool  and  slightly  raised.  If 
there  is  any  likelihood  of  gangrene,  as  in  the  lower  limbs  of 
elderly  people,  the  extremity  should  be  thoroughly  purified,  and 
wrapped  in  aseptic  wool  immediately  after  the  operation,  in  order 
to  avoid  septic  complications. 

There  are  two  great  dangers  liable  to  follow  the  ligation  of  an 
artery  in  its  continuity  : 

i.  Secondary  Haemorrhage  (vide  p.  239). 

2.  Gangrene,  which  may  arise  from  a  variety  of  causes : 
(a)  From  simple  loss  of  vitality,  the  maximum  amount  of  blood 
transmitted  by  the  collateral  circulation  being  insufficient  to 
maintain  in  life  the  whole  of  the  part  supplied  by  the  artery 
ligated.  This  is  particularly  the  case  when  the  peripheral  vessels 
are  in  a  condition  of  calcareous  degeneration.  The  tissues  which 
receive  the  smallest  amount  of  blood  die  first,  e.g.,  the  fingers  or 
toes,  or  the  subcortical  white  substance  of  the  brain.  Severe  loss 
of  blood  after  the  operation,  as  from  secondary  haemorrhage,  is 
also  sufficient  in  some  cases  to  determine  tissue  necrosis.  Under 
such  circumstances  it  always  takes  on  the  dry  form  if  involving 
the  terminal  joints  of  a  limb,  but  in  more  fleshy  parts  it  may  be 
moist,  (b)  Interference  with  the  venous  return,  as  by  injury  to 
the  vein  during  operation,  such  as  inclusion  in  the  ligature,  or 
thrombosis  induced  subsequently  by  septic  periphlebitis,  is  very 
likely  to  cause  gangrene,  and  then  it  is  of  the  moist  type  ;  the  in- 
jurious pressure  of  a  tight  bandage,  obstructing  the  venous  circula- 
tion, will  have  a  similar  effect,  (c)  Injudicious  after-treatment, 
such  as  too  great  elevation  of  the  limb,  the  application  of  cold 
lotions,  an  icebag,  or  fomentations  during  the  period  of  diminished 


LIGATURE  OF  VESSELS  283 

vitality  immediately  following  the  operation,  or  even  an  attack  of 
erysipelas,  may  also  bring  about  the  death  of  some  of  the  tissues 
involved. 

Every  precaution  must  be  taken  to  prevent  the  occurrence  of 
gangrene,  as  indicated  above,  and  as  soon  as  there  is  any  sus- 
picion of  its  onset  the  whole  limb  must  be  thoroughly  purified, 
and  subsequently  maintained  aseptic.  The  Treatment  of  aseptic 
gangrene  following  ligature  is  expectant  in  character,  the  parts 
being  allowed  to  separate  naturally.  But  if  there  is  much  pain, 
or  any  tendency  to  spread,  or  if  septic  mischief  is  present,  giving 
rise  to  fever  and  general  disturbance,  it  is  wiser  to  remove  the 
limb  well  above  the  line  of  demarcation. 

The  Innominate  Artery  has  now  been  tied  with  success  on  six  separate 
occasions  out  of  a  total  of  about  thirty  operations.  An  incision  is  made  along 
the  lower  third  of  the  anterior  border  of  the  sterno-mastoid,  and  is  prolonged 
downwards  to  sweep  over  the  upper  edge  of  the  episternal  notch.  The 
platysma,  the  superficial  and  deep  fasciae  are  divided,  and  the  anterior  jugular 
vein  secured  if  necessary  between  two  ligatures  ;  the  sterno-mastoid  is  drawn 
outwards,  and  its  inner  tendinous  fibres  are  divided,  whilst  the  sterno-hyoid 
and  -thyroid  muscles  are  severed  close  to  the  sternum  and  drawn  inwards. 
The  carotid  sheath  is  now  laid  bare  and  opened  at  its  lower  part,  so  as  to 
expose  the  carotid  artery  and  enable  it  to  be  tied,  and  by  following  this 
downwards  the  innominate  trunk  is  reached.  In  some  cases  it  may  expedite 
matters  to  remove  portions  of  the  sternum  and  inner  end  of  the  clavicle. 
The  right  internal  jugular  and  innominate  veins  lie  to  the  outer  side  of  the 
vessel,  but  if  much  engorged  may  project  over  the  artery,  and  must  then  be 
drawn  aside  by  retractors,  whilst  the  inferior  thyroid  plexus  may  course 
directly  in  front  of  the  vessel,  and  even  need  to  be  ligatured.  To  the  outer 
or  right  side  are  placed  the  vagus  nerve  and  pleural  sac,  and  these  must  be 
carefully  separated  from  the  artery,  whilst  the  needle  is  passed  from  without 
inwards,  and  from  below  upwards.  A  double-curved  aneurism  needle  will 
probably  be  required  to  effect  this.  A  broad  animal  ligature  should  be  used 
for  this  vessel,  and  the  inner  and  middle  coats  must  not  be  divided. 

Collateral  Circulation. — Intracranial:  Vertebrals  and  carotids  in  the  circle 
of  Willis. 

Face  and  Neck  :  Branches  of  the  two  external  carotids  across  middle  line. 

Trunk  :  First  aortic  intercostal  with  superior  intercostal  of  subclavian  ;  upper 
aortic  intercostals  with  thoracic  branches  of  axillary  and  intercostals  of  internal 
mammary  ;  deep  epigastric  and  phrenic  with  terminal  divisions  of  internal 
mammary. 

The  Carotid  Artery  may  be  tied  at  one  of  two  places,  either  above  or  below 
the  level  at  which  it  is  crossed  by  the  anterior  belly  of  the  omo-hyoid.  The 
line  of  the  vessel  is  indicated  by  that  drawn  from  the  sterno-clavicular  articula- 
tion to  a  point  midway  between  the  angle  of  the  jaw  and  the  tip  of  the  mastoid 
process,  the  bifurcation  being  situated  on  a  level  with  the  upper  border  of  the 
thyroid  cartilage. 

Ligature  above  the  Omo-hyoid. — This  operation  is  usually  chosen,  if  practicable, 
since  the  vessel  is  here  more  superficial,  the  ligature  being  applied  on  a  level  with 
the  cricoid  cartilage.  The  patient  lies  upon  the  back,  with  the  chin  raised  and 
the  head  turned  a  little  towards  the  opposite  side.  A  3-inch  incision  is  made  in 
the  line  of  the  vessel,  the  centre  on  a  level  with  the  cricoid  (Fig.  72,  A).  The 
skin,  platysma,  and  fasciae  are  divided,  and  the  anterior  edge  of  the  sterno- 
mastoid  defined  as  the  first  rallying-point.  The  deep  fascia  is  incised  along  its 
inner  border,  so  that  it  may  be  drawn  aside  by  a  retractor  ;  the  sterno-mastoid 


284 


A  MANUAL  OF  SURGERY 


branch  of  the  superior  thyroid  artery  may  be  divided  at  this  stage,  and  a  vein 
passing  between  the  facial  and  anterior  jugular  may  also  need  to  be  ligatured. 
( )n  the  inner  side  of  the  wound  the  omo-hyoid  muscle  must  now  be  looked  for, 
trending  forwards  and  upwards  from  under  cover  of  the  sterno-mastoid.  In 
the  angle  formed  by  these  two  structures  the  pulsation  of  the  vessel  should  be 
felt  and  the  sheath  readily  recognised,  with  the  descendens  cervicis  nerve 
upon  it.  It  is  opened  on  the  inner  side,  and  the  artery  well  cleared.  The 
needle  is  passed  from  without  inwards,  and  if  the  sheath  has  been  efficiently 
opened,  the  vagus  nerve  will  run  no  risk  of  being  included. 

Ligature  below  the  Omo-hyoid. — The  incision  is  made  in  a  similar  direction  to 
the  above,  but  lower  in  the  neck,  reaching  from  the  cricoid  cartilage  nearly  to 


Fig.  72. — Incisions  for  Various  Operations  on  Head  and  Neck. 

For  ligature  of  carotid  ;  V,  for  ligature  of  vertebral  artery  ;  B,  for  ligature 
of  subclavian  ;  C,  for  ligature  of  the  first  part  of  the  axillary  ;  M,  for  the 
internal  mammary  ;  H,  for  the  lingual ;  E,  flap  incision  used  in  trephining 
for  meningeal  haemorrhage  ;  F,  flap  incision  for  operations  on  the  roots  of 
the  fifth  nerve. 


the  sterno-clavicular  joint.  The  sterno-mastoid  is  drawn  outwards,  and  per- 
haps the  anterior  fibres  may  need  to  be  divided  ;  the  sterno-hyoid  and  -thyroid 
muscles  are  retracted  inwards  or  divided,  and  the  omo-hyoid  can  usually  be 
drawn  upwards.  The  sheath  is  thus  exposed,  and  opened  on  the  inner  side, 
the  needle  being  passed  as  in  the  previous  operation.  It  must  be  remembered 
that  both  internal  jugular  veins  are  directed  towards  the  right  side  in  the  lower 
part  of  their  course,  and  hence  the  left  vein  is  likely  to  lie  somewhat  in  front 


LIGATURE  OF  VESSELS  285 

of  the  artery.  The  inferior  thyroid  veins  may  also  be  seen,  and  need  to  be 
drawn  aside  or  ligatured. 

The  effects  of  ligature  of  the  carotid  upon  the  brain  are  of  great  interest  and 
importance.  Statistics  go  to  prove  that  in  about  25  per  cent,  of  the  patients 
operated  on  cerebral  symptoms  manifest  themselves,  either  immediately  in  the 
form  of  syncope  from  cerebral  anaemia,  or  in  the  course  of  a  few  days  from 
cerebral  softening,  causing  paralysis  on  the  opposite  side  of  the  body,  and 
even  death.  A  fatal  issue  is  likely  to  result  in  about  half  the  cases  thus 
affected.  Occasionally  a  somewhat  acute  form  of  congestion  of  the  lungs 
follows  ligature  of  the  carotid  within  a  few  hours,  possibly  due  to  interference 
with  the  circulation  in  the  medulla,  or  to  irritation  or  injury  to  the  vagus  or 
sympathetics  ;  it  may  run  on  to  subacute  inflammation,  and  is  best  remedied 
by  free  stimulation,  or  venesection. 

Collateral  Circulation.  —  Intracranial :  Circle  of  Willis. 

Extracranial  :  Communications  across  the  middle  line  of  branches  of  the 
external  carotids  and  vertebrals  ;  inferior  thyroid  with  the  superior  thyroid  ; 
profunda  cervicis  with  princeps  cervicis  of  occipital ;  superficial  cervical  with 
branches  of  occipital  and  vertebral. 

Ligature  of  the  Internal  Carotid  is  rarely  needed,  but  has  been  employed  for 
haemorrhage  and  traumatic  aneurisms.  Any  part  of  the  vessel  may  be  tied, 
but  the  ligature  is  usually  placed  just  above  the  bifurcation.  The  operation 
is  practically  the  same  as  for  securing  the  common  carotid,  only  at  a  higher 
level.  An  incision  is  made  along  the  anterior  border  of  the  sterno-mastoid, 
its  centre  being  opposite  the  great  cornu  of  the  hyoid  bone  ;  the  muscle  is 
pulled  well  backwards,  and  the  posterior  belly  of  the  digastric  is  now  seen  and 
drawn  up.  The  external  carotid  presents  itself,  and  is  carefully  displaced 
forwards,  and  then  the  internal  carotid  in  its  sheath  appears.  The  latter  is 
opened,  and  the  aneurism  needle  passed  from  the  jugular  vein. 

The  Collateral  Circulation  to  the  brain  is  maintained  by  the  circle  of  Willis. 

Ligature  of  the  External  Carotid  is  occasionally  required,  the  site  of  election 
for  applying  the  ligature  being  between  the  superior  thyroid  and  lingual 
branches.  An  incision  is  made  along  the  anterior  border  of  the  sterno-mastoid, 
3  inches  in  length,  its  centre  corresponding  to  the  great  cornu  of  the  hyoid 
bone.  The  edge  of  the  muscle  is  defined  and  drawn  outwards,  and  the  posterior 
belly  of  the  digastric  sought  for  above,  the  hypoglossal  nerve  lying  just  below 
it.  The  sheath  is  now  opened  below  the  tip  of  the  great  cornu  of  the  hyoid  bone, 
and  the  needle  passed  from  without  inwards.  The  operation  may  be  rendered 
exceedingly  difficult  by  the  presence  of  enlarged  glands  or  veins,  especially  the 
lingual,  facial  and  superior  thyroid,  which  often  lie  directly  in  front  of  the 
vessel.  The  superior  laryngeal  nerve  is  placed  immediately  behind  it,  and 
must  necessarily  be  avoided. 

Collateral  Circulation. —  Vide  ligature  of  common  carotid  (extracranial 
portion). 

Ligature  of  the  Lingual  Artery  is  chiefly  needed  as  a  preliminary  to  removal 
of  the  organ  for  malignant  disease  ;  it  is  also  occasionally  employed  in  traumatic 
cases.  The  vessel  can  be  secured  either  close  to  its  origin  from  the  external 
carotid,  or  in  the  submaxillary  triangle  under  cover  of  the  hyoglossus  muscle. 

In  the  Submaxillary  Triangle. — The  patient  lies  on  his  back,  with  the 
shoulders  raised,  and  the  head  extended  backwards  and  turned  to  the 
opposite  side.  A  crescentic  incision  commencing  about  1  inch  below  and 
external  to  the  symphysis  menti,  and  skirting  the  angle  of  the  jaw,  is  made, 
the  centre  opposite  the  great  cornu  of  the  hyoid  bone  (Fig.  72,  H).  The 
integument  and  platysma  are  divided,  the  lower  border  of  the  submaxillary 
gland  is  defined,  and  along  it  the  deep  fascia  is  incised.  The  gland  is  now 
drawn  upwards,  and  held  over  the  margin  of  the  jaw  with  a  retractor 
(Fig.  73,  Gs).  On  thoroughly  opening  up  the  wound  the  two  bellies  of  the 
digastric  muscle  (.1/   biv)   are  seen    converging    to  the  hyoid    bone  (Z),  the 


286 


A   MANUAL  OF  SURGERY 


anterior  belly  passing  superficial  to  the  fibres  of  the  mylohyoid  muscle 
(M  myho),  which  course  nearly  transversely  to  the  mandible,  and  of  which  the 
posterior  fibres  may  be  divided  with  advantage.  The  digastric  tendon  is  drawn 
down  with  a  blunt  hook,  and  in  the  space  thus  cleared  the  hyoglossus  muscle 
(M  hyogl)  becomes  evident,  with  its  fibres  passing  vertically  upwards,  and 
resting  upon  it  the  hypoglossal  nerve  (5),  coursing  forwards  to  get  under  cover 
of  the  mylohyoid,  and  either  above  or  below  it  the  ranine  vein.  The  fibres  of 
the  hyoglossus  are  now  divided  transversely  midway  between  the  nerve  and 
the  hyoid  bone,  and  in  the  opening  made  by  their  retraction  is  seen  the  artery 
(3),  lying  on  the  middle  constrictor.  Should  it  not  be  found  in  this  situation, 
the  incision  in  the  hyoglossus  should  be  extended  backwards,  and  the  vessel 
will  then  usually  come  in  sight. 

In  the  Neck  close  to  its  Origin. — An  incision  is  made  along  the  anterior  border 
of  the  sterno-mastoid  similar  to  that  needed  for  ligature  of  the  external  carotid. 


Fig.   73. — Ligature  of  Lingual  Artery.     (Tillmanns.) 

The  submaxillary  gland  (Gs)  has  been  drawn  over  the  side  of  the  jaw  with  a 
hook  ;  Z ,  hyoid  bone  ;  i,  external  carotid  ;  2,  internal  jugular  ;  3,  lingual 
artery  ;  4,  ranine  branch  of  facial  ;  5,  hypoglossal  nerve  ;  M  biv,  digastric  ; 
M  styl,  stylohyoid;  M  myho,  mylohyoid  ;  M  hyogl,  hyoglossus.  The  place 
where  the  artery  is  tied  is  indicated  by  a  window  in  the  hyoglossus, 
through  which  it  can  be  seen. 

The  muscle  is  drawn  backwards,  and  the  great  cornu  of  the  hyoid  bone  defined. 
The  small  space  is  now  cleared  between  that  bony  process  and  the  posterior 
belly  of  the  digastric,  in  which  the  artery  can  be  felt  resting  upon  the  middle 
constrictor,  and  secured  just  as  it  rises  from  the  external  carotid. 

The  Facial  Artery  may  be  exposed  and  tied  through  a  horizontal  incision, 
1  inch  in  length,  made  directly  over  the  vessel  as  it  crosses  the  lower  border  of 
the  jaw  immediately  in  front  of  the  masseter.  The  platysma  will  need  division, 
as  well  as  the  skin  and  fascia. 

The  Temporal  Artery  is  reached  in  front  of  the  auditory  meatus,  and  as  it 
crosses  the  zygoma,  through  a  vertical  incision.  It  is  merely  covered  by  skin 
and  fascia,  but  must  be  carefully  isolated  from  the  auriculo-temporal  nerve. 

The  Occipital  Artery  is  tied  through  an  incision  extending  from  the  apex  of 
the  mastoid  process  backwards  for  about  2  inches  towards  the  occipital  pro- 
tuberance.     The  posterior  fibres    of    the  sterno-mastoid,  the    splenius   and 


LIGATURE  OF  VESSELS  287 


trachelo-mastoid  are  divided  so  as  to  expose  the  artery  as  it  emerges  from  the 
groove  on  the  under  surface  of  the  mastoid  process,  where  it  is  easily  secured. 

The  Subclavian  Artery  has  been  tied  in  each  part  of  its  course,  but  most 
frequently  in  the  third.  Ligatures  of  the  first  and  second  parts  are  such  unusual 
proceedings  that  we  must  refer  students  to  larger  text-books  for  descriptions. 

Ligature  of  the  third  part  is  performed  for  axillary  aneurism,  for  haemorrhage, 
as  a  distal  operation  for  aortic  or  innominate  aneurism,  and  sometimes  as  a 
preliminary  to  amputation  of  the  upper  extremity.  The  patient  is  placed  on 
the  back,  close  to  the  edge  of  the  table  ;  the  arm  is  well  depressed,  and  the 
head  turned  to  the  opposite  side.  The  skin  is  now  drawn  down  by  the  left 
hand,  and  an  incision  3  or  4  inches  long  made  over  the  clavicle  (Fig.  72,  B). 
On  releasing  the  skin  it  retracts  upwards,  so  that  the  wound  comes  to  be 
situated  about  J  inch  above  the  clavicle,  and  thus  the  external  jugular  vein  is 
more  efficiently  protected.  The  incision  should  be  placed  with  its  centre  about 
1  inch  to  the  inner  side  of  the  middle  of  the  clavicle,  and  should  expose  the 
space  between  the  sterno-mastoid  and  trapezius  muscles,  the  fibres  of  which 
are  divided  to  a  suitable  extent  if  they  abnormally  encroach  upon  the  bone. 
The  skin,  superficial  fascia  and  nerves,  with  the  platysma,  are  divided  along 
the  whole  length  of  the  incision,  as  also  the  deep  fascia.  The  external  jugular 
and  other  veins  now  come  into  view,  often  constituting  a  plexus,  which  may 
give  the  surgeon  much  trouble  ;  when  possible,  they  should  be  gently  drawn 
out  of  the  way  by  means  of  blunt  hooks,  but  if  necessary  they  must  be  divided 
between  ligatures.  The  cellular  tissue  is  then  further  incised  in  the  line  of 
the  wound,  care  being  taken  to  avoid  the  transverse  cervical  and  supra- 
scapular arteries,  the  former  of  which  is  above  the  line  of  operation,  whilst 
the  latter  is  hidden  behind  the  clavicle,  and  should  not  appear.  The  posterior 
belly  of  the  omohyoid,  if  seen  at  all,  is  drawn  upwards.  Various  layers  of 
fascia  must  be  carefully  cut  or  torn  through  until  the  nerves  of  the  brachial 
plexus  appear  ;  the  finger  can  then  readily  define  the  scalene  tubercle  on  the 
first  rib.  The  subclavian  vein  is  situated  in  front  of  the  finger,  but  on  a 
lower  level,  whilst  the  artery  itself  can  be  detected  pulsating  under  the  pulp 
of  the  finger  between  it  and  the  rib.  The  cords  of  the  brachial  plexus  are 
placed  above  and  external  to  it,  the  lower  cord  passing  down  behind.  The 
needle  is  insinuated  from  above  downwards,  and  must  be  kept  very  close  to 
the  artery  to  prevent  all  possibility  of  including  the  lowest  cord  of  the  plexus. 
The  operation  in  a  thin  patient  may  be  easy,  but  in  a  stout  subject,  with  a 
short  thick  neck  and  high  clavicle,  the  greatest  difficulty  may  be  experienced 
in  finding  the  vessel.  The  chief  dangers  arise  from  wounding  the  aneurismal 
sac,  the  pleural  cavity,  or  the  superficial  veins,  whilst  the  proximity  of  the 
cords  of  the  brachial  plexus  must  not  be  forgotten. 

Collateral  Circulation. — Thoracic  set :  Branches  of  the  aortic  intercostals  and 
internal  mammary  with  thoracic  branches  of  axillary. 

Scapular  set :  Suprascapular  and  posterior  scapular  with  subscapular  and  its 
dorsalis  branch  in  the  venter  or  on  the  dorsum  of  scapula. 

Acromial  set :  Suprascapular  with  acromio-thoracic. 

The  Internal  Mammary  Artery  (Fig.  72,  M)  may  be  exposed  and  tied  by 
dividing  the  intercostal  aponeurosis  and  muscles  for  an  inch  or  more  from 
the  outer  edge  of  the  sternum,  from  which  margin  it  is  distant  about  ^  inch. 
If  the  vessel  has  been  divided,  and  the  ends  have  retracted,  it  may  be  necessary 
to  excise  a  portion  of  costal  cartilage  in  order  to  secure  both  ends — a  most 
necessary  proceeding,  owing  to  the  freedom  of  the  collateral  circulation  and 
the  consequent  liability  to  continued  haemorrhage. 

Ligature  of  the  Vertebral  Artery  has  been  undertaken  for  wounds,  for 
secondary  haemorrhage  after  ligature  of  the  innominate  and  in  the  treatment 
of  epilepsy,  but  without  much  permanent  benefit  in  the  last  case.  The  opera- 
tion, though  by  no  means  easy,  is  usually  successful  as  far  as  the  immediate 


288  A  MANUAL  OF  SURGERY 

surgical  procedure  is  concerned.  An  incision  is  made  along  the  lower  half  o 
the  posterior  border  of  the  sterno-mastoid  (Fig.  72,  V),  the  platysma  and  deep 
fascia  divided,  a  few  of  the  posterior  fibres  of  the  muscle  itself  incised  if  need 
be,  and  its  belly  drawn  well  forwards.  The  scalenus  anticus  muscle  is  clearly 
defined,  together  with  the  phrenic  nerve.  The  interval  between  it  and  the 
longus  colli  muscle  can  now  be  demonstrated,  with  the  ascending  cervical 
artery  lying  upon  it  The  anterior  transverse  process  of  the  sixth  cervical 
vertebra  must  be  made  out.  Just  below  this  the  vertebral  vessels  are  found 
entering  the  canal  in  the  transverse  process,  and  the  vein,  which  is  placed 
anteriorly,  is  drawn  outwards  to  allow  the  needle  to  be  passed  from  without 
inwards.  A  few  sympathetic  twigs  are  included  in  the  ligature,  and  the 
resulting  contraction  of  the  pupil  may  (according  to  MacCormac)  be  looked 
upon  as  satisfactory  evidence  that  the  vertebral  has  been  in  reality  secured. 

Ligature  of  the  Thyroid  Vessels  is  sometimes  used  as  a  means  of  arresting 
the  growth  of  a  goitre. 

The  superior  thyroid  artery  is  tied  by  an  operation  similar  to  that  for  the 
external  carotid.  The  incision  along  the  anterior  margin  of  the  sterno- 
mastoid  has  its  centre  opposite  the  upper  border  of  the  thyroid  cartilage  ; 
the  external  carotid  is  defined,  and  the  superior  thyroid  secured  as  it  rises 
from  it. 

The  inferior  thyroid  artery  is  reached  by  an  incision  along  the  inner  border  of 
the  sterno-mastoid,  extending  upwards  from  the  clavicle  for  3  inches.  This 
muscle  and  the  subjacent  carotid  sheath  are  drawn  outwards,  the  sterno-hyoid 
and  -thyroid  usually  needing  to  be  divided.  The  transverse  process  of  the 
sixth  cervical  vertebra  is  sought  for,  and  the  vessel  found  passing  inwards 
immediately  below.  It  is  taken  up  just  behind  the  carotid,  and  as  far  from  the 
recurrent  nerve  as  possible. 

The  Axillary  Artery  is  tied  for  punctured  wounds  of  the  axilla,  as  a  distal 
operation  for  subclavian  aneurism,  occasionally  for  wounds  of  the  palmar 
arch,  and  possibly  for  secondary  haemorrhage  from  the  brachial.  For  aneurism 
of  the  brachial,  one  would  nowadays  prefer  extirpation  of  the  sac  if  compres- 
sion fails.  Two  classical  operations  are  described  and  practised  in  classes  on 
operative  surgery. 

1.  Ligature  of  the  first  part  of  the  vessel  is  usually  undertaken  through  a  curved 
incision,  with  its  concavity  upwards,  extending  from  the  coracoid  process  to 
within  1  inch  of  the  sterno-clavicular  joint,  and  i,  inch  below  the  clavicle 
(Fig.  72,  C).  The  clavicular  origin  of  the  pectoralis  major  is  divided,  and  the 
costo-coracoid  membrane  exposed,  and  divided  along  the  lower  border  of  the 
subclavius  muscle.  Branches  of  the  acromio-thoracic  axis  are  displaced 
downwards,  and  the  main  trunk  is  exposed  by  a  blunt  dissector  and  forceps. 
The  vein  lies  within  and  below,  and  the  cords  of  the  brachial  plexus  above 
and  to  the  outer  side.  The  needle  is  passed  from  below  upwards.  The 
divided  muscular  fibres  should  be  subsequently  sutured  together. 

An  incision  which  gives  an  unusually  good  approach  and  involves  less 
division  of  muscular  fibres  is  one  which  follows  the  lower  border  of  the 
clavicle  from  its  centre  outwards  to  the  coracoid  process,  and  then  turns  down 
to  lie  over  the  interspace  between  the  pectoralis  major  and  deltoid  muscles. 
This  intersection  is  opened  up  and  the  outermost  fibres  of  origin  from  the 
clavicle  of  the  pectoralis  are  divided.  The  costo-coracoid  membrane  is  thus 
exposed,  and  the  cephalic  vein  will  act  as  a  guide  to  the  vessels. 

2.  Ligature  of  the  third  part  of  the  artery  is  performed  from  the  axilla.  The 
arm  is  fully  abducted,  and  the  surgeon  stands  between  it  and  the  body.  An 
incision  is  made  in  the  course  of  the  vessel  at  the  junction  of  the  anterior  and 
middle  thirds  of  the  space  between  the  axillary  folds  (Fig.  74,  A).  The  inner 
border  of  the  coraco-brachialis  muscle  is  clearly  defined,  and  forms  the  first 
rallying-point ;  it  is  drawn  slightly  outwards,  and  the  median  nerve,  together 
with  the  musculo-cutaneous  trunk ,  at  once  comes  into  view.    On  drawing  these 


LIGATURE  OF  VESSELS 


inwards,  the  artery  itself  is  seen,  with  the  vein  to  the  inner  side,  together  with 
the  internal  cutaneous  nerve.     The  needle  is  passed  from  the  vein. 

Collateral  Circulation. — If  above  the  acromio-thoracic,  the  same  as  for  the 
third  part  of  the  subclavian  (q.v.). 

If  above  the  subscapular  and  circumflex :  Long  thoracic  and  intercostals 
with  thoracic  branches  of  subscapular  ;  suprascapular  and  posterior  scapular 
with  scapular  branches  of  subscapular ;  suprascapular  and  acromio-thoracic 
with  posterior  circumflex  in  the  deltoid. 

If  below  the  circumflex,  same  as  for  ligature  of  brachial  above  the  superior 
profunda — i.e.,  posterior  circumflex  with  superior  profunda  in  the  deltoid. 

The  Brachial  Artery  may  need  to  be  ligatured  for  haemorrhage  from  the 
palmar  arches,  or  from  a  wound  in  the  forearm  or  about  the  elbow,  for 
aneurisms,  or  for  arterio-venous  wounds  at  the  bend  of  the  elbow.  It  may  be 
tied  in  one  of  two  places  : 

i.  At  the  Middle  of  the  Arm. — The  arm  is  held  away  from  the  side  at  a  right 
angle,  with  the  hand  supine,  but  with  no  support  beneath  it,  for  fear  of 
pushing  forwards  the  triceps  and  displacing  the  vessel.  The  surgeon  stands 
between  the  arm  and  the  trunk.  An  incision  2  inches  long  is  made  in  the  line 
of  the  vessel  along  the  inner  border  of  the  biceps  muscle  (Fig.  74,  B),  and  the 
thin  fascial  investment  of  the  limb  divided.  The  inner  edge  of  the  muscle  is 
clearly  exposed,  and  by  drawing  it  slightly  forwards  the  median  nerve  is 
brought  into  view,  and  perhaps  the  basilic  vein.  The  nerve,  which  is  at  this 
spot  crossing  the  artery  from   without  inwards,   is  drawn  inwards,  and  the 


sss^^^j^^WII^K 


Fig.  74. — Incisions  for  tying  the  Arteries  of  the  Arm. 

A,  Third  part  of  the  axillary  ;  B,  brachial ;  C,  brachial  at  the  bend  of  the 
elbow ;  D,  middle  third  of  radial ;  G,  middle  third  of  ulnar ;  E  and  F, 
lower  thirds  of  radial  and  ulnar. 

sheath  of  the  vessel  found  beneath  it.  The  artery  is  separated  from  its  venae 
comites,  and  the  ligature  passed  and  tied. 

The  operation  is  by  no  means  always  an  easy  one,  as  there  are  many  traps 
into  which  the  beginner  may  fall.  Thus  the  median  nerve  may  cross  behind 
the  vessel  instead  of  in  front  of  it ;  the  basilic  vein  may  lie  over  its  situation, 
and  be  mistaken  for  it  ;  or  there  may  be  a  high  division,  and  two  trunks, 
usually  lying  close  together,  must  then  be  sought  for  instead  of  one.  The  most 
common  mistake  consists  in  not  defining  the  biceps  muscle,  and  in  seeking  for 
the  artery  behind  its  proper  situation. 

2.  At  the  Bend  of  the  Elbon*. — An  oblique  incision  is  made,  about  2  inches 
long,  parallel  to  the  inner  border  of  the  biceps  tendon,  its  lower  end  cor- 
responding to  the  crease  of  the  elbow  (Fig.  74,  C).  The  wound  should  be 
placed  at  about  an  angle  of  forty-five  degrees  to  the  axis  of  the  limb,  and  to 
the  outside  of,  and  nearly  parallel  to,  the  median  basilic  vein,  which,  if  seen, 
must  be  drawn  inwards.  The  bicipital  fascia  is  now  incised,  and  the  artery 
with  its  venae  comites  exposed  in  the  loose  fat,  the  median  nerve  being  well 
away  on  the  inner  side.     The  needle  is  passed  from  within  outwards. 

Collateral  Circulation.— If  above  the  origin  of  the  superior  profunda,  pos- 
terior circumflex  in  deltoid  with  ascending  branches  of  superior  profunda. 

19 


290 


A   MANUAL  OF  SURGERY 


If  below  the  origin  of  the  inferior  profunda,  the  anastomoses  around  the 
elbow-joint. 

The  Ulnar  Artery  rarely  needs  ligature  except  for  palmar  haemorrhage  or 
direct  wounds  In  the  former  case  the  artery  can  easily  be  secured  just  above 
the  wrist,  in  the  latter  case  by  enlarging  the  original  wound.  The  following 
stereotyped  operations  are  described,  but  are  more  often  seen  in  the  examina- 
tion room  or  dead-house  than  in  the  operating  theatre.  It  should  be  borne  in 
mind  that  the  artery  curves  inwards  from  the  centre  of  the  bend  of  the  elbow 
to  the  radial  side  of  the  pisiform  bone.  The  lower  two-thirds  of  its  course  is 
indicated  by  a  line  drawn  from  the  internal  condyle  of  the  humerus  to  the 
same  spot  below. 

1.  At  the  Wrist. — An  incision  about  1  inch  in  length  is  made  directly  upwards 
from  the  flexure  of  the  wrist  in  the  line  of  the  vessel  (Fig.  74,  F).  The  deep 
fascia  is  opened  ;  the  tendon  of  the  flexor  carpi  ulnaris  drawn  to  the  inner  side, 
and  the  vessels  are  then  seen,  accompanied  by  the  nerve  which  lies  to  the 
ulnar  side  of  the  artery.  If  possible,  the  venae  comites  should  be  separated, 
and  not  included  in  the  ligature. 

2.  In  the  Middle  of  the  Forearm. — An  incision  is  made  along  a  line  drawn  from 
the  anterior  edge  of  the  tip  of  the  inner  condyle  to  the  radial  side  of  the  pisi- 
form bone  (Fig.  74,  G).  The  white  line  indicating  the  intermuscular  septum 
between  the  flexor  carpi  ulnaris  and  flexor  sublimis  digitorum  is  then  sought 
for  and  opened  up;  it  is  often  very  slightly  marked,  and  may  be  difficult  to 
distinguish.  If  the  correct  interspace  has  been  opened,  the  surgeon  is  directed 
towards  the  ulnar,  and  readily  finds  the  vessels  under  cover  of  the  flexor  carpi 
ulnaris,  with  the  nerve  lying  a  little  way  to  the  inner  side.  The  most  common 
mistake  consists  in  getting  too  far  tr.  the  radial  side,  and  in  separating  various 
portions  of  the  flexor  sublimis,  or  in  passing  between  it  and  the  palmaris 
longus.  Occasionally,  even  when  the  correct  interspace  has  been  entered,  a 
beginner  may  pass  beyond  the  vessels,  and  find  himself  between  the  flexor 
carpi  ulnaris  and  the  flexor  profundus. 

The  extreme  upper  limit  of  the  ulnar  artery  can  also  be  reached  through 
an  oblique  incision  extending  along  the  upper  border  of  the  pronator  teres, 
thus  opening  up  the  ante-cubital  fossa,  and  exposing  the  bifurcation  of  the 
brachial. 

Radial  Artery  — The  line  of  the  vessel  extends  from  the  middle  of  the 
bend  of  the  elbow  to  the  interspace  at  the  wrist  between  the  flexor  carpi 
radialis  and  the  supinator  longus.  It  then  turns  outwards,  and  may  be  felt 
beating  in  the  space  described  by  French  anatomists  as  '  la  tabatiere  '  (or 
snuff-box),  between  the  tendons  of  the  extensor  primi  and  secundi  internodii 
muscles. 

1.  At  the  Back  of  the  Wrist  the  vessel  may  be  secured  by  opening  up  the 
above-mentioned  intertendinous  hollow,  where  the  artery  is  found  coursing 
onwards  to  the  base  of  the  first  interosseous  space.  An  oblique  incision  is 
made  between  the  tendons,  extending  from  the  back  of  the  styloid  process  of 
the  radius  to  the  base  of  the  first  metacarpal  bone.  The  superficial  radial 
vein  is  found  beneath  the  skin,  and  a  few  twigs  of  the  radial  nerve.  A  deeper 
layer  of  fascia  is  then  divided,  passing  between  the  tendons,  and  beneath  it 
the  artery  is  exposed,  crossing  the  incision  obliquely.  The  synovial  sheaths 
accompanying  the  tendons  should  not  be  opened,  or  some  limitation  of  the 
movements  of  the  thumb  may  result. 

2.  Above  the  Wrist  an  incision  is  made  in  the  line  of  the  vessel  (Fig.  74,  E), 
which  is  found  after  division  of  the  fascia  between  the  supinator  longus  and 
flexor  carpi  radialis.  The  radial  nerve  has  passed  to  the  dorsum  ere  this,  and 
if  any  nerve  filaments  are  seen  they  are  derived  from  the  external  cutaneous. 
A  small  superficial  vein  usually  lies  over  the  artery. 

3.  In  the  Middle  or  Upper  Third  of  the  Forearm  an  incision  is  made  in  the  line 
of  the  vessel  (Fig.  74,  D),  and  the  inner  border  of  the  supinator  longus  sought 


LIGATURE  OF   VESSELS 


291 


for  and  retracted.     The  vessels  are  found  under  cover  of  this  structure,  with 
the  radial  nerve  to  the  outer  side,  though  separated  by  an  interval  above. 

Ligature  of  the  Abdominal  Aorta*  has  been  undertaken  in  fourteen  instances 
for  severe  primary  or  secondary  haemorrhage,  or  for  diffuse  inguinal  or  iliac 
aneurism,  when  no  other  method  of  treatment  was  practicable.  All  these 
cases  have  proved  fatal,  though  one  patient  operated  on  by  Monteiro  in  South 
America  survived  till  the  tenth  day,  whilst  Keen's  and  Tillaux's  lived  forty- 
eight  and  thirty-nine  days  respectively.  The  fatal  issue  was  in  most  instances 
due  to  septic  contamination  of  the  wound  and  secondary  haemorrhage,  and 
as  the  operation  has  certainly  been  successful  in  animals,  it  is  possible  that 
we  may  vet  be  able  to  chronicle  a  satisfactory  result  as  a  triumph  of  modern 
surgery. 

Two  distinct  plans  of  operation  have  been  followed,  viz.,  the  trans-peritoneal, 
and  the  extra-  or  retro-peritoneal,  but  no  one  would  attempt  the  latter  nowa- 
days. The  trans-peritoneal  operation  consists  in  opening  the  abdomen  through 
an  incision  slightly  to  the  left  of  the  middle  line,  having  the  umbilicus  on  a 
level  with  its  centre.  The  intestines  are  retracted  on  either  side,  and  the 
posterior  layer  of  the  serous  membrane  covering  the  aorta  carefully  divided  ; 
there  is  then  no  difficulty  in  passing  a  ligature  around  the  vessel.  Possibly 
the  same  precaution  to  prevent  excessive  backflow  of  blood  would  be  advisable 
as  in  tying  the  innominate,  viz.,  to  secure  one  or  both  of  the  common  iliac 
trunks  in  addition  ;  such  would  in  no  way  interfere  with  the  establishment  of 
the  collateral  circulation. 

The  Common  Iliac  Artery  extends  for  a  distance  of  2  inches  from  the  bifur- 
cation of  the  aorta  opposite  the  left  side  of  the  body  of  the  fourth  lumbar 
vertebra  to  the  front  of  the  sacro-iliac  synchondrosis.  It  may  be  reached,  as 
the  aorta,  by  two  methods,  the  trans-  and  the  retro-peritoneal. 

In  the  retro-peritoneal  operation  a  curved  incision  (Fig.  75,  A  or  B)  is  made 
through  the  abdominal  parietes,  somewhat  similar  to  that  for  ligaturing  the 
external  iliac,  but  extending  higher.  The  muscles  and  fascia  transversalis  are 
carefully  divided,  and  the  peritoneum,  together  with  its  contents,  stripped  up 
and  held  out  of  the  way  with  a  broad  retractor.  The  ureter  which  crosses 
the  artery  is  usually  carried  forwards  with  the  peritoneum.  The  vessel  is  now 
sought  for,  carefully  cleaned,  and  a  ligature  passed  from  right  to  left  (of  the 
patient)  on  both  sides  of  the  body,  the  vein  lying  behind  the  artery  on  the 
right  side,  and  behind  and  internal  to  it  on  the  left. 

The  trans-peritoneal  plan  has  already  been  undertaken  with  success,  and  will 
doubtless  henceforth  supersede  all  other  methods.  An  incision  is  made  in 
the  median  line  with  its  centre  a  little  below  the  umbilicus,  the  peritoneum 
opened,  the  intestines  retracted,  the  vessel  sought  for  and  exposed  bv  an 
incision  through  the  posterior  layer  of  the  parietal  peritoneum,  and  a  ligature 
passed  and  tied.  The  ureter  which  crosses  the  artery  just  above  its  bifurca- 
tion must  be  carefully  avoided. 

Collateral  Circulation  after  Ligature  of  Common  Iliac  Artery.  —  Blood 
reaches  the  external  iliac  and  its  branches  by  means  of  the  anastomoses  of  the 
lumbar  arteries  with  the  circumflex  iliac,  and  of  the  superior  epigastric, 
lumbars,  and  intercostals  with  the  superficial  and  deep  epigastric.  The 
internal  iliac  and  its  branches  are  supplied  by  the  union  of  (a)  the  lumbar 
branches  with  the  ilio-lumbar  ;  (b)  the  middle  sacral  with  the  lateral  sacral  ; 
(c)  the  retro-pubic  anastomosis  of  the  two  obturator  arteries  ;  and  (</)  the 
communications  of  the  pudic,  haemorrhoidal,  and  vesical  trunks  with  those  of 
the  opposite  side. 

Ligature  of  the  Internal  Iliac  Artery  is  occasionally  performed  for  haemor- 

*  See  Tillaux  and  Riche,  '  Revue  de  Chirurgie,'  January,  Februarv,  and 
March,  1901. 

1 9 — 2 


292 


A   MANUAL  OF  SURGERY 


rhage  from,  or  aneurism  of,  one  of  its  branches,  the  gluteal  being  that  most 
commonly  affected,  and  lately  has  been  recommended  as  a  means  of  diminish- 
ing the  size  of  an  enlarged  prostate.  The  trunk  is  a  chort  one,  at  most 
i.V  inches  in  length,  and  is  best  reached  by  opening  the  abdomen  in  the 
middle  line  below  the  umbilicus  (Fig.  75,  C),  pushing  aside  the  intestines,  and 
searching  for  the  bifurcation  of  the  common  iliac.  The  posterior  layer  of 
the  peritoneum  is  then  carefully  incised,  the  ureter  avoided,  and  an  armed 
aneurism  needle  passed  without  wounding  the  vein. 

The  Collateral  Circulation  is  the  same  as  that  given  for  the  internal  iliac 
division  of  the  common  iliac. 

The  Gluteal  Artery  occasionally  needs  to  be  secured  at  its  point  of  emergence 
from  the  pelvis  through  the  upper  part  of  the  great  sacro-sciatic  foramen. 
This  spot  is  indicated  by  the  junction  of  the  inner  and  middle  thirds  of  a  line 


Fig.  75. — Incisions  for  Operations  on  Lower  Part  of  Abdomen 
and  Thighs. 

A,  Mott's  incision  for  tying  common  iliac  artery ;  B,  Marcellin  Duval's  incision 
for  the  same;  C,  incision  for  trans-peritoneal  ligature  of  internal  iliac 
artery  ;  D,  incision  for  excision  of  hip  by  the  anterior  method  ;  F,  Aber- 
nethy's  modified  operation  for  ligature  of  external  iliac ;  G,  Astley 
Cooper's  incision  for  same;  H,  ligature  of  femoral  artery  at  apex  of 
Scarpa's  triangle  ;  K,  ligature  of  femoral  artery  in  Hunter's  canal. 


drawn  from  the  posterior  superior  iliac  spine  to  the  top  of  the  great  trochanter. 
An  incision  is  made  in  the  direction  of  this  line,  i.e.,  along  the  fibres  of  the 
gluteus  maximus,  which  are  separated  and  held  apart.  The  deep  fascia 
beneath  this  muscle  is  then  opened  up,  and  the  space  between  the  gluteus 
medius  and  pyriformis  defined.  Through  this  the  upper  margin  of  the  sacro- 
sciatic  notch  can  be  detected,  as  also  the  pulsation  of  the  artery.  The  vessel 
must  be  secured  as  deeply  as  possible  on  account  of  its  early  division.  It  is 
always  a  troublesome  dissection,  and  possibly  in  most  cases  it  would  be  wiser 
to  deal  with  the  trunk  of  the  internal  iliac  from  the  front. 

The  Sciatic  and  Pudic  Arteries  seldom  require  to  be  tied,  but  may  be 
reached  opposite  the  ischial  spine,  at  the  junction  of  the  middle  and  lower 
thirds  of  a  line  drawn  from  the  posterior  superior  iliac  spine  to  the  tuber 


LIGATURE  OF  VESSELS  293 

ischii.  An  incision  about  4  inches  in  length  is  made  over  this  spot,  cor- 
responding in  direction  to  the  fibres  of  the  gluteus  maximus,  which  are 
separated.  The  spine  of  the  ischium  and  lower  border  of  the  pvriformis 
should  now  be  defined,  and  the  vessels  and  nerves  seen  emerging  from  the 
foramen.  The  pudic  vessel  lies  to  the  inner  side  of  the  sciatic ;  the  ligature  is 
passed  as  high  as  possible. 

The  External  Iliac  Artery  is  easily  accessible  in  any  part  of  its  course,  which 
measures  from  3^  to  4  inches  in  length  ;  it  has  but  few  branches,  and  those 
situated  low  down.  Its  position  is  indicated  by  the  lower  two-thirds  of  a 
line  drawn  from  the  bifurcation  of  the  aorta  to  midway  between  the  anterior 
superior  spine  and  the  symphysis  pubis,  i.e.,  to  a  point  a  little  internal  to  the 
middle  of  Poupart's  ligament. 

Many  suggestions  as  to  the  best  means  of  reaching  the  artery  have  been 
made,  and  both  trans-  and  extra-peritoneal  methods  have  been  adopted.  It  is 
so  readily  secured,  however,  by  the  latter  that  it  seems  unnecessary  to  open 
the  peritoneum.     There  are  two  chief  forms  of  extra-peritoneal  operation. 

Astley  Cooper's  Operation. — An  incision  is  made  parallel  to  the  outer  half  of 
Poupart's  ligament,  commencing  a  little  to  the  inner  side  of  its  centre,  and 
-§  inch  above  it,  and  extending  upwards  and  outwards  to  about  1  inch  internal 
to  the  anterior  superior  spine  (Fig.  75,  G).  The  external  oblique  aponeurosis 
is  divided  along  this  line,  and  the  exposed  lower  margins  of  the  internal 
oblique  and  transversalis  muscles  arching  over  the  inguinal  canal  are  drawn 
upwards  by  retractors.  The  transversalis  fascia  and  loose  subperitoneal  fat 
are  now  opened  with  forceps  and  director,  and  the  vessel  is  felt  pulsating 
immediately  under  the  finger.  It  is  very  important  not  to  damage  either  the 
epigastric  or  circumflex  iliac  arteries  during  this  manipulation,  since  they 
are  most  essential  factors  in  establishing  the  collateral  circulation,  whilst  the 
circumflex  iliac  vein  crossing  the  main  trunk  must  also  be  avoided.  The 
needle  is  passed  from  within  outwards,  the  ligature  tied,  and  the  divided 
muscular  and  aponeurotic  structures  brought  accurately  together  by  buried 
sutures. 

Abernethy's  Modified  Operation  is  more  commonly  utilized.  The  incision, 
about  4  inches  in  length,  extends  from  a  point  1^  inches  within  and  above  the 
anterior  superior  iliac  spine  to  just  external  to,  and  |  inch  above,  the  middle 
of  Poupart's  ligament  (Fig.  75,  F).  Through  this  the  aponeurosis  of  the 
external  oblique  is  divided  along  the  course  of  its  fibres,  as  also  the  internal 
oblique  and  transversalis.  The  transversalis  fascia  is  now  carefully  incised  ; 
it  varies  considerably  in  thickness,  being  sometimes  well  developed,  but  is 
occasionally  so  attenuated  as  to  be  scarcely  recognisable,  and  in  such  cases 
the  peritoneum  may  unintentionally  be  opened.  In  the  present  day  this  is  an 
accident  of  slight  importance,  the  wound  being  readily  closed  by  a  continuous 
suture,  and  no  harm  resulting.  The  fingers  are  now  introduced  into  the 
wound,  and  the  peritoneum  and  its  contents  stripped  from  the  iliac  fossa, 
and  drawn  inwards  and  forwards,  where  they  are  kept  out  of  the  way  by  a 
broad  spatula.  In  the  space  thus  opened  up  one  can  see  the  iliacus  muscle 
covered  by  its  fascia,  and  to  its  inner  side  the  rounded  outline  of  the  psoas. 
The  vessel  lies  to  the  inner  border  of  this,  and  can  usually  be  readily  found, 
enveloped  in  a  fascial  sheath,  with  the  genito-crural  nerve  coursing  over  it, 
and  perhaps  some  lymphatic  glands  upon  it.  The  artery  is  separated  from 
the  vein  which  lies  to  the  inner  side,  and  the  needle  passed  from  within 
outwards.  If  the  transversalis  fascia  has  not  been  properlv  opened,  it  is  quite 
possible  to  strip  it  up  together  with  the  peritoneum,  and  carry  the  vessels 
forwards  with  it,  when  they  may  be  found  under  cover  of  the  spatula. 

On  comparing  the  two  operations,  we  are  very  distinctly  in  favour  of  the 
latter  plan.  By  Cooper's  method  the  artery  is  tied  very  close  to  important 
collateral  branches,  whilst  but  a  small  portion  of  the  trunk  is  exposed,  so  that 
if  that  is  diseased  and  unsuitable  for  the  application  of  a  ligature,  no  further 
choice  is  possible.     In  Abernethy's,  on  the  other  hand,  the  vessel  is  tied  well 


294   •  A  MANUAL  OF  SURGERY 


away  from  collateral  branches,  and  if  the  exposed  portion  of  the  trunk  is 
diseased,  the  common  iliac  can  be  reached  and  secured  without  much  difficulty 
bj  extending  the  incision  upwards.  As  to  the  greater  tendency  to  hernia 
stated  to  exist  in  this  method,  this  may  have  been  the  case  in  pre-antiseptic 
days,  when  the  muscles  were  not  sutured  for  fear  of  retaining  septic  discharges ; 
but  careful  asepsis,  the  use  of  buried  sutures,  and  the  possibility  of  doing 
without  drainage  tubes  should  render  such  a  sequela  impossible. 

Collateral  Circulation. — Anterior  set:  Superior  epigastric  of  internal  mam- 
mary, lumbar,  and  lower  intercostals  with  superficial  and  deep  epigastric  in 
sheath  of  rectus. 

Posterior  set  :  Gluteal  and  sciatic  with  internal  and  external  circumflex  and 
first  perforating  of  profunda  at  back  of  great  trochanter  (crucial  anastomosis). 

External  set:  Ilio-lumbar  and  gluteal  with  deep  and  superficial  circumflex 
iliac  and  ascending  branch  of  external  circumflex. 

Internal  set:  Obturator  with  internal  circumflex;  and  terminal  divisions  of 
internal  pudic  with  superficial  and  deep  external  pudic. 

The  Common  Femoral  Artery  is  but  rarely  ligatured,  except  as  a  preliminary 
measure  in  amputation  at  the  hip-joint,  since  the  number  of  branches  arising 
from  it  is  likely  to  interfere  with  its  sound  occlusion,  and  the  collateral  circula- 
tion is  better  after  ligature  of  the  external  iliac.  It  may  be  reached  by  a  vertical 
incision  over  the  line  of  the  vessel,  extending  both  a  little  above  and  below 
Poupart's  ligament.  The  superficial  lymphatics  and  veins  must  be  carefully 
avoided,  the  fascia  lata  divided,  the  sheath  exposed  and  opened,  and  the  liga- 
ture passed  from  the  inner  side. 

Collateral  Circulation  — Interna!  set :  Obturator  with  internal  circumflex,  and 
internal  pudic  with  external  pudic. 

External  set :  Circumflex  iliac  with  ascending  branch  of  external  circumflex. 

Posterior  set :  Gluteal  and  sciatic  with  internal  and  external  circumflex,  and 
first  perforating  ;  comes  nervi  ischiadici  with  perforating  of  the  profunda  and 
muscular  of  popliteal. 

The  Superficial  Femoral  Artery  is  indicated  by  a  line  drawn  from  midway 
between  the  anterior  superior  spine  and  the  symphysis  pubis  to  the  tuberosity 
of  the  internal  condyle,  the  limb  being  flexed,  abducted,  and  a  little  everted. 
It  may  be  secured  at '  the  site  of  election,'  i.e.,  at  the  apex  of  Scarpa's  triangle, 
or  in  Hunter's  canal. 

Ligature  at  the  Apex  of  Scarpa's  Triangle. — A  4-inch  incision  is  made  in  the 
line  of  the  artery,  the  centre  being  about  4  inches  (or  a  hand's  breadth)  below 
Poupart's  ligament  (Fig.  75,  H).  The  integument  and  fascia;  are  divided,  the 
inner  border  of  the  sartorius  exposed,  and  the  sheath  found  immediately  behind 
it,  the  muscle  being  drawn  slightly  outwards;  the  middle  cutaneous  nerve  is 
perhaps  brought  into  view.  A  muscular  branch  to  the  sartorius  may  be  met 
with  at  this  spot,  and  should  be  separately  ligatured.  The  vein  is  placed 
behind  the  artery,  so  that  the  needle  may  be  passed  either  way,  special  care 
being  taken  to  keep  it  close  to  the  vessel. 

Collateral  Circulation. — External  circumflex  with  lower  muscular  of  femoral, 
anastomotica  magna,  and  superior  articular  of  popliteal. 

•   Profunda  femoris  by  its  perforating  and  terminal  branches  with  the  muscular 
and  articular  branches  of  femoral  and  popliteal. 

Ligature  in  Hunter's  Canal. — An  incision  4  inches  in  length  is  made  along  the 
line  of  the  artery  in  the  middle  of  the  thigh  (Fig.  75,  K).  The  sartorius 
is  exposed  by  division  of  the  fascia  lata,  its  fibres  running  downwards  and 
inwards  ;  its  outer  border  should  be  defined,  and  the  muscle  retracted  inwards. 
The  aponeurotic  covering  of  Hunter's  canal  is  now  in  view,  stretching  between 
the  adductor  longus  and  vastus  internus  ;  it  is  incised,  and  the  sheath  of  the 
vessel  found  below  it,  with  the  nerve  to  the  vastus  internus  lying  to  its  outer 
side,  the  long  saphenous  nerve  crossing  it  from  without  inwards,  and  the  vein 
passing  behind  it,  to  become  external  lower  down.    The  needle  maybe  passed 


LIGATURE  OF  VESSELS  295 


in  either  direction,  and  the  ligature  should  not  be  placed  too  low  on  account 
of  the  contiguity  of  the  anastomotica  magna.  A  common  mistake  made  by 
students  in  tying  this  artery  on  the  dead  subject  is  to  burrow  down  along  the 
vastus  internus  on  the  outer  side  of  the  vessels  ;  this  is  to  be  avoided  by  always 
keeping  close  to  the  under  surface  of  the  sartorius  until  the  glistening  trans- 
verse fibres  of  Hunter's  aponeurosis  are  clearly  visible. 

Collateral  Circulation  is  maintained  through  the  profunda  and  its  branches. 

The  Popliteal  Artery  may  be  tied  either  just  after  it  has  passed  through  the 
adductor  opening,  or  in  the  depths  of  the  popliteal  space,  but  preferably  in  the 
former  situation.     Neither  operation  is  often  required. 

To  tie  the  upper  part,  the  limb  is  fully  abducted  and  everted  so  as  to  enable 
the  adductor  tubercle  and  tendon  of  the  adductor  magnus  to  be  clearly  defined. 


Fig.   76 — Incisions  for  Ligature  of  the  Upper  Part  of  the  Popliteal 
(a),  and  of  the  posterior  tibial  arteries  (b,  c,  and  d) . 

E,  Site  for  Introduction  of  Knife  in  Tenotomy  of  Tibialis  Posticus  ; 
F,  Ditto  for  Tendo  Achillis. 

An  incision,  4  inches  in  length,  is  then  made  from  the  tubercle  upwards 
(Fig.  76,  A),  and  the  tendon  exposed.  The  internal  saphenous  vein  and  nerve 
may  be  seen,  but  are  drawn  backwards  by  means  of  a  broad  retractor,  together 
wdth  the  sartorius,  gracilis,  and  semi-membranosus.  If  possible,  the  branch  of 
the  anastomotica  magna  which  courses  along  the  tendon  should  be  spared. 
The  fascial  space  behind  is  now  opened  up,  and  the  artery  found  surrounded 
by  a  good  deal  of  loose  connective  tissue.  The  vein  is  usually  seen  on  the 
outer  side,  and  is  here  very  thick  and  dense,  so  that  in  the  dead  subject  it  can 
be  readily  mistaken  for  the  artery. 

The  lower  part  is  tied  through  an  incision  in  the  middle  line  of  the  popliteal 
space,  dividing  the  deep  fascia,  and  drawing  out  of  the  way  the  heads  of  the 


296 


A  MANUAL  OF  SURGERY 


gastrocnemius  muscle,  and  the  internal  popliteal  nerve.  The  vein  is  superficial 
to  the  artery,  and  is  found  by  following  the  short  saphenous  trunk.  The 
needle  is  passed  from  the  inner  side. 

Collateral  Circulation  is  maintained  by  the  anastomoses  around  the  knee- 
joint. 

The  Posterior  Tibial  Artery  but  seldom  requires  to  be  ligatured  except 
for  haemorrhage,  or  on  the  face  of  amputation  stumps;  hence  the  operations 
described  below  are  rarely  seen  away  from  the  dead-house.  The  line  of  the 
vessel  is  indicated  by  one  drawn  from  the  centre  of  the  popliteal  space  to 
a  point  a  finger's  breadth  behind  the  internal  malleolus. 

1.  In  the  Middle  of  the  Calf. — The  leg  is  placed  on  its  outer  side,  and  flexed, 


Fig.  77. — Incisions  for  Liga- 
ture of  Anterior  Tibial 
(A  and  B)  and  Peroneal 
(C)  Arteries.  D,  Site  for 
Introduction  of  Knife  in 
Tenotomy  of  Peronei. 


Fig.  78.  —  Incisions  for 
Ligature  of  Lower 
Part  of  Anterior 
Tibial  (A)  and  Dorsalis 
Pedis  (B;  Arteries.  C, 
Site  for  performing 
Tenotomy  of  Tibialis 
Anticus. 


and  an  incision  4  inches  long  is  made  a  finger's  breadth  behind  the  inner 
border  of  the  tibia  (Fig.  76,  B),  dividing  the  skin  and  subcutaneous  tissues,  the 
long  saphenous  vein  and  nerve  being  drawn  aside  if  necessary.  The  tibial  origin 
of  the  soleus  is  thus  exposed,  and  incised  directly  towards  the  tibia,  until  the 
fibrous  aponeurosis  on  its  deeper  surface  is  met  with.  This  having  been  cut 
through,  the  muscle  is  drawn  backwards  with  the  retractor,  and  the  vessels, 
ensheathed  in  a  deep  layer  of  fascia,  are  seen  lying  on  the  tibialis  posticus, 
and  with  the  posterior  tibial  nerve  to  the  outer  side.  The  venae  comites  are 
separated,  if  possible,  and  the  ligature  passed  from  the  nerve.  Sometimes  the 
above-mentioned  aponeurosis  is  in  the  substance  of  the  soleus,  and  a  thin  layer 
of  muscular  fibres  exists  on  its  deeper  aspect. 


LIGATURE  OF  VESSELS  297 

2.  In  the  Lower  Third  of  the  Leg. — An  incision  is  made  midway  between  the 
tendo  Achillis  and  inner  border  of  the  tibia  (Fig.  76,  C).  The  skin  and  fasciae, 
including  the  upper  part  of  the  internal  annular  ligament,  are  divided,  and  the 
vessels  seen  lying  on  the  flexor  longus  digitorum,  with  the  nerve  behind  and  to 
the  outer  side. 

3.  Behind  the  Malleolus. — An  incision  is  made  about  a  finger's  breadth  from 
the  malleolus,  curving  round  its  lower  border  (Fig.  76,  D).  The  deep  fascia 
(or,  as  it  is  here  termed,  the  internal  annular  ligament)  is  divided  over  the 
vessels  between  the  tendons  of  the  flexor  longus  digitorum  and  flexor  proprius 
hallucis.and  the  artery  is  then  readily  cleared  and  ligatured.  The  sheaths  of 
the  tendons  should  not  be  opened. 

The  Anterior  Tibial  Artery  is  found  along  a  line  stretching  from  a  point 
midway  between  the  outer  tuberosity  of  the  tibia  and  the  head  of  the  fibula 
above,,  to  the  central  point  between  the  two  malleoli  below.  It  may  be  tied  in 
three  situations. 

1.  In  the  Upper  Third  of  the  Leg. — An  incision  is  made  exactly  in  the  line  of 
the  artery  (Fig.  77,  A),  and  the  deep  fascia  incised.  The  intermuscular  space 
between  the  tibialis  anticus  and  the  extensor  communis  digitorum  is  opened. 
The  vessel  lies  between  these  muscles  upon  the  interosseous  membrane,  the 
anterior  tibial  nerve  being  to  the  outer  side. 

2.  In  the  Middle  of  the  Leg  (Fig.  77,  B). — The  same  intermuscular  space  is 
opened,  being  indicated  here  by  a  definite  white  line,  due  to  a  slight  sub- 
fascial deposit  of  fat.  The  vessels  lie  between  the  tibialis  anticus  and  the 
deeply  placed  extensor  proprius  hallucis,  the  nerve  usually  lying  on  the  artery 
and  needing  to  be  drawn  aside. 

3.  In  the  Lower  Third  of  the  Leg. — An  incision  is  made  in  the  line  of  the  artery, 
reaching  upwards  for  2  inches  from  a  point  just  above  the  ankle  (Fig  78,  A). 
The  deep  fascia  and  upper  part  of  the  annular  ligament  are  divided,  and  the 
vessel  is  found  between  the  tendons  of  the  tibialis  anticus  and  of  the  extensor 
proprius  hallucis,  the  nerve  lying  to  the  outer  side. 

The  Dorsalis  Pedis  Artery  extends  from  the  centre  of  the  line  between  the 
two  malleoli  to  the  interval  between  the  bases  of  the  first  two  metatarsal 
bones.  An  incision  is  made  in  this  direction  (Fig.  78,  B),  the  deep  fascia 
opened,  and  the  artery  found  lying  between  the  extensor  proprius  hallucis, 
which  has  now  crossed  and  is  internal  to  the  vessel,  and  the  innermost  slip  of 
the  extensor  brevis  digitorum.  It  is  by  no  means  easy  to  find,  and  for  practical 
purposes  the  best  plan  would  be  to  divide  the  vessel  by  an  incision  extending 
to  the  bones,  and  then  pick  up  and  tie  the  bleeding  ends. 

The  Peroneal  Artery  can  be  reached  through  an  incision  along  the  posterior 
border  of  the  centre  of  the  fibula,  the  leg  being  laid  on  its  inner  side 
(Fig.  77,  C).  The  outer  edge  of  the  soleus  is  defined  and  drawn  inwards,  the 
lower  fibres  of  attachment  to  the  fibula  being  divided,  if  necessary.  The  flexor 
longus  hallucis  is  thereby  exposed,  and  incised  in  such  a  manner  as  to  allow 
the  surgeon  to  reach  the  postero-internal  border  of  the  fibula  ;  the  artery  is 
then  readily  found  lying  in  an  osseo-aponeurotic  canal. 


CHAPTER  XL 
SURGERY  OF  THE  VEINS. 

Thrombosis. 

By  Thrombosis  is  meant  intravascular  coagulation  in  any  part  of 
the  circulatory  system.  Normally  the  blood  remains  in  a  fluid 
condition,  owing  to  some  interaction  between  it  and  the  vessel 
walls.  Any  factor  producing  a  disturbance  of  this  normal 
equilibrium  may  determine  thrombosis,  and  any  part  of  the 
vascular  tract  may  be  affected  by  it,  whether  the  heart,  arteries, 
veins,  or  capillaries.  We  have  already  discussed  some  of  the 
conditions  associated  with  capillary  or  arterial  thrombosis  ;  that 
which  follows,  whilst  referring  primarily  to  venous  thrombosis,  is 
also  in  a  measure  true  of  the  other  forms. 

Causes. — (i)  Changes  in  the  vessel  walls,  as  a  result  of  which  the 
integrity  of  the  endothelium  is  disturbed — e.g.,  injury  (either 
division,  rupture,  puncture,  compression,  or  contusion),  inflamma- 
tion or  degeneration  (as  in  varicose  veins). 

(2)  Changes  in  I  he  constitution  of  the  blood,  whereby  its  coagula- 
bility is  increased.  Excess  of  excretives,  as  after  pregnancy 
during  involution  of  the  uterine  walls,  may  have  this  effect,  or  the 
presence  of  toxins  arising  from  bacterial  activity  ;  hence  septic 
diseases  are  commonly  associated  with  thrombosis.  Great  loss 
of  blood  up  to  a  half  of  the  whole  amount  in  the  body  also 
increases  its  coagulability,  but  excess  of  leucocytes,  as  in  leukaemia, 
has  the  opposite  effect.  A.  E.  Wright  has  shown  that  the  per- 
centage of  calcium  chloride  in  the  blood  is  an  important  factor. 
If  o*6  per  cent,  of  this  salt  is  present,  coagulation  is  hastened, 
and  he  has  proposed  to  reduce  the  loss  of  blood  during  opera- 
tions to  a  minimum  by  injecting  into  the  rectum  half  an  hour 
previously  a  pint  of  warm  water  containing  in  solution  2  oz.  of 
this  salt.  In  one  or  two  cases  in  which  we  have  seen  it  used, 
it  appears  to  have  been  efficacious,  but  its  general  utility  is 
doubtful,  since  it  might  lead  to  coagulation  in  unwished-for 
localities. 


SURGERY  OF  THE  VEINS  299 

(3)  Diminished  rate  of  the  blood  stream  predisposes  to  thrombosis 
if  some  other  condition  is  present  to  determine  it.  Lister  showed 
years  ago  that  blood  can  remain  fluid  for  a  long  time  if  confined 
in  a  tube  formed  of  a  suitable  length  of  the  vein  wall ;  but  when 
either  of  the  preceding  factors  is  present,  a  retardation  of  the 
blood  stream  materially  assists  in  causing  coagulation.  Thus, 
when  a  vein  is  pressed  upon  by  a  tumour,  the  obstruction  to 
the  blood  flow  produces  a  clot  at  the  spot  where  the  nutrition 
of  the  wall  is  interfered  with.  After  fevers,  such  as  typhoid  or 
rheumatic,  where  the  character  of  the  blood  is  somewhat  altered 
and  the  action  of  the  heart  weakened  by  changes  in  the  muscular 
fibres,  the  defective  vis-a-tevgo  causes  a  retardation  of  the  flow 
in  the  veins,  as  a  result  of  which  the  intravenous  pressure  is 
diminished,  and  the  valves  are  only  partially  pushed  back,  spaces 
being  left  behind  them  in  which  the  blood  stagnates.  Coagulation 
is  probably  determined  by  some  slight  injury  or  pressure  which  is 
not  noticed  by  the  patient,  or  by  some  lessened  vitality  of  the  wrall 
of  the  vein,  or  by  disintegration  of  the  leucocytes  and  setting  free 
of  fibrin  ferment  owing  to  the  defective  circulation.  The  clots 
thus  formed  behind  the  valves  gradually  increase  in  size  until 
the  whole  lumen  of  the  vessel  is  obstructed.  The  white  leg  of  the 
puerperal  woman  is  sometimes  induced  in  the  same  way,  although 
it  is  probable  that  in  most  cases  the  coagulum  extends  to  the 
femoral  vein  from  the  uterine  plexuses.  A  similar  condition 
occurs  during  or  after  appendicitis,  and  is  then  probably  due 
to  the  direct  action  of  inflammatory  phenomena  around  the  iliac 
vein. 

The  Character  of  the  clot  varies  according  to  whether  it  is 
deposited  slowly  or  is  due  to  a  rapid  coagulation  of  the  blood. 
In  the  former  case  the  so-called  White  Thrombus  is  met  with, 
which  is  formed  upon,  and  adheres  to,  the  vessel  wall,  and 
gradually  increases  by  fresh  deposits  of  fibrin  until  it  entirely 
blocks  the  channel.  If  a  certain  number  of  red  corpuscles  are 
entangled  in  the  meshes  of  the  clot,  it  is  termed  a  Mixed 
Thrombus ;  the  more  rapid  its  formation,  the  greater  the  number 
of  red  corpuscles  present.  Should  the  blood  coagulate  en  masse  in 
a  vein,  as  after  its  total  division  or  ligature,  an  ordinary  Red 
Thrombus  is  produced,  which  at  first  is  not  adherent  to  the  wall, 
but  becomes  so  later  on,  especially  at  its  base.  A  similar  type  of 
clot  is  usually  found  post-mortem  capping  any  white  clot  which  has 
formed  previously. 

The  Effects  of  thrombosis  may  be  considered  under  the  follow- 
ing headings  :  local,  distal,  and  proximal. 

Locally,  the  following  conditions  may  obtain  :  (a)  The  clot 
may  be  organized  into  connective  tissue,  a  fibrous  cord  replacing 
the  vessel  in  the  same  way  as  was  described  for  arterial  throm- 
bosis in  a  previous  chapter  (p.  227).  (b)  The  lumen  of  the 
vein    may  be   re-established   by  cleavage   and   shrinking   of  the 


3°o 


A   MANUAL  OF  SURGERY 


thrombus  to  one  side  of  the  vein  wall,  or  by  canalization  of  the 
clot  or  of  the  fibrous  cicatrix  replacing  it,  owing  to  the  dilatation 
of  the  vessels  contained  within,  (c)  The  clot  may  soften,  dis- 
integrate, and  be  washed  away  in 
minute  particles  into  the  circulation.  If 
this  is  unattended  with  sepsis,  no  harm 
need  follow ;  but  if  septic  in  origin, 
local  abscesses,  or  even  diffuse  suppura- 
tion, may  occur  along  the  vein,  together 
with  general  pyaemia,  (d)  The  clot  may 
shrink  or  become  loosened  in  an  ampulla 
of  a  varicose  vein,  forming  a  fibrinous 
mass  which  is  subsequently  infiltrated 
with  calcareous  particles,  constituting  a 
vein  stone  or  Phlebolith. 

Distally,  congestion  of  the  terminal 
veins  is  caused  by  the  obstruction  to 
the  circulation,  and  if  a  main  trunk  is 
affected,  oedema  of  the  limb  follows, 
and  possibly  ulceration  or  gangrene.  In 
favourable  cases  the  collateral  circula- 
tion is  soon  established  by  the  opening 
up  and  dilatation  of  other  venous 
channels,  which  after  a  time  become 
varicose,  and  if  situated  superficially, 
are  often  very  obvious.  Thus,  if  the 
common  femoral  or  external  iliac  vein 
is  occluded  above  Poupart's  ligament, 
the  internal  saphenous  and  superficial 
epigastric  veins  become  distended  and  varicose,  and  the  latter  may 
be  seen  coursing  up  the  abdominal  wall  towards  the  umbilicus,  and 
uniting  with  the  same  branch  on  the  opposite  side  to  find  its  way 
to  the  saphena  vein  of  that  limb.  If  the  inferior  vena  cava  is 
obstructed,  the  mammary  and  epigastric  veins  become  dilated  and 
tortuous,  standing  out  prominently  on  the  anterior  abdominal  wall. 
Proximally,  the  process  may  gradually  extend  upwards,  and 
finally  involve  larger  and  more  important  trunks  than  that  in 
which  it  originated.  Moreover,  a  portion  of  a  thrombus  may  be 
detached  as  an  Embolus  (Fig.  79,  B).  If  the  clot  is  undergoing 
molecular  disintegration  and  only  minute  portions  are  set  free, 
they  are  filtered  off  by  the  lungs  or  kidneys,  and  no  symptoms 
need  be  caused.  If,  however,  a  large  portion  is  detached,  urgent 
dyspnoea  and  even  death  occur  from  obstruction  to  the  pulmonary 
vessels  and  subsequent  arrest  of  the  circulation.  If  the  clot 
becomes  septic  and  fragments  conveying  organisms  are  carried 
into  the  circulation,  pyaemia  is  the  result,  preceded,  however,  in 
the  portal  area  by  pylephlebitis — i.e.,  suppurative  phlebitis  of  the 
portal  trunks  in  the  liver. 


Fig.  79. — Thrombus  and 
Embolus.  (Keen  and 
White.) 


A,  Thrombus  in  situ  ;  B, 
bolus  detached  from 
same. 


em- 
the 


SURGERY  OF  THE   VEINS 


301 


The  Clinical  Signs  and  Treatment  of  venous  thrombosis  are  the 
same  as  for  phlebitis  (q.v.). 

Embolism. 

An  Embolus  is  the  term  applied  to  any  foreign  body  which  travels  for  a 
greater  or  less  distance  in  the  bloodvessels  until  it  becomes  lodged  within 
them  and  causes  obstruction.  There  are  four  main  varieties  of  embolus  : 
(a)  Simple  Emboli,  e.g.,  blood-clot,  granulations  or  fibrinous  vegetations  from 
the  cardiac  valves  after  acute  endocarditis,  atheromatous  plates,  air-bubbles, 
fat  globules,  etc.  (6)  Infective  Emboli  consist  of  either  zooglcea  masses  of 
bacteria  or  disintegrated  portions  of  blood-clot  carrying  micro-organisms  and 
originating  a  pysemic  abscess  wherever  they  lodge,  (c)  Malignant  Emboli 
are  formed  by  portions  of  some  malignant  growth,  from  which  the  various 
secondary  deposits  originate  ;  such  are  met  with  more  frequently  in  the 
sarcomata  than  in  the  carcinomata.  (d)  Parasitic  Emboli  also  occur,  such 
as  the  ova  and  scolices  of  the  Tania  echinococcus,  and  the  Filaria  sanguinis 
I10 111  in  is. 

Emboli  may  be  detached  from  the  heart,  veins,  or  arteries,  although  neces- 
sarily they  are  never  arrested  in  a  systemic  vein,  but  only  in  the  arteries  or 
portal  vein.  They  are  of  all  sizes,  and  the  character  of  the  resulting  symp- 
toms depends  much  on  this.  A  large  embolus  started  in  a  peripheral  vein 
lodges  in  one  of  the  branches  of  the  pulmonary  artery,  and  may  cause  instant 
death  ;  a  smaller  one  is  arrested  in  one  of  the  smaller  arteries  of  the  lung  and 
may  do  but  little  harm,  whilst  minute  ones  may  possibly  pass  through  the 
pulmonary  capillaries  to  the  left  side  of  the  heart,  and  subsequently  become 
impacted  in  the  systemic  vessels. 

Effects  of  an  Embolus. — The  Local  effects  of  the  lodgment  of  a  simple 
embolus  consist,  firstly,  in  the  deposit  of  fibrin  upon  it,  rendering  the  obstruc- 
tion complete  ;  organization  of  the  thrombus  usually  follows,  although  occa- 
sionally it  may  disintegrate  and  disappear.  Under  these  circumstances  a 
weak  spot  mav  be  left  in  the  arterial  wall,  from  which  an  aneurism  is  subse- 
quently developed.  The  local  effects  of  infective,  malignant,  and  parasitic 
emboli  are  dealt  with  elsewhere. 

The  Distal  effects  of  embolic  obstruction  depend  entirely  on  the  relation  of 
the  vessel  blocked  to  the  surrounding  circulation. 

(1)  Should  the  embolus  be  lodged  in  an  artery  which  gives  off  anastomotic 
branches  below  the  point  of  obstruction,  or  if  the  capillary  anastomosis  is 
abundant,  a  transient  anaemia  is  all  that  occurs  in  most  cases.  If  the  artery 
is  small,  or  goes  to  unimportant  structures,  no  symptoms  need  arise  from  this  ; 
but  if  the  vessel  is  large,  or  supplies  delicate  and  important  tissues,  serious 
results  may  follow  even  a  temporary  arrest  of  the  circulation ;  thus,  embolus 
of  the  central  artery  of  the  retina  always  causes  permanent  blindness,  although 
the  retina  still  lives. 

(2)  Should  the  embolus  block  what  Cohnheim  called  a  '  terminal  artery  ' 
(i.e.,  one  with  no  anastomosis  between  the  embolus  and  the  terminal  capil- 
laries), or  a  vessel  with  insufficient  collateral  circulation,  the  obstruction  will 
lead  to  death  of,  at  any  rate,  a  portion  of  the  anaemic  region — e.g. ,  gangrene 
in  a  limb,  or  white  or  yeilow  softening  in  the  brain.  In  an  organ  such  as  the 
kidney  or  spleen,  the  result  of  embolic  obstruction  to  one  of  the  terminal 
arteries  is  the  development  of  what  is  known  as  an  infarct—  i.e.,  a  wedge- 
shaped  area  of  tissue  with  the  blocked  artery  at  its  apex  becomes  devitalized, 
and  in  consequence  looks  white  and  feels  firmer  than  the  surrounding  parts. 
The  tissues  cannot  be  properly  stained  for  microscopic  purposes.  Sometimes 
the  anaemic  area  becomes  engorged  with  blood  to  such  an  extent  as  to  lead  to 
extravasation,  and  a  firm,  solid  patch  of  a  dark  red  colour  results,  known  as  a 
haemorrhagic  infarct.  Whatever  its  appearance,  the  infarct  is  subsequently 
invaded  by  granulation  tissue  developed  from  the  surrounding  healthy  parts, 
and  this  finally  results  in  the  formation  of  a  depressed  cicatrix  containing, 


302  A  MANUAL  OF  SURGERY 

perhaps,  a  few  haematoidin  crystals.  The  conditions  necessary  for  the  pro- 
duction of  an  infarct  are  met  with  in  the  lungs,  spleen,  kidney,  and  brain  ; 
in  the  liver  the  anastomosis  is  generally  too  free  to  allow  of  its  formation, 
although  it  has  been  known  to  occur. 

Effects  of  the  Lodgment  of  Emboli  in  Various  Organs. — In  the  Brain,  the 
middle  cerebral  artery  is  most  commonly  blocked,  resulting  in  immediate 
hemiplegia,  which  may  be  almost  entirely  recovered  from,  but  commonly 
leaves  some  impairment  of  function.  In  children  the  symptoms  are  less 
marked,  but  aneurism  of  the  affected  vessel  occasionally  follows.  In  the 
Central  Artery  of  the  Retina,  sudden,  total  and  irremediable  blindness  is  pro- 
duced ;  the  branches  of  the  vessel  are  seen  to  be  almost  empty,  the  retina 
becomes  cedematous,  the  macula  alone  retaining  its  normal  colour,  appear- 
ing as  a  cherry-red  spot,  contrasting  markedly  with  the  pallid  cedematous 
tissues  around.  In  the  Lung,  fatal  results  supervene  from  obstruction  to  a 
large  vessel ;  whilst,  if  a  smaller  one  is  blocked,  a  certain  amount  of  pain  and 
dyspnoea  is  produced,  followed  by  the  formation  of  an  infarct,  as  indicated  by 
dulness,  bronchial  breathing,  and  bronchophony.  In  the  Liver,  an  embolus  of 
the  hepatic  artery  causes  sudden  hypochondriac  pain,  and  perhaps  a  passing 
glycosuria.  The  portal  vein  and  its  branches  are  not  unfrequently  obstructed 
by  emboli,  which,  being  usually  of  a  septic  nature,  give  rise  to  pysemic 
symptoms  (pvlephlebitis).  In  the  Spleen,  a  sudden  pain  in  the  left  hvpo- 
chondrium  is  experienced,  the  organ  becomes  enlarged,  and  a  considerable 
rise  of  temperature  may  follow  In  the  Kidney,  sudden  pain  in  the  loin 
and  a  temporary  haematuria  constitute  the  main  symptoms.  In  the  Intestine, 
localized  ulceration  or  extensive  gangrene  is  likely  to  follow,  according  to  the 
size  of  the  vessel  obstructed.  In  the  Limbs,  the  emboli  usually  lodge  at  the 
hi  furcations  of  main  vessels,  often  saddling  across  the  fork,  and  blocking  both 
branches.  Sudden  pain  is  felt  at  the  spot,  shooting  downwards,  and  either 
recovery  or  gangrene  ensues  (p.  73). 

Phlebitis. 

Phlebitis,  or  inflammation  of  the  vein  wall,  arises  from  a 
variety  of  causes,  and  is  not  uncommon  in  surgical  practice.  The 
following  forms  may  be  described  : 

1.  Simple  Phlebitis,  in  which  a  more  or  less  localized  inflam- 
mation of  the  wall  of  a  vein  is  attended  by  thrombosis  ;  it  extends 
for  a  variable  distance  up  and  down  the  vessel,  but  usually  not 
further  than  the  next  patent  branches,  (a)  It  may  arise  from 
injury,  either  subcutaneous  or  open,  or  from  the  continued  pressure 
and  irritation  of  a  tumour  or  aneurism ;  (b)  it  may  be  idiopathic 
in  nature,  attacking  the  larger  veins  of  the  lower  extremity,  or 
vessels  which  have  been  long  subject  to  varix,  especially  in  gouty 
individuals,  (c)  It  may  follow  primary  thrombosis,  the  blood 
usually  clotting  first  in  one  of  the  pouches  or  ampullae  of  a  vari- 
cose vein  ;  or  (d)  it  may  be  induced  by  inflammation  of  the  tissues 
around  the  vein  (periphlebitis),  usually  of  septic  origin. 

2.  Infective  Phlebitis  is  a  much  more  serious  condition,  inas- 
much as  the  thrombus  resulting  therefrom  is  always  invaded  by 
micro-organisms,  and  the  disease  is  often  of  a  spreading  type.  It 
was  this  form  of  phlebitis  which  in  the  old  days  so  commonly 
followed  operations,  and  made  surgeons  fear  any  interference 
with  veins  ;  it  has  now  been  almost  banished  as  a  sequela  of 
surgical  operations  by  antisepsis,  and  there  is  no   more  fear  of 


SURGERY  OF  THE   VEINS 


dealing  with  veins  than  with  any  other  tissue  of  the  body.  It 
may,  however,  arise  (a)  in  traumatic  cases  where  asepsis  has  not 
been  attended  to  or  has  failed,  the  organisms  invading  the  clot 
which  lies  in  the  open  mouth  of  the  vein  ;  or  (b)  as  a  result  of 
septic  periphlebitis  in  wounds,  or  in  septic  inflammation  of  bones, 
such  as  when  a  septic  mastoiditis  leads  to  disease  of  the  mastoid 
emissary  vein  and  of  the  lateral  sinus.  The  usual  results  are 
localized  or  spreading  suppuration  in  the  course  of  and  around 
the  vein,  and  general  pyaemia,  (c)  It  may  possibly  be  induced 
by  auto-infection  of  the  clot  present  in  simple  phlebitis. 

The  Morbid  Anatomy  of  phlebitis  shows  nothing  unusual ;  the 
walls  of  the  vein  are  congested  and  thickened,  and  the  endo- 
thelial lining  is  hypertrophied ;  the  thrombus  contained  in  the 
vessel  varies  in  its  characters.  If  infected,  it  becomes  soft  and 
pultaceous,  resembling  dirty-looking  pus;  a  localized  abscess  may 
form,  or  the  suppuration  may  extend  for  some  distance  along  and 
around  the  vein.  In  the  more  favourable  cases  the  spread  of  the 
infection  is  limited  by  the  terminal  portions  of  the  clot  remaining 
firm  and  unaffected. 

The  Symptoms  of  inflammation  of  a  superficial  vein  are  suffi- 
ciently obvious.  The  vessel  becomes  swollen,  hard  and  painful, 
with  localized  enlargements  or  knobs  corresponding  to  the  valves, 
or  to  the  pouches  in  varicose  veins.  The  skin  over  them  is 
dusky  and  congested,  and  there  may  be  some  oedema  of  the 
region  from  which  the  blood  flowing  in  the  vein  is  gathered  ; 
this,  however,  rarely  amounts  to  much,  since  the  collateral  cir- 
culation is  always  abundant.  If  suppuration  occurs,  the  signs  of 
a  localized  abscess  are  noted  ;  on  opening  this,  care  must  be 
devoted  to  maintaining  the  part  aseptic  in  order  to  prevent,  as 
far  as  possible,  the  extension  of  the  inflammation. 

When  the  deeper  veins  are  involved,  it  may  be  impossible  to 
detect  them  on  palpation,  although  a  blocked  common  femoral  is 
easily  felt  ;  but  acute  deeply-seated  pain  over  the  vein  and  well- 
marked  fever  are  characteristic  evidences  of  what  has  occurred. 
(Edema  of  a  more  or  less  solid  character  develops,  although 
if  the  limb  is  maintained  in  the  horizontal  position  throughout  the 
attack  this  need  not  occur.  Obliteration  of  the  vessel,  and  any  of 
the  local,  distal,  or  general  processes  detailed  under  thrombosis 
(p.  299)  may  result. 

The  onset  of  Septic  Spreading  Phlebitis  is  marked  by  fever  and 
perhaps  rigors,  whilst  the  local  signs  are  due  to  the  rapid  extension 
of  a  suppurative  inflammation  along  the  vein  and  its  branches,  so 
that  a  large  tract  of  tissue  is  very  quickly  invaded,  and  diffuse 
suppuration  follows.  The  development  of  pyaemia  would  be  indi- 
cated by  a  repetition  of  the  rigors. 

Treatment  of  Simple  Phlebitis. — The  limb  must  be  kept  abso- 
lutely at  rest  to  limit  the  inflammation  and  to  prevent  the 
detachment  of  emboli,  and  also  elevated  to  assist  venous  return. 


304  A   MANUAL  OF  SURGERY 


Locally,  belladonna  fomentations  may  be  applied,  or  the  parts 
may  be  painted  with  glycerine  and  extract  of  belladonna, 
swathed  in  a  thick  layer  of  cotton-wool,  and  lightly  bandaged. 
The  patient  should  be  kept  on  an  unstimulating,  though 
nutritious,  diet,  and  the  general  health  attended  to.  When 
every  sign  of  inflammation  has  subsided,  and  sufficient  time 
has  been  allowed  for  the  absorption  or  organization  of  the  clot 
(six  to  eight  weeks),  massage  may  be  commenced,  to  assist  in 
the  removal  of  oedema  and  local  thickening,  and  an  elastic 
bandage  is  usually  serviceable  in  restoring  the  circulation. 
Operation  is  sometimes  undertaken  in  cases  of  phlebitis  associated 
with  varix  (p.  307),  but  not  when  the  deeper  veins  are  involved. 
If  abscesses  form,  however,  they  must  be  opened  antiseptically. 

Spreading  Infective  Phlebitis  is  treated  by  following  up  the  sup- 
purative process  with  the  knife,  laying  open  the  tissues  around  the 
involved  veins.  The  wounds  thus  made  should  be  treated  with 
peroxide  of  hydrogen  and  lightly  stuffed  ;  at  the  same  time,  the 
limb  is  raised  and  kept  absolutely  quiet.  Should  pyaemic  phe- 
nomena develop,  it  may  be  possible  to  place  a  ligature  between 
the  disintegrating  clot  and  the  heart,  and  to  scrape  or  wash  away 
the  septic  mass ;  thus  in  septic  thrombosis  of  the  lateral  sinus, 
following  suppuration  in  the  middle  ear,  the  internal  jugular  vein 
should  be  ligatured,  the  lateral  sinus  opened,  and  the  clot  removed. 
Of  course,  such  treatment  is  only  feasible  in  cases  where  a  single 
trunk  is  affected.  When  the  process  affects  the  veins  of  a  limb, 
and  cannot  be  stopped  by  either  of  these  plans  of  treatment,  the 
question  of  amputation  may  even  have  to  be  raised. 

Varicose  Veins,  or  Varix. 

A  vein  is  said  to  be  varicose,  or  in  a  condition  of  varix, 
when  it  has  become  permanently  lengthened,  dilated,  and  more 
or  less  tortuous.  The  superficial  veins  of  the  leg,  especially  the 
internal  and  external  saphena,  are  those  most  commonly  affected  ; 
the  spermatic  veins  are  often  in  a  similar  condition,  constituting 
what  is  known  as  a  varicocele,  whilst  piles  are  primarily  due  to 
varicosity  of  the  hemorrhoidal  plexus.  We  shall  here  only  deal 
with  the  first  of  these  three  manifestations. 

Causes. — Varix  is  induced  by  any  condition  which  leads  to  a 
frequently  repeated  or  more  or  less  permanent  distension  of  a  vein, 
such  as  prolonged  standing,  as  in  those  serving  behind  counters  ; 
the  pressure  of  tight  garters,  especially  if  worn  below  the  knee  ; 
prolonged  or  forcible  exertion  of  the  limb,  as  possibly  in  cyclists, 
whereby  the  blood  is  driven  from  the  deeper  into  the  more  super- 
ficial veins  ;  the  pressure  of  a  pregnant  or  displaced  uterus,  or  of 
a  pelvic  tumour.  Obstruction  to  and  occlusion  of  the  deeper 
veins  is  another  well -recognised  cause  of  varix,  and  we  have 
already  drawn  attention  to  the  effect  produced  by  blocking  of  the 


SURGERY  OF  THE   VEINS 


305 


common  femoral  vein  and  inferior  vena  cava.  A  less  known 
instance  is  the  varix  of  the  internal  saphena  or  some  of  its 
branches  below  the  knee,  which  follows  thrombosis  of  the  venae 
comites  of  the  posterior  tibial,  due  to  strains  of  the  leg  and  similar 
injuries.  If  the  thrombus  is  absorbed,  the  dilatation  disappears  ; 
but  if  the  block  is  permanent,  the  varix  persists  and  usually 
extends  to  just  below  the  knee.  Any  abnormal  communication 
between  an  artery  and  a  vein  also  causes  varicosity,  from  the 
inability  of  the  latter  to  withstand  arterial  blood  pressure  (vide 
Aneurismal  Varix,  p.  249).  Inherited  weakness,  or  the  relaxation 
of  system  due  to  sedentary  habits,  must  be  looked  on  as  pre- 
disposing causes.  The  tendency  to  varix  increases  with  age  till 
the  middle  period  of  life  is  reached.  When  a  vein  is  varicose 
and  its  walls  are  thin  and  expanded,  the  valves  become  incompe- 
tent, and  the  superincumbent  weight  of  the 
blood  tends  to  still  further  increase  the 
mischief. 

Morbid  Anatomy. — To  the  naked  eye  a 
varicose  vein  in  an  early  stage  appears 
thickened,  distended,  and  tortuous  ;  the  walls 
are  so  thick  that  the  vein  when  cut  across  does 
not  collapse,  but  presents  a  gaping  mouth,  like 
an  artery  ;  the  valves  atrophy,  and  are 
functionally  useless.  After  a  time  the  walls 
become  further  stretched  and  irregularly  ex- 
panded, forming  pouch-like  dilatations,  which 
are  very  obvious  under  the  attenuated  skin,  to 
which  they  are  often  adherent.  Micro- 
scopically, the  change  consists  in  a  transforma- 
tion of  the  normal  structures  of  the  vein  wall 
into  fibro- cicatricial  tissue.  The  tunica 
media  is  mainly  affected,  most  of  the  muscular 
fibres  disappearing,  whilst  the  tunica  intima  is 
but  little  changed,  and  the  adventitia  thickened. 
In  the  pouches  the  middle  coat  is  atrophied, 
and,  indeed,  is  often  completely  absent. 

Clinical  History. — The  enlarged  veins  are 
seen  ramifying  under  the  skin  with  a  more  or 
less  tortuous  and  serpentine  course  (Fig.  So), 

and  they  often  feel  thickened.     One  or  more  fig.    80. Varix    of 

veins  may  be  affected,  and  the  tortuosity  may  Internal    Saphena. 
be  at  parts  so  marked  as  to  constitute  large  (From    a    Photo- 
clusters  of  dilated  vessels,  which  look  bluish  GRAPH) 
under  the  attenuated  skin. 

The  Effects  of  this  condition  are  very  varied.  The  circulation 
in  the  lower  parts  of  the  leg  may  be  impaired,  especially  that  of 
the  skin.  The  limb  feels  heavy  and  painful ;  forcible  exertion 
may  cause  a  sensation  of  tension,  and  after  standing  or  exercise 

20 


306  A  MANUAL  OF  SURGERY 

there  is  usually  a  little  cedema  of  the  ankle.  The  capillaries  in 
the  papillae  often  become  dilated,  appearing  as  minute  reddish 
puncta,  which  subsequently  run  together  and  form  brownish 
patches  of  pigmentation.  Eczema  is  induced  by  the  irritation  of 
rough  and  coarse  trousers  or  dirt,  often  terminating  in  actual 
ulceration.  Any  lesion,  such  as  a  scratch  or  abrasion,  instead  of 
healing  readily  under  a  scab,  tends  to  spread  and  form  an  ulcer. 
Injury  to  the  vein  may  lead  to  thrombosis  and  spontaneous  cure, 
but  coagulation  sometimes  occurs  idiopathically  in  the  pouches, 
and  the  clot  may  subsequently  shrink  and  form  a  small  fibrinous 
or  calcareous  mass,  known  as  a  '  phlebolith.'  Gouty  persons 
with  varicose  veins  are  especially  prone  to  attacks  of  phlebitis. 
If  these  are  limited  in  extent,  no  serious  harm  results  ;  but 
sometimes  the  thrombosis  spreads  into  deeper  or  larger  veins, 
whilst  fragments  of  clot  may  be  detached  as  emboli.  Occasionally 
the  dilated  pouch  of  a  varicose  vein  gives  way,  and  an  alarming 
gush  of  blood  results  ;  the  same  may  follow  the  extension  of 
ulceration  through  the  vein  wall.  The  blood  under  these  circum- 
stances is  derived,  not  only  from  the  lower,  but  also  from  the 
upper  end,  inasmuch  as  the  valves  have  become  incompetent  ;  a 
column  of  blood  extending  from  the  right  auricle  is  thus  tapped 
near  its  lower  end,  and,  unless  prompt  precautions  are  taken,  the 
patient's  life  may  be  lost. 

The  Treatment  of  varicose  veins  may  be  described  as  palliative 
and  radical. 

Palliative  Treatment  consists  in  removing  any  source  of  obstruc- 
tion in  the  shape  of  tight  garters,  in  limiting  the  amount  of  stand- 
ing, in  moderate  massage,  together  with  the  application  of  either 
an  elastic  stocking  or  an  indiarubber  bandage.  The  bowels 
should  be  kept  well  open,  and  the  general  health  attended  to. 
Eczema  may  be  treated  by  the  application  of  soothing  and  drying 
ointments,  e.g.,  ung.  zinci  benzoatis  ;  or  if  the  skin  is  chronically 
infiltrated  and  thickened,  by  the  use  of  weak  tarry  applications, 
e.g.,  ol.  Rusci  (i  part  to  4  of  vaseline),  or  of  ichthyol  (5  or  10  per 
cent,  in  vaseline).  Varicose  ulcers  are  treated  on  ordinary  prin- 
ciples, or  by  Unna's  method  (p.  62) ;  but  repair  is  often  delayed 
till  the  veins  have  been  dealt  with  by  operation. 

Radical  Treatment  consists  in  the  excision  of  the  distended  veins. 
Before  operating  it  is  important  to  make  certain  that  the  con- 
dition is  not  due  to  thrombosis  of  the  deep  trunks,  as  interference 
would  then  do  more  harm  than  good,  and  the  varix  would  be 
certain  to  recur  in  neighbouring  collateral  veins.  Operation  is 
specially  indicated  when  thin,  dilated  pouches  exist ;  when  elastic 
stockings  cannot  be  comfortably  worn,  as  in  the  tropics  ;  when 
ulcers  exist  which  refuse  to  heal  ;  when  the  condition  is  very 
extensive  and  painful,  and  especially  if  large  bunches  of  dilated 
veins  are  seen  ;  or  when  there  is  a  distinct  impulse  or  thrill  on 
coughing,  indicating  that  the  valves  which  protect  the  veins  of 


SURGERY  OF  THE  VEINS  307 


the  leg  are  defective.  It  may  not  be  practicable  to  remove  all, 
but  if  the  largest  and  most  prominent  are  taken  away,  the  others 
will  probably  shrink  and  disappear.  There  are  two  chief  plans  of 
doing  this  :  (a)  Small  portions  are  removed  at  several  different 
situations.  The  skin  is  pinched  up  over  the  vein,  and  incised  by 
transfixion  ;  the  vessel  is  usually  bared  by  this  means,  but  may 
need  a  little  cleaning.  An  aneurism  needle  is  passed  beneath  it, 
and  the  vein  isolated  sufficiently  to  allow  of  its  being  grasped  by 
two  pairs  of  forceps,  and  divided  between.  Each  end  is  now 
freed,  and  drawn  out  of  the  wound  as  far  as  possible  ;  it  is  then 
ligatured  and  removed.  Probably  i\  inches  of  vein  may  be  taken 
away  through  a  i-inch  incision.  The  wound  is  sutured  without 
drainage  and  dressed,  (b)  Long  incisions  are  made,  perhaps  6 
inches  or  more,  through  which  larger  clusters  of  veins  may  be 
dealt  with.  The  wound  should  not  lie  over  the  most  dilated  parts 
of  the  vessel,  as  there  the  skin  is  often  thin  and  unhealthy,  but 
should  be  curved  so  as  to  include  as  much  sound  skin  as  possible, 
whilst  crossing  the  vessels  once  or  twice.  All  collateral  branches, 
especially  the  deep  ones,  must  be  secured,  and  this,  in  fact,  con- 
stitutes the  great  advantage  of  the  operation,  viz.,  that  so  many 
anastomosing  channels  are  obliterated.  A  simpler  procedure  has 
been  advocated  by  Trendelenburg,  viz.,  the  removal  of  a  portion 
of  the  internal  saphena  high  up,  so  as  to  break  the  weight  of  the 
superjacent  column  of  blood.  In  cases  where  there  is  an  impulse 
on  coughing,  it  is  a  most  valuable  measure,  but  the  enlarged  veins 
should  also  be  excised. 

Inflamed  Varicose  Veins  are  not  unfrequent,  and  may  result  in 
a  natural  cure  of  the  condition.  The  symptoms  are  those  of  a 
superficial  phlebitis,  and  the  treatment  indicated  for  that  condition 
should  be  followed.  In  cases  where  there  is  much  pain  it  may  be 
justifiable  to  excise  the  thrombosed  vessels,  taking  the  precaution 
to  first  secure  by  ligature  the  vein  above  the  clot,  so  as  to  prevent 
any  risk  of  embolic  detachment.  Operation  of  a  similar  type  is 
also  required  when  thrombosis  is  gradually  spreading  upwards, 
and  threatening  to  affect  the  deep  trunks,  e.g.,  in  the  neighbour- 
hood of  the  saphenous  opening  ;  or  when  portions  of  clot  are 
being  detached  as  emboli  giving  rise  to  pulmonary  symptoms. 

Haemorrhage  from  a  Ruptured  Vein  needs  prompt  and  decisive 
treatment.  The  bleeding  spot  should  be  commanded  by  digital 
compression,  and  the  patient  laid  on  the  back  with  the  limb 
elevated,  until  either  a  pad  of  antiseptic  dressing  can  be  applied 
to  the  wound,  or  a  handkerchief  or  bandage  secured  over  it. 

Nsevus. 
A  naevus  is  a  vascular  tumour  developing  in  the  skin  and   in 
subcutaneous  or  submucous  tissues,  and  consists  of  a  congeries  of 
vessels  held  together  by  connective  tissue.      Nsevi  are  of  con- 
genital origin,  or  develop  soon  after  birth.     Left  to  themselves, 

20 — 2 


3o8  A  MANUAL  OF  SURGERY 

they  may  shrink  and  disappear,  but  more  often  they  increase  in 
size  more  or  less  rapidly,  whilst  sometimes  they  remain  passive 
and  persist  through  life.     Two  chief  varieties  are  described  : 

The  Capillary  Nsevus  (or  mother's  mark)  occurs  in  the  form  of 
a  slightly  raised  flattened  mass,  bright  red  or  purple  in  colour, 
according  to  the  relative  amount  of  arterial  or  venous  blood 
present,  and  with  occasionally  a  somewhat  irregular  or  nodulated 
surface,  in  which  larger  vessels  may  be  seen  ramifying.  It 
consists  merely  of  a  mass  of  capillaries  lined  with  endothelium 
communicating  with  a  few  arterioles  and  venules,  and  held 
together  by  loose  connective  tissue.  Several  such  growths  may 
be  present  in  the  same  individual,  and  they  are  usually  quite 
small,  not  exceeding  an  inch  or  two  in  diameter,  though  some- 
times they  extend  widely  over  the  face  and  neck,  and  are  then 
very  superficial  in  character,  and  somewhat  dusky  in  colour,  con- 
stituting the  '  port-wine  stain.'  If  cut  into,  they  bleed  freely,  but 
the  haemorrhage  is  easily  stopped  by  pressure. 

Occasionally  a  naevoid  development  may  be  observed  involving 
half  the  body,  and  limited  almost  exactly  by  the  middle  line  ;  this 
condition  is  known  as  ncevus  unius  latevis.  It  may  consist  of  a 
purely  vascular  manifestation,  or  the  skin  may  be  hypertrophied 
and  covered  with  small  soft  papillary  excrescences.  In  a  case 
under  our  observation  recently,  the  trunk,  head,  and  limbs  were 
distinctly  asymmetrical,  the  naevoid  half  being  larger  and  better 
developed,  except  in  the  case  of  the  leg. 

Treatment  is  usually  simple  in  the  extreme.  Small  superficial 
naevi  can  be  completely  cured  by  some  form  of  cauterization,  such 
as  the  application  of  the  electric  or  actual  cautery,  ethylate  of  soda, 
or  nitric  acid ;  in  applying  fluid  caustics,  the  surrounding  skin 
must  be  protected  by  a  thick  layer  of  vaseline.  In  exposed 
situations  electrolysis  (vide  infra)  is  the  best  plan  to  adopt  in  order 
to  prevent  the  formation  of  a  scar,  but  excision  will  often  give  an 
equally  good  result. 

The  Cavernous  or  Venous  Nsevus  most  commonly  involves  both 
skin  and  subcutaneous  tissues,  but  is  sometimes  purely  sub- 
cutaneous. It  consists  of  a  more  or  less  prominent  swelling, 
soft  to  the  touch,  and  easily  compressible,  but  refilling  when 
the  pressure  is  removed.  There  is  no  pulsation  or  bruit,  and  the 
mass  may  be  lobulated.  If  subcutaneous,  the  skin  over  it  is 
somewhat  bluish  in  colour,  but  the  mixed  forms  are  dusky  red. 
Occasionally  it  may  undergo  spontaneous  cure  from  inflammation 
and  thrombosis,  and  cysts  are  sometimes  found  in  the  centre  of  a 
naevoid  mass,  indicating  that  a  partial  attempt  at  this  process  has 
occurred.  Venous  naevi  consist  of  a  collection  of  vascular  spaces 
lined  with  endothelium,  some  tubular-like  veins  or  capillaries, 
others  mere  pouches,  held  together  by  fibrous  tissue.  The  arterial 
supply  is  not  very  great,  but  the  arteries  usually  open  directly  into 
the  venous  spaces  without  the  intervention  of  capillaries  (p.  170). 


SURGERY  OF  THE   VEINS  309 

The  Treatment  is  by  no  means  as  simple  as  in  the  former 
varieties.     The  following  plans  may  be  mentioned  : 

1.  Excision  of  the  growth  should  always  be  adopted  where 
practicable.  Cases  which  formerly  were  dealt  with  by  strangula- 
tion are  now  treated  by  this  means.  The  bleeding  is  never  great, 
even  if  the  naevoid  tissue  is  encroached  upon  by  the  knife,  and 
only  a  few  vessels  will  need  to  be  tied.  Circular  growths  should 
be  removed  by  crescentic  incisions,  and  a  little  undercutting  will 
usually  enable  the  edges  to  be  easily  approximated. 

2.  The  Injection  of  coagulating  and  irritating  fluids,  such  as 
perchloride  of  iron  or  pure  liquefied  carbolic  acid,  has  been 
employed,  but  has  no  advantages  over  electrolysis,  and  is  more 
risky  and  less  certain  in  its  results. 

3.  Where  excision  is  impossible,  or  where  it  is  important  to 
leave  no  scars  or  only  minute  ones,  Electrolysis  should  be  em- 
ployed. It  consists  in  the  passage  of  a  current  of  high  electro- 
motive force  through  the  mass,  producing  chemical  and  physical 
changes  in  the  contained  blood.  A  Stohrer's  battery  can  be  used, 
or  any  suitable  collection  of  cells,  connected  in  series.  Both 
needles  may  be  inserted  into  the  mass,  but  it  is  sometimes  wiser 
only  to  use  one  or  more  needles  connected  with  the  positive 
pole,  whilst  the  negative  pole  is  attached  to  a  large  electrode 
moistened  and  placed  on  some  indifferent  part  of  the  body,  such 
as  the  arm,  back,  or  thigh.  The  needle  is  often  with  advantage 
made  of  iron  or  steel,  since  it  is  usually  corroded,  and  the  chloride 
of  iron  thus  formed  acts  beneficially  in  determining  coagulation 
of  the  blood  ;  it  must  be  carefully  and  thoroughly  insulated  when 
deep  naevi  are  treated,  so  as  to  protect  the  skin  and  prevent  the 
current  passing  through  it.  The  use  of  the  negative  pole  is  more 
likely  to  produce  scarring,  since  a  caustic  sodium  compound  is 
formed  around  it,  and  this  may  lead  to  sloughing  of  the  tissues  ; 
the  clot,  moreover,  is  loose  and  spongy,  whilst  a  much  firmer 
coagulum  occurs  around  the  positive  pole.  If  the  positive  pole 
alone  is  introduced,  a  current  equal  to  about  200  milliamperes,  as 
measured  by  a  galvanometer,  may  be  passed  for  10  or  15  minutes; 
if  both  poles  are  used,  a  current  half  this  strength  is  sufficient. 
An  anaesthetic  is  needed,  and  the  immediate  effect  should  be  to 
make  the  mass  feel  hard  and  firm  by  the  coagulation  of  the  blood ; 
the  tumour  is  subsequently  disintegrated  and  absorbed.  The 
application  may  require  to  be  repeated  several  times,  and  the 
needles  should  be  freely  worked  about  through  the  mass.  Not 
uncommonly  the  child  becomes  pale  and  faint  if  the  naevus  is 
on  the  head,  probably  as  an  effect  of  the  strong  current  upon  the 
cerebral  centres.  For  the  treatment  of  superficial  naevi,  there  is 
no  necessity  to  have  the  needle  coated ;  it  is  introduced  into  the 
mass  in  a  number  of  places,  especially  where  any  definite  vessels 
are  seen,  and  of  course  does  not  penetrate  deeply.  A  very  short 
application  of  the  current  usually  suffices  at  each  puncture ;  the 


3io  A   MANUAL  OF  SURGERY 


naevoid  tissue  turns  white,  and  there  is  a  little  bubbling  of  gas 
around  the  needle.  It  is  best  to  deal  first  with  the  periphery  of 
a  naevus,  and  then,  when  its  extension  is  arrested,  the  central 
parts  can  be  treated.  Of  course  some  scarring  cannot  be  avoided, 
and  hence  it  is  wise  not  to  do  too  much  at  one  sitting,  and  to 
make  the  intervals  sufficiently  long  to  allow  cicatrization  to  take 
place. 

A  Nsevo-Lipoma  is  the  name  given  to  a  somewhat  rare  tumour, 
in  which  a  fatty  element  is  blended  with  naevoid  tissue.  It  is 
usually  of  congenital  origin,  or,  at  any  rate,  appears  early  in  life, 
and  is  probably  due  to  the  undifferentiated  formative  cells  of  the 
"embryo  developing  in  a  twofold  direction  so  as  to  produce  not 
only  fatty  connective  tissue,  but  also  vessels.  It  gives  rise  to 
a  swelling,  lobulated  and  doughy,  like  a  fatty  tumour,  although 
it  is  usually  a  little  denser  in  texture  than  the  ordinary  lipoma. 
It  may  be  possible  to  reduce  its  size  by  compression,  but  no 
thrill  or  pulsation  can  be  detected ;  a  few  dilated  veins  or 
capillaries  are  often  seen  on  the  surface.  The  only  treatment  is 
excision. 

Venesection. 

Venesection  or  phlebotomy  is  a  means  of  treatment  which  has 
largely  fallen  into  disuse  of  late  years,  but  is  still  occasionally 
employed  with  benefit.  When  a  patient  is  becoming  cyanosed, 
and  asphyxia  is  threatening  either  (a)  as  a  result  of  pulmonary 
engorgement  from  mitral  incompetency,  owing  to  the  heart  being 
unable  to  drive  the  blood  into  the  systemic  circulation  ;  or  (b)  as 
a  consequence  of  some  accident  involving  the  chest  wall  and 
lungs,  whereby  the  blood-aerating  surface  is  so  diminished  that 
it  cannot  deal  with  the  blood  reaching  it  through  the  right  side 
of  the  heart,  which  hence  becomes  enormously  distended  and 
threatens  to  stop  in  a  condition  of  diastole  ;  or  (c)  where  inflam- 
mation of  the  brain  is  pending,  and  the  pulse  is  hard  and  full ; 
or  (<f)  in  many  inflammatory  states  in  strong,  full-blooded  indi- 
viduals where  the  pulse  tension  is  high — in  any  of  these  conditions 
venesection  may  be  used  with  advantage. 

The  median  basilic  vein  at  the  bend  of  the  elbow  is  that  usually 
opened,  since  it  is  larger  than  the  median  cephalic,  though  placed 
more  directly  over  the  brachial  artery,  from  which  it  is  separated 
by  the  bicipital  fascia. 

Requisites. — A  pad  of  antiseptic  wool  or  gauze  ;  a  strip  of 
bandage  about  4  feet  long  ;  a  lancet ;  a  graduated  bleeding-bowl ; 
and  finally  a  stick  or  bandage  to  be  grasped  by  the  hand,  so  as  to 
cause  contraction  of  the  muscles,  thus  pressing  the  blood  from  the 
deep  into  the  superficial  veins  along  the  communicating  branch 
which  enters  the  median  just  below  its  bifurcation. 

Operation. — The  patient  should  be  seated  in  a  chair  ;  standing 
would  produce  syncope  too  rapidly,  whilst  the  recumbent  posture 


SURGERY  OF  THE   VEINS 


would  allow  too  great  an  abstraction  of  blood  before  Nature's 
danger-signal  (i.e.,  syncope)  is  evident.  The  skin  in  front  of  the 
elbow  having  been  purified,  as  also  the  fingers  of  the  surgeon  and 
the  lancet,  the  pad  is  placed  on  the  front  of  the  arm,  and  the 
bandage  tied  firmly  over  it,  so  that  the  venous  circulation  may  be 
arrested  whilst  the  arterial  supply  is  unimpeded.  Grasping  the 
stick  firmly  causes  the  veins  to  become  prominent.  The  median 
basilic  is  now  steadied  by  the  left  thumb,  and  an  oblique  incision 
made  into  it  in  the  axis  of  the  limb  (Fig.  81).     Blood  will  flow 


Fig.  8i. — Venesection. 


from  it  in  a  full  stream,  and  is  collected  in  the  bowl.  When 
sufficient  has  been  withdrawn,  the  stick  is  removed  from  the 
patient's  hand,  the  surgeon's  thumb  is  placed  over  the  bleeding 
spot,  the  bandage  above  is  relaxed,  the  pad  placed  over  the 
wound  and  firmly  bandaged  in  position  ;  the  arm  is  kept  at 
rest  for  a  few  days  to  allow  the  small  incision  to  heal.  Occa- 
sionally neuralgic  pain  is  caused  by  the  implication  of  some  of  the 
fibres  of  the  internal  cutaneous  nerve  in  the  cicatrix  ;  whilst,  if 
the  lancet  is  plunged  too  deeply,  an  arterio-venous  wound  may  be 
produced. 


CHAPTER  XII. 
DISEASES  OF  THE  LYMPHATICS. 

Affections  of  Lymphatic  Vessels. 

Acute  Lymphangitis,  or  Inflammation  of  the  Lymphatic  Vessels. 
—The  Cause  is  almost  invariably  the  absorption  from  an  impure 
wound  of  septic  material,  with  or  without  bacteria.  In  either 
case  the  toxins  diffuse  themselves  along  the  lymphatics,  and  give 
rise  to  irritation  and  inflammation  of  the  surrounding  tissues, 
which  may  run  on  to  suppuration,  especially  if  pyogenic  organisms 
have  also  been  taken  up  from  the  wound.  The  process  is  usually 
limited  by  the  nearest  lymphatic  glands,  which  filter  off  the  toxic 
products,  but  occasionally  it  spreads  beyond  them,  and  may  give 
rise  to  general  infection  of  the  system.  Dissecting  or  post-mortem 
wounds  are  not  unfrequently  of  this  nature. 

Morbid  Anatomy. — The  walls  of  the  lymphatics  become  hyper- 
aemic  and  infiltrated,  and  the  tissues  around  are  inflamed.  The 
lymph  is  said  to  coagulate  in  the  vessels,  forming  a  pinkish  clot. 

Clinical  Signs. — The  characteristic  appearance  is  that  of  fine  red 
lines  or  streaks  following  the  course  of  the  lymphatics,  perhaps 
up  to  the  nearest  glands  ;  the  parts  thus  inflamed  are  tender  and 
cedematous.  If  the  mischief  is  limited  to  the  main  trunks  (tubular 
lymphangitis),  these  red  lines  remain  isolated  from  each  other;  but 
if  all  the  smaller  lymphatic  channels  of  a  part  are  affected  (retiform 
lymphangitis),  the  redness  merges  into  a  generalized  blush,  and  the 
condition  is  practically  identical  with  cellulitis.  Localized  foci  of 
suppuration  often  follow,  the  redness  increasing,  and  the  parts 
becoming  dusky  and  brawny,  until  finally  the  centres  soften  and 
fluctuate.  These  phenomena  are  associated  with  the  general  signs 
of  fever  and  malaise,  the  temperature  rising  to  1020  or  1030,  pos- 
sibly attended  by  rigors,  vomiting,  and  diarrhoea. 

The  Diagnosis  of  acute  lymphangitis  from  erysipelas  turns  on 
the  more  localized  and  patchy  or  streaky  character  of  the  redness, 
whilst  the  margin  is  by  no  means  so  sharply  limited  or  defined  as 
in  the  latter  disease. 


DISEASES  OF  THE  LYMPHATICS 


Under  suitable  treatment  resolution  rapidly  follows,  but  sup- 
puration may  occur  either  in  the  glands  or  in  some  loose  mass  of 
cellular  tissue  traversed  by  the  lymphatic  trunks,  or  as  a  chain  of 
abscesses  in  the  course  of  the  vessels.  Occasionally  the  lymphatic 
vessels  become  permanently  occluded,  and  a  form  of  solid  or  lym- 
phatic oedema  results.  In  a  few  cases  the  patient  dies  from  general 
septicaemia,  or  from  exhaustion  following  diffuse  suppuration. 

Treatment  is  first  of  all  directed  to  the  septic  wound,  which 
must  be  thoroughly  purified,  so  as  to  cut  off  the  supply  of 
irritating  toxins  to  the  lymphatics.  The  limb  itself  is  kept  at 
rest  in  a  slightly  elevated  position,  and  either  irrigated  with  cold 
lotions,  or  treated  with  belladonna  fomentations.  Abscesses  are 
opened  as  soon  as  they  develop.  Any  subsequent  oedema  of  the 
limb  is  remedied  by  massage  and  firm  bandaging,  provided  no 
venous  complications  are  present. 

Constitutional  treatment  consists  in  the  administration  of  a 
purge,  followed  by  quinine  and  tonics,  care  being  taken  that 
constipation  is  not  thereby  produced.  A  light  and  nutritious  diet 
is  ordered,  together  with  stimulants,  if  necessary. 

Chronic  Lymphangitis  either  results  as  a  sequela  of  an  acute 
attack,  or  is  met  with  as  a  separate  condition.  It  is  most  fre- 
quently seen  in  connection  with  venereal  disease,  the  dorsal  lym- 
phatics of  the  penis  becoming  enlarged,  hard,  and  cord-like, 
especially  in  cases  of  primary  syphilis.  This  is  usually  accom- 
panied by  a  solid  ©edematous  condition  of  the  prepuce,  and  en- 
largement of  the  inguinal  glands.  Under  appropriate  anti-syphilitic 
treatment,  the  swelling  subsides  in  a  few  weeks. 

A  tuberculous  type  of  chronic  lymphangitis  also  exists  in  which 
a  primary  focus,  say,  on  a  finger  is  associated  with  secondary 
deposits  along  the  lymphatics  up  the  arm.  Each  nodule  is  at 
first  of  firm  consistency,  but  gradually  softens  and  breaks  down. 
Naturally  such  a  case  is  liable  to  be  followed  by  general  dis- 
semination. The  treatment  consists  in  the  excision,  if  possible,  of 
each  focus. 

Rupture  or  Division  of  the  Thoracic  Duct  during  operations  on 
the  neck  is  manifested  by  an  escape  of  chylous  fluid,  which 
coagulates  on  standing  ;  if  the  flow  continues,  exhaustion  quickly 
follows.  Cases,  however,  have  been  published  showing  that  the 
condition  is  not  necessarily  fatal,  and  that  if  the  wounded  vessel 
can  be  secured,  as  by  ligature  or  forcipressure,  recovery  may 
ensue.  In  such  instances  the  thoracic  duct  probably  opens  by 
several  mouths  into  the  subclavian  vein,  and  only  one  of  the 
branches  has  been  injured. 

Lymphatics,  like  bloodvessels,  are  liable  to  distension  and 
dilatation  which   may  be  either  congenital  or  acquired,  and  are 


3r4  A   MANUAL  OF  SURGERY 


known  as  Lymphangioma  or  Lymphangiectasis.  It  is  impossible 
to  draw  an  absolute  line  of  distinction  between  the  two  conditions, 
but  the  latter  term  is  applied  mainly  to  cases  where  normal 
lymphatics  are  dilated  and  their  continuity  with  the  normal 
lymphatic  circulation  persists,  whilst  a  lymphangioma  is  the 
result  of  a  new  formation.  Of  course,  the  two  conditions  may 
develop  side  by  side. 

Lymphangiomata  are  growths  composed  of  newly-formed  lym- 
phatics, together  with  a  variable  amount  of  connective  tissue, 
which  is  sometimes  of  a  markedly  fatty  nature.  They  may  be 
congenital  or  acquired,  but  even  in  the  latter  case  there  is  pro- 
bably some  underlying  congenital  element,  which  was  only  awaiting 
some  irritation  or  localized  injury  to  determine  its  development. 
Two  varieties  may  be  described,  the  capillary  and  cavernous. 

(a)  The  Capillary  Lymphangioma  is  usually  congenital  in 
origin,  but  often  increases  considerably  as  the  child  grows,  and 
may  attain  large  proportions.  It  is  often  termed  a  lymphatic 
nawus,  and  in  origin  and  development  it  well  merits  the  title. 
The  patch  is  usually  of  a  dull  yellowish-brown  colour,  but  this 
varies  with  the  amount  of  blood  present ;  it  may  be  smooth-topped 
like  a  wheal,  or  warty  in  appearance,  but  on  examination  with  a 
lens  each  projecting  point  contains  a  vesicle.  This  type  of  growth 
is  sometimes  very  extensive,  and  may  be  associated  with  tumours 
of  the  underlying  connective  tissues.  We  recently  removed  a 
large  fatty  mass  from  the  anterior  thoracic  wall  of  a  child,  the 
greater  portion  of  the  projecting  surface  of  which  was  covered 
with  a  capillary  lymphangioma.  The  only  treatment  for  this  con- 
dition is  excision  or  destruction  by  a  caustic. 

(b)  Cavernous  Lymphangioma. — The  lymphatics  here  lose  their 
tubular  condition  and  give  rise  to  cyst-like  swellings  which  vary 
much  in  size. 

In  the  skin  they  are  often  small  and  not  larger  than  a  split  pea, 
and  this  type  may  coexist  with  the  capillary  variety.  Any  part 
of  the  body  may  be  affected,  and  the  lesion  manifests  itself  as  a 
series  of  small  vesicles  which  persist  and  are  unaccompanied  by 
any  inflammatory  redness,  thus  serving  to  distinguish  it  from 
herpes.  They  contain  lymph,  and,  if  opened,  a  considerable  flow 
of  this  fluid  (lymphorrhcea)  may  result,  lasting  for  some  time. 
They  have  been  observed  most  frequently  on  the  inner  side  of 
the  thigh  and  on  the  prepuce.  Treatment  consists  in  excision  or 
in  laying  them  open  and  cauterizing  the  base. 

In  the  deeper  structures  large  multilocular  cystic  swellings  may 
be  produced ;  these  are  most  frequently  seen  in  the  neck,  and  the 
condition  is  often  termed  a  Cystic  Hygroma.  The  description 
given  in  Chapter  XXIX.  would  apply  equally  well  to  a  tumour 
of  this  nature  in  any  other  part  of  the  body.  Removal  by  dis- 
section is  often  very  difficult,  especially  in  old-standing  neglected 
cases ;  the  limitations  of  the  mass  are  sometimes  very  indefinite, 


DISEASES  OF  THE  LYMPHATICS  315 


and  it  may  be  necessary  to  leave  the  wound  open  and  pack  it,  so 
as  to  ensure  healing  by  granulation. 

Lymphangiectases  are  more  frequently  acquired  than  congenital, 
but  the  latter  condition  occurs,  and  is  then  probably  due  to  some 
abnormal  development  of  the  lymphatics  or  to  ante-natal  inflam- 
matory mischief. 

Macroglossia  and  macrocheilia  are  congenital  enlargements  of 
the  tongue  and  lip,  due  to  lymphatic  obstruction  and  to  an  asso- 
ciated overgrowth  of  the  connective  tissues  of  the  parts.  (See 
Chapter  XXIV.) 

In  a  few  cases  the  opening  of  the  thoracic  duct  has  been  obstructed 
or  compressed,  leading  to  such  backward  tension  that  the  recep- 
taculum  chyli  has  ruptured  and  the  peritoneal  and  pleural  cavities 
have  been  filled  with  a  serous  or  chylous  exudation.  Virchow 
described  one  case  where  the  opening  was  congenitally  absent 
(in  a  calf)  and  the  lymphatics  throughout  the  body  were  enor- 
mously distended,  especially  those  of  the  small  intestine. 

The  condition  known  as  Chylous  Hydrocele,  in  which  there  is 
an  effusion  of  milky  fluid  (presumably  chyle)  into  the  tunica 
vaginalis,  is  probably  due  to  some  such  obstructive  cause.  In  a 
case  under  our  care  the  lymphatics  of  the  spermatic  cord  were 
dilated  by  a  similar  fluid  in  a  beaded  manner. 

Chronic  forms  of  lymphatic  obstruction  arise  from  the  deposit 
of  tuberculous  or  cancerous  material  in  the  lymphatic  glands, 
from  repeated  attacks  of  subacute  lymphangitis,  due  to  the 
continuous  irritation  of  a  large  ulcer  or  extensive  eczema  of 
the  leg,  or  from  the  growth  within  the  lymphatics  of  living 
organisms,  e.g.,  the  Filaria  sanguinis  hominis.  The  latter  con- 
dition is  the  cause  of  the  disease  known  as  Elephantiasis  Arabum, 
whilst  the  former  may  give  rise  to  a  spurious  form  of  this 
affection,  known  as  Pseud-elephantiasis.  Three  chief  phenomena 
manifest  themselves  as  the  outcome  of  such  obstruction,  viz., 
(a)  Solid  or  lymphatic  oedema,  a  condition  in  which  the  subcutaneous 
tissues  become  firm,  infiltrated,  and  brawny,  but  the  fluid  cannot 
be  expressed  from  them,  as  in  an  ordinary  cedema ;  (b)  hyperplasia 
follows,  affecting  not  only  the  subcutaneous  tissues,  which  are 
markedly  thickened  and  increased  in  amount,  but  also  the  skin, 
which  becomes  coarse  and  wart-like  in  appearance,  and  is  very 
prone  to  ulcerate  ;  and  (c)  lymphatic  fistula  are  liable  to  develop, 
from  which  a  large  amount  of  fluid  exudes  (lymphorrhaa). 

Solid  oedema  of  the  prepuce  is  a  not  very  unfrequent  com- 
plication of  suppurative  balanitis,  and  occurs  most  usually  in 
cases  of  syphilis.  The  dorsal  lymphatics  can  be  felt  enlarged, 
and  the  prepuce  becomes  swollen  and  indurated  to  such  a  degree 
that  retraction  is  impossible.  In  cases  of  hypospadias,  where 
the  prepuce  is  voluminous  and  hangs  like  a  hood  over  the  glans, 
the  occurrence  of  solid  cedema  renders  it  so  prominent  as  almost 
to  resemble  the  glans  in  colour  and  size. 


316 


A  MANUAL  OF  SURGERY 


The  removal  of  tuberculous  glands  from  the  neck  maybe  followed 
by  a  puffy  condition  of  the  lower  half  of  the  face,  which  remains 
enlarged  for  some  time,  but  after  a  while  regains  its  usual  size. 
The  cheeks  are  occasionally  involved  in  a  solid  cedematous  process 
spreading  from  either  side  of  the  nose,  and  due  to  attacks  of 
chronic  lymphangitis,  caused  by  the  absorption  of  toxins  from  sores 
or  ulcers  within  the  nostril.  The  thick  lips  occurring  in  tuberculous 
children  are  of  a  similar  nature,  and  due  to  the  constant  irritation 
of  cracks  along  the  margins. 

The  pseud-elephantiasis  arising  from  chronic  ulcers,  or  from 
disease  of  the  lymphatic  glands,  can  usually  be  dealt  with  by  the 
pressure  of  an  elastic  bandage  ;  but  the  limb  is  very  likely  to 
remain  permanently  enlarged,  and  in  some  cases  where  intract- 
able ulceration  and  lymph  fistulae  exist  amputation  is  the  best 
treatment. 

Elephantiasis  Arabum  (syn.:  Barbadoes  leg)  requires  but  little 


A  B 

Fig.  82. — Elephantiasis  of  Feet. 


notice  here,  as  it  is  seldom  seen  in  this  country,  being  mainly 
limited  to  the  tropics,  especially  the  West  Indies  and  South 
America.  The  legs,  scrotum,  and  vulva  are  the  parts  most  fre- 
quently attacked,  but  the  face  or  breast  may  also  be  affected.  It 
manifests  itself  as  a  hyperplasia  of  variable  size  of  the  sub- 
cutaneous tissues,  whilst  the  skin  becomes  thickened  and  wart- 
like (Fig.  82,  A  and  B),  and  from  it  a  copious  discharge  of 
lymph  may  escape.  The  parts  sometimes  attain  enormous 
dimensions,  the  scrotum  even  reaching  to  the  ground  when  the 
patient  is  sitting.  The  disease  persists  for  many  years,  and  is 
not  directly  fatal. 

The  condition  is  due,  as  already  mentioned,  to  the  obstruction 
caused  by  the  development  of  the  Filavia  sanguinis  hominis  in  the 
lymphatics.  These  are  spread  (according  to  Manson)  by  the 
agency  of  mosquitoes,  in  whose  bodies  the  intermediate  stage  is 
passed.  The  dead  mosquito,  with  its  parasitic  contents,  falls 
upon  the  water,  and  in  this  way  the  ova  find  an  entrance  into  the 
human  stomach,  where  the  young  worm  is  set  free,  bores  through 


DISEASES  OF  THE  LYMPHATICS  317 


the  gastric  mucous  membrane,  and  finally  becomes  lodged  in  the 
lymphatics,  especially  those  of  the  extremities.  Not  more  than  two 
or  three  pairs  of  mature  filariae  are  generally  present  in  the  same 
individual.  The  body  of  the  female  worm  (which  attains  a  length 
of  3  inches)  is  mainly  occupied  by  the  reproductive  organs,  and 
a  countless  number  of  embryonic  filariae  are  produced.  Some 
remain  coiled  up  in  the  lymphatic  spaces,  and  give  rise  to  the 
phenomena  of  lymphatic  obstruction.  Others  become  uncoiled, 
and  are  then  about  ^.;  inch  in  length  ;  they  find  their  way  into 
the  blood  stream,  usually  at  night,  and  can  be  readily  seen  under 
the  microscope.  Manson  claims  that  they  are  taken  into  the 
body  of  the  mosquito  with  the  blood  which  it  abstracts,  and  thus 
a  fresh  generation  is  developed. 

The  Treatment  is  extremely  unsatisfactory.  Of  course,  if  one 
can  localize  the  situation  of  the  parent  filariae,  as  has  been 
possible  in  a  few  cases,  they  should  be  excised  ;  but  more  fre- 
quently one  has  to  depend  on  less  satisfactory  measures.  When 
the  face  or  trunk  is  involved,  but  little  can  be  done.  When  the 
scrotum  is  affected,  the  morbid  tissue  can  be  freely  dissected 
away,  sufficient  skin  being  left  to  cover  in  the  wound  if  possible  ; 
the  penis  and  testes  must  first  be  isolated,  and  then  the  scrotum 
amputated,  a  tourniquet  being  used  to  restrain  the  bleeding.  In 
the  leg  elastic  bandages,  elevation,  and  possibly  scarification,  may 
be  useful  in  the  slighter  cases  ;  but  where  the  limb  is  enormously 
enlarged  the  greatest  measure  of  success  seems  to  have  followed 
ligature  of  the  main  artery,  so  as  to  diminish  the  blood  supply,  and 
so  check  the  growth  by  a  process  of  starvation.  Failing  this, 
amputation  is  the  only  resource. 

Affections  of  Lymphatic  Glands. 

Acute  Lymphadenitis,  or  Inflammation  of  Lymphatic  Glands. — 
The  Cause  of  this  condition  is  almost  always  the  absorption  of 
some  irritative  material  (toxic  or  infective)  from  the  periphery. 
When  a  part  becomes  inflamed,  there  is  always  an  increased  flow 
through  the  efferent  lymph  channels,  owing  to  the  exudation  ; 
the  result  of  this  is  an  increase  in  size  of  the  glands  to  which  the 
lymph  is  carried,  which  quickly  subsides  when  the  inflammatory 
process  is  at  an  end.  If,  however,  irritating  toxins  are  produced 
in  the  inflamed  area,  they  give  rise  to  a  more  prolonged  and 
serious  affection,  whether  accompanied  or  not  by  a  similar  con- 
dition of  the  lymphatic  vessels.  When  pyogenic  organisms  are 
also  absorbed,  suppuration  almost  invariably  results.  In  fact,  the 
lymphatic  glands  must  be  looked  on  as  the  filters  by  means  of 
which  Nature  eliminates  many  sources  of  disease.  It  is  curious 
that  certain  peripheral  infective  conditions  are  not  at  all  liable  to 
produce  enlargement  of  the  glands,  e.g.,  spreading  gangrene,  and 
many  forms  of  cellulitis  ;  possibly  the  acuteness  of  the  process 


3i8  A  MANUAL  OF  SURGERY 


causes  lymphatic  thrombosis  in  the  efferent  trunks,  and  thus 
hinders  the  absorption  of  the  noxious  material. 

Pathologically,  the  condition  is  characterized  by  hyperaemia  of, 
and  exudation  into,  the  gland,  which  becomes  redder,  firmer,  and 
larger  than  usual.  Suppuration  usually  starts  in  more  than  one 
spot.  A  certain  amount  of  peri-adenitis,  or  inflammation  of  the 
surrounding  tissues,  is  always  associated  with  it,  even  in  the  early 
stages  ;  the  latter  may  be  of  little  importance,  but  when  the 
capsule  has  given  way  it  may  become  so  extensive  as  to  constitute 
a  diffuse  suppurative  cellulitis. 

Clinically,  the  glands  can  be  felt  as  enlarged,  tender,  and 
rounded  masses,  the  skin  over  them  being  red  and  cedematous  ; 
when  pus  has  formed,  the  swelling,  which  is  at  first  hard  and 
brawny,  becomes  soft  and  fluctuating.  They  early  contract 
adhesions  to  neighbouring  tissues,  and  suppuration  may  extend 
widely  beyond  the  glands,  especially  where  there  is  much  loose 
areolar  tissue,  as  in  the  axilla.  Fever,  malaise,  and  all  the 
general  phenomena  associated  with  an  acute  inflammation,  are 
usually  well  marked. 

The  Treatment  consists,  in  the  first  place,  in  the  removal  of  all 
sources  of  irritation,  both  physical  and  physiological.  The  part 
must  be  kept  at  rest  and  protected  from  injury,  and  the  offending 
wound  or  causative  lesion  dealt  with  by  such  antiseptic  measures 
as  may  be  needed  to  hasten  its  restoration  to  a  healthy  state. 
Fomentations  are  applied  over  the  gland,  and  the  patient,  after 
the  administration  of  a  purge,  may  be  given  quinine  and  iron,  if 
necessary.  As  soon  as  pus  has  formed,  it  should  be  let  out  by  an 
incision,  and  the  wound  dressed  antiseptically.  Linseed-meal 
poultices,  whilst  useful  in  encouraging  the  formation  of  pus,  are 
most  undesirable  after  the  abscess  has  been  opened  (vide  Treat- 
ment of  Acute  Abscess,  p.  48). 

Special  Forms  of  Acute  Lymphadenitis. 

The  Axillary  Glands  are  usually  affected  as  a  result  of  poisoned  wounds  of 
the  hand  or  fingers,  although  other  glands  exist  lower  down  in  the  arm,  viz., 
the  supra-condyloid,  just  above  the  internal  condyle.  Boils  in  the  axilla  and 
excoriations  or  septic  wounds  of  the  breast  may  also  cause  an  axillary  abscess. 
In  this  region  a  suppurative  periadenitis  is  often  superadded,  extending  widely 
under  and  between  the  pectoral  muscles,  reaching  even  up  to  the  clavicle. 
Care  must  be  taken  in  opening  such  an  abscess  to  avoid  the  main  vessels  by 
cutting  from  above  downwards,  midway  between  the  anterior  and  posterior 
axillary  folds,  whilst  Hilton's  method  should  be  adopted  in  all  cases  where  the 
pus  is  situated  deeply. 

In  the  Groin  there  are  three  groups  of  glands :  (1)  The  oblique  set,  running 
parallel  to  Poupart's  ligament,  and  becoming  inflamed  in  affections  of  the 
penis,  scrotum,  perineum,  anus,  buttock,  and  lower  part  of  the  abdomen; 
(2)  a  superficial  vertical  set,  running  with  the  long  saphenous  vein,  and  receiving 
lymph  from  all  the  superficial  parts  of  the  limb,  except  perhaps  those  from 
which  the  blood  is  returned  by  the  external  saphenous  vein,  the  popliteal 
glands  receiving  the  lymph  from  this  region ;  and  (3)  the  deep  vertical  set, 
receiving  the  deep  lymphatics  of  the  limb.     Abscess  in  the  groin  is  opened  by 


DISEASES  OF  THE  LYMPHATICS  319 

a  vertical  incision,  so  as  to  allow  the  wound  to  gape  when  the  patient  sits,  and 
prevent  pocketing  of  matter. 

Suppuration  in  the  glands  of  the  Neck  is  exceedingly  common,  arising  most 
often  from  affections  of  the  scalp  (eczema  or  pediculosis),  ear  (otorrhcea  or 
eczema),  throat,  or  lips.  As  to  the  exact  distribution  of  the  lymphatics  we 
must  refer  students  to  anatomical  text-books.  When  opening  a  cervical 
abscess,  care  must  be  taken  to  avoid  important  structures,  such  as  the  external 
jugular  vein,  and  to  make  incisions  across  the  fibres  of  the  platysma  in  order 
to  gain  space  for  efficient  drainage. 

Chronic  Lymphadenitis. — Three  varieties  of  chronic  inflamma- 
tion of  lymphatic  glands  are  met  with,  viz.,  the  simple,  syphilitic, 
and  tuberculous. 

1.  Chronic  Simple  Lymphadenitis  is  a  condition  resulting  from 
some  peripheral  irritation,  which  is  insufficient  to  cause  an  acute 
attack.  It  also  occasionally  results  from  blows  and  strains,  as  in 
over-walking,  being  in  such  cases  possibly  due  to  obstruction  to 
the  lymphatic  flow,  owing  to  compression  or  rupture  of  the  efferent 
vessels.  The  glands  become  enlarged,  tender,  and  painful,  but 
as  a  rule  they  do  not  become  adherent  to  one  another,  or  to 
adjacent  structures,  and  show  but  little  tendency  to  suppurate. 
This  condition  often  precedes,  and,  indeed,  may  be  looked  on  as 
a  predisposing  cause  of,  tuberculous  lymphadenitis.  The  Treat- 
ment consists  in  keeping  the  part  at  rest,  removing  if  possible  all 
sources  of  local  irritation,  combined  perhaps  with  the  local  appli- 
cation of  iodine  paint,  or  friction  with  iodide  of  potassium  or  iodide 
of  mercury  ointment.  The  general  health  should  also  be  attended 
to,  especially  in  children  predisposed  to  the  development  of  tuber- 
culous disease. 

2.  Chronic  Syphilitic  Lymphadenitis. — The  lymphatic  glands 
are  involved  in  several  ways  in  the  course  of  syphilitic  disease  : 
(a)  The  primary  lesion  is  associated  with  the  development  of  an 
indolent  bubo  in  the  nearest  lymphatic  glands,  which  become 
hard,  somewhat  like  almonds  or  bullets  beneath  the  skin.  But 
little  pain  is  noticed  unless  suppuration  is  taking  place  ;  this  is 
never  due  to  the  syphilitic  virus  alone,  but  to  the  absorption  of 
some  septic  matter  from  the  primary  lesion.  There  is  usually 
much  more  infiltration  and  enlargement  of  glands  in  extra  genital 
chancres  than  in  those  occurring  about  the  genital  organs,  (b)  In 
the  second  stage,  when  general  infection  has  occurred,  the  glands 
in  many  parts  of  the  body  are  affected  in  the  same  indolent  fashion. 
(c)  In  the  tertiary  period  the  lymphatic  glands  may  undergo  a 
true  gummatous  change,  or  become  enlarged  and  tender  owing  to 
the  absorption  of  septic  material  from  a  broken-down  gumma. 
For  further  particulars  and  Treatment,  see  p.  125. 

3.  Chronic  Tuberculous  Lymphadenitis  occurs  most  commonly  in 
children  or  young  adults,  who  have  inherited  a  predisposition  to 
the  development  of  tuberculous  disease,  and  more  especially  in 
those  whose  surroundings  are  unhealthy,  and  whose  general 
condition  is  deteriorated  by  insufficient  or  bad  food  and  want  of 


32o  A  MANUAL  OF  SURGERY 


fresh  air.  Some  local  focus  of  irritation  is  usually  present  in  the 
form  of  pediculosis  capitis,  decayed  teeth,  chronic  otorrhaea, 
adenoids,  or  eczema  of  the  face.  As  a  result  of  this,  neighbour- 
ing glands  become  chronically  inflamed,  and,  as  Sir  T.  Burdon 
Sanderson  says,  '  the  soil  is  thereby  prepared  for  the  seed.' 
The  bacilli  are  conveyed  to  the  gland  by  the  blood  or  lymph, 
gaining  access  through  some  breach  of  surface,  or  even  perhaps 
through  a  healthy  mucous  membrane,  or  perhaps  they  may  be 
derived  from  some  deep  focus  of  quiescent  tubercle,  say,  in  the 
bronchial  or  mediastinal  glands,  a  situation  in  which  tubercle  is 
often  unexpectedly  found.  Any  lymphoid  tissue  in  the  body  may 
become  the  seat  of  tuberculous  disease  ;  but  the  glands  of  the 
neck,  especially  the  submaxillary  and  the  concatenate,  are  much 
more  commonly  involved  than  any  others.  The  axillary  and 
inguinal  glands  are  also  not  unfrequently  affected,  whilst  tuber- 
culous disease  of  those  in  the  mesentery  gives  rise  to  the  affection 
known  as  'tabes  mesenterica.' 

The  course  of  the  case  may  be  described  under  the  following 
headings,  although  it  must  be  remembered  that  the  stages  do  not 
necessarily  follow  one  another  in  exact  sequence  :  (i.)  The  earliest 
manifestation  of  the  disease  consists  in  a  fleshy  enlargement  of  the 
glands  which  cannot  at  first  be  distinguished,  either  clinically  or 
pathologically,  from  a  simple  chronic  hyperplasia.  The  gland 
may  be  enlarged  to  many  times  its  natural  size,  and  on  section 
looks  pinkish  in  colour,  and  is  of  firm  consistence.  Microscopic- 
ally, all  that  is  noticed  is  a  great  increase  in  the  lymphoid 
corpuscles,  together  with  some  overgrowth  and  thickening  of  the 
fibrous  capsule  and  trabecular.  When  tuberculous  infection  has 
occurred,  the  characteristic  nodules  can  be  seen  under  the  micro- 
scope, but  there  is  at  first  no  change  in  the  naked-eye  appearances, 
(ii.)  Caseation  follows  sooner  or  later,  and  since  the  tuberculous 
nodules  are  often  disseminated  widely  through  the  gland,  many 
caseating  foci  will  be  found,  (iii.)  Calcification  of  the  caseous 
detritus  sometimes  occurs  in  those  cases  which  are  tending  to 
recovery.  Such  is  accompanied  by  a  fibroid  thickening  of  the 
gland,  resulting  from  overgrowth  of  the  capsular  and  trabecular 
connective  tissue.  This  change  is  most  frequently  observed  in 
the  mediastinal  and  mesenteric  glands,  and  is  not  very  uncommon 
in  the  neck,  (iv.)  More  frequently  suppuration  ensues,  sometimes 
from  a  simple  emulsification  of  the  caseating  material,  sometimes 
from  infection  with  pyogenic  organisms  from  without.  Foci  of  pus 
develop  at  various  spots  in  the  glandular  parenchyma,  and  when 
once  formed,  these  tend  to  amalgamate  and  cause  the  destruction 
of  the  rest  of  the  glandular  tissue,  the  fibrous  trabecular  remaining 
longest  unaffected,  so  that  finally  the  gland  is  represented  by  a 
single  abscess  cavity  surrounded  by  a  pyogenic  membrane  of  the 
ordinary  tuberculous  type,  in  which  traces  of  the  capsule  can  be 
observed.    Several  of  these  abscesses  may  merge  into  one  another, 


DISEASES  OF  THE  LYMPHATICS  321 


and  thus  a  large  multiloculated  cavity,  containing  pus  mixed  with 
curdy  debris,  is  formed,  (v.)  A  certain  amount  of  peri-adenitis  is 
almost  always  present,  though  not  to  any  great  extent  in  the  early 
stages  ;  when,  however,  suppuration  has  occurred,  or  if  the  glands 
are  exposed  to  pressure  or  friction,  they  become  adherent  not  only 
to  neighbouring  glands,  but  also  to  surrounding  structures.  In 
the  more  chronic  cases  the  fibro-cicatricial  tissue  thus  formed  may 
be  so  extensive  as  to  firmly  fix  the  mass  to  the  deeper  parts,  such 
as  the  main  vessels  and  nerves,  rendering  removal  by  enuclea- 
tion dangerous  and  almost  impracticable.  Important  vessels  are 
occasionally  eroded  by  an  extension  of  the  suppurative  process, 
and  this  may  lead  to  fatal  haemorrhage,  (vi.)  Sooner  or  later  the 
abscess,  if  left  to  itself,  bursts  either  at  one  or  several  spots, 
leaving  ulcerated  openings,  through  which  is  seen  cedematous 
granulation  tissue  mixed  with  caseating  material.  The  edges  are 
undermined,  thin,  and  purplish,  and  the  granulations  sometimes 
sufficiently  prominent  to  protrude  through  the  openings  as 
fungating  masses.  A  variable  amount  of  pus  escapes  from  these, 
and  the  condition  may  persist  for  many  years  if  radical  treatment 
is  not  undertaken,  (vii.)  Under  suitable  local  and  constitutional 
measures  these  sores  may,  and  usually  do,  heal  after  a  time, 
giving  rise  to  a  pulpy  spongy  cicatrix,  which  is  often  puckered  and 
more  or  less  keloidal,  and  may  retain  its  vascularity  for  a  much 
longer  period  than  would  a  healthy  scar.  Lymphatic  oedema  in 
the  region  drained  by  the  affected  glands  is  sometimes  observed 
as  a  late  consequence  of  this  affection. 

The  usual  complications  met  with  in  the  course  of  all  tuberculous 
diseases  may  also  manifest  themselves  (p.  144). 

The  Treatment  of  tuberculous  glands  is  palliative  or  radical. 

Palliative  Treatment  consists  mainly  in  improving  the  general 
health  by  means  of  suitable  diet  and  tonics,  such  as  cod-liver  oil 
and  syrup  of  the  iodide  of  iron,  together  with  residence  in  a 
healthy,  bracing  situation,  especially  at  the  seaside,  as,  for 
instance,  at  Margate.  All  sources  of  local  irritation  must  be 
removed  so  as,  if  possible,  to  prevent  infection  with  pyogenic 
organisms,  and  counter-irritants,  such  as  iodine  paint,  are  best 
avoided.  Rest  of  the  affected  part  should  be  enforced  as  much  as 
possible  ;  in  some  cases  the  application  of  splints  to  restrict  move- 
ment is  advisable. 

Radical  Treatment. — Wherever  practicable,  glands  evidently 
tuberculous  should  be  completely  removed  by  dissection,  and 
even  amongst  the  wealthy  too  much  time  should  not  be  wasted  in 
palliative  measures,  inasmuch  as  the  longer  the  glands  are  left,  the 
firmer  will  be  the  adhesions  which  they  are  likely  to  contract  with 
surrounding  tissues.  In  the  later  stages,  so  far  may  this  process 
have  gone  that  removal  by  dissection  is  hopeless.  In  such  cases 
a  free  opening  is  made  down  to  the  diseased  tissues,  and  as  large 
a  portion  removed  as  possible,  whilst  the  remaining  deeper  parts 

21 


322  A   MANUAL  OF  SURGERY 


axe  scraped  with  a  Volkmann's  spoon.  The  wound  can  rarely  be 
entirely  closed,  and  must  be  packed  with  gauze  soaked  in  an 
iodoform  emulsion  (10  per  cent),  and  allowed  to  heal  by  granula- 
tion. In  septic  cases  the  same  line  of  treatment  must  necessarily 
be  adopted. 

In  the  neck  very  extensive  operations  may  have  to  be  under- 
taken for  the  removal  of  tuberculous  glands.  The  incision  varies 
with  the  situation  of  the  mass,  but  where  feasible  it  is  kept  well 
behind  the  sterno-mastoid.  When,  however,  enlarged  glands 
exist  both  in  front  of,  behind,  and  beneath  the  muscle,  it  is  well 
to  make  the  incision  parallel  to  the  course  of  the  external  jugular 
vein,  entirely  dividing  the  sterno-mastoid,  which  may  subsequently 
be  stitched  together.  Special  care  must  be  taken  of  the  chief 
vessels  and  nerves,  particularly  of  the  internal  jugular  vein,  to 
which  the  glands  are  frequently  adherent ;  in  some  cases,  however, 
it  is  necessary  to  divide  the  vein  or  excise  a  segment  of  it,  a 
comparatively  unimportant  proceeding  in  children.  The  situation 
of  the  spinal  accessory  nerve  as  it  crosses  the  posterior  triangle 
must  also  be  remembered.  Naturally,  adherent  glands  may  be 
dealt  with  very  much  more  freely  in  the  posterior  than  in  the 
anterior  portion  of  the  neck. 

The  pYe-auriculnr  gland,  lying  on  the  capsule  of  the  parotid,  is 
sometimes  affected,  and  may  cause  facial  paralysis,  either  as  a 
result  of  the  sclerosing  peri-adenitis,  or  from  injudicious  surgery. 
Any  incisions  made  with  a  view  to  remove  the  gland  or  to  open 
an  abscess  therein  should  be  made  in  the  direction  of  the  fibres  of 
the  facial  nerve,  i.e.,  horizontally. 

In  the  groin,  tuberculous  glands  are  often  mistaken  for  some 
condition  due  to  venereal  disease.  The  history  of  onset  and  the 
extreme  chronicity  should  suffice  to  establish  a  diagnosis.  The 
iliac  glands  will  often  be  found  similarly  affected,  and  operations 
in  this  region  are  sometimes  very  extensive  in  consequence. 
Well-marked  peri-adenitis  is  usually  present  in  the  iliac  fossa, 
and  the  glands  may  be  very  adherent.  Atrophy  of  the  testicle 
sometimes  follows,  either  from  division  of  the  spermatic  vessels, 
or  from  their  implication  in  the  cicatrix. 

Tumours  of  Lymphatic  Glands. 

The  Primary  New  Growths  occurring  in  lymphatic  glands  are 
lymphadenoma"  and  lympho-sarcoma.  A  few  instances  of  appar- 
ently primary  epithelioma  have  been  recorded.  Amongst  others, 
Sir  James  Paget  mentions  some  cases  of  epithelioma  of  the  inguinal 
glands,  following  eczema  of  the  scrotum,  caused  by  soot,  tar,  or 
paraffin,  in  which,  on  the  most  careful  examination,  no  primary 
scrotal  growth  was  discovered ;  possibly  it  had  disappeared. 

*  The  term  Lymphoma  is  sometimes  applied  to  these  conditions,  but  is 
obviously  inaccurate,  as  etymologically  it  should  mean  '  a  tumour  consisting 
of  lymph.' 


DISEASES  OF  THE  LYMPHATICS 


523 


Lymphadenoma  is  the  term  given  to  a  new.  growth  occurring 
in  lymphatic  glands,  corresponding  in  structure  with  normal 
lymphoid  tissue — that  is  to  say,  it  consists  of  a  stroma,  more  or 
less  delicate  according  to  the  consistency  of  the  mass,  in  the 
meshes  of  which  are  packed  a  great  number  of  small  round  cells 
resembling  leucocytes. 

There  has  been  much  discussion  as  to  the  nature  of  this  growth, 
and  also  as  to  the  relation  it  bears  to  leukaemia.  Nothing  final 
has  as  yet  been  made  out,  but  there  seems  every  probability  in 
favour  of  the  view  that  it  is  to  be  looked  on  as  an  infective  disease, 
due  to  some  specific  micro-organism,  and  therefore  to  be  placed 
midway  between  tubercle  and  cancer.  Occasionally  it  develops 
as  a  strictly  local  affection,  and  can  then  be  readily  eradicated ; 
sometimes  it  involves  a  whole  series  of  lymphatic  glands,  but  is 
limited  to  one  region  of  the  body,  both  the  above  types  being 
included  below  under  the  term  '  benign '  lymphadenoma.  On  the 
other  hand,  it  is  sometimes  disseminated  widely  throughout  the 
system,  affecting  not  only  the  external  lymphoid  tissues,  but  also 
the  spleen  and  other  internal  tissues  of  a  lymphatic  nature  ;  it  is 
then  known  as  Hodgkin's  disease,  or  pseudo-leukaemia.  Leuk- 
aemia (or  leucocythaemia)  is  an  affection  with  special  and  peculiar 
blood  features,  dependent  on  changes  occurring  in  the  spleen, 
lymphatic  glands,  or  marrow  of  bones.  The  spleno-medullary 
type  is  the  commonest ;  lymphatic  leukaemia  is  much  rarer,  and 
the  glands  are  even  then  seldom  larger  than  walnuts. 

Benign  or  Localized  Lymphadenoma  is  usually  met  with  in  young 
adults,  affecting  either  one  gland  or  a  large  number.  It  is  most 
often  seen  in  the  neck,  and  though  the  patient  may  be  slightly 
anaemic,  he  never  presents  any  leukaemic  blood  changes. 

When  a  single  gland  is  affected  it  becomes  slowly  enlarged,  and 
shows  no  tendency  to  caseate  or  suppurate ;  it  remains  free  from 
adhesions  to  adjacent  structures,  and  is  hence  moveable  and  pain- 
less. It  is  quite  possible  that  many  glands  thought  to  be  of  this 
nature  are  in  reality  tuberculous,  in  the  early  stages  of  fleshy 
enlargement.     The  Treatment  of  such  is  by  removal. 

When  many  glands  are  affected,  the  disease  may  be  limited  to 
one  region,  or  several  groups  may  be  enlarged  in  different  parts 
of  the  body;  the  neck  is  a  favourite  situation,  both  sides  being 
often  involved,  and  the  disease  may  here  be  so  extensive  as  to 
render  the  wearing  of  a  collar  impossible.  The  special  character- 
istics of  this  condition  are :  that  many  glands  are  enlarged,  that 
they  have  no  tendency  to  suppurate,  caseate,  or  ulcerate,  and 
that  there  is  but  little  peri-adenitis  ;  hence  they  are  freely  move- 
able one  on  another  and  on  surrounding  tissues,  and  are  neither 
painful  nor  tender. 

On  removal,  the  glands  vary  somewhat  in  consistency,  being 
sometimes  firm  and  elastic,  presenting  on  section  with  the  knite 
a  pink   and    fleshy  cortical   portion,  whilst    the    central    part    is 


324  A  MANUAL  OF  SURGERY 

grayish  and  somewhat  indurated  ;  but  in  other  cases  they  are  soft 
and  more  friable,  and  on  scraping  the  cut  surface  with  the  knife  a 
milky  juice  is  obtained,  the  cells  of  which,  however,  are  leucocytes 
and  not  epithelial,  as  in  the  juice  obtained  by  scraping  a  can- 
cerous tumour.  This  difference  in  texture  depends  mainly  on 
the  rate  of  growth,  the  soft  growing  rapidly,  and  the  firm  slowly. 
Microscopically,  no  changes  in  structure  from  ordinary  lymphoid 
tissue  are  observed.  Constitutionally,  there  is  usually  a  good 
deal  of  anaemia  present,  but  no  leukaemia. 

This  affection  is  sometimes  markedly  amenable  to  Treatment, 
especially  to  the  administration  of  arsenic.  Small  doses  of  liquor 
arsenicalis  combined  with  iron  are  at  first  given,  but  these  are 
gradually  increased,  and  as  the  patient  comes  under  the  influence 
of  the  drug,  retrogression  of  the  glands  may  be  observed.  If, 
however,  they  persist  in  spite  of  medicinal  treatment,  their  re- 
moval should  not  be  delayed.  Where  many  glands  are  affected, 
this  may  involve  extensive  and  repeated  operations. 

Hodgkin's  Disease  (syn.  :  General  Lymphadenosis  or  Pseudo- 
leukaemia)  is  a  condition  usually  met  with  in  adults,  and  is 
characterized  by  an  overgrowth  of  all,  or  nearly  all,  the  lymphoid 
tissues  in  the  body,  including  glands,  the  spleen,  the  solitary 
or  agminated  follicles  of  the  intestine,  etc.  Marked  blood  changes 
are  present,  consisting  in  a  great  increase  in  the  number  of  leuco- 
cytes, whilst  the  red  corpuscles  are  deficient  both  in  number  and 
in  the  amount  of  haemoglobin  contained  in  them.  In  true 
leukaemia  the  proportion  of  white  corpuscles  to  red  is  enormous, 
one  to  ten  of  the  latter  being  a  common  experience  ;  in  pseudo- 
leukaemia  the  proportion  rarely  exceeds  one  to  forty  or  fifty.  The 
character  of  the  leucocytes  and  their  reaction  to  staining  reagents 
also  varies,  so  that  a  microscopical  examination  of  the  blood 
will  at  once  differentiate  Hodgkin's  disease  from  lymphatic 
leukaemia,  although  the  external  swellings  may  be  indistinguish- 
able. 

The  tumours  thus  produced  grow  slowly,  are  painless,  and, 
when  groups  of  glands  are  affected,  adhere  together,  forming 
lobulated  masses,  but  with  no  tendency  to  caseate  or  suppurate. 
The  skin  may  become  involved  in  the  tumour  later  on,  and  super- 
ficial ulceration  follow,  but  there  is  no  subsequent  fungation. 

The  prognosis  is  exceedingly  grave,  the  disease  usually  pro- 
gressing in  spite  of  all  treatment  to  a  fatal  issue  from  exhaustion. 

Treatment. — Arsenic  combined  with  iron  may  be  administered, 
and,  latterly,  injection  of  an  emulsion  of  bone-marrow  has  been 
strongly  recommended,  but  the  results  gained  hitherto  have  not 
been  at  all  satisfactory.  It  is  useless  attempting  to  remove  the 
external  growths,  since  they  are  only  an  evidence  of  a  deep- 
seated  general  affection. 

Lympho-sarcoma. — Lymphatic  glands  sometimes  become  the 
seat  of  a  primary  sarcomatous  growth,  the  microscopic  characters 


DISEASES  OF  THE  LYMPHATICS 


of  which  have  been  detailed  elsewhere  (p.  156).  The  disease 
occurs  in  adults  and  is  met  with  not  uncommonly  in  the  tonsil, 
sometimes  in  the  glands  at  the  root  of  the  neck,  and  may  occa- 
sionally originate  in  the  mediastinum  or  in  the  testis.  When  com- 
mencing in  a  region  where  its  development  can  be  followed,  it  is 
seen  to  form  a  rapidly  growing  tumour,  which  is  at  first  firm,  elastic, 
and  painless  ;  later  on,  however,  as  it  increases  in  size,  it  becomes 
tender,  and  may  cause  great  pain  from  pressure  on,  or  implication 
of,  nerves.  It  early  contracts  adhesions  to  surrounding  parts, 
and  gives  rise  to  secondary  growths  in  neighbouring  glands  by 
direct  transmission.  The  superjacent  skin  is  at  first  unaltered  in 
colour  and  texture,  but  as  the  tumour  increases,  it  becomes  con- 
gested and  shiny,  and  contains  a  network  of  dilated  veins. 
Finally,  it  is  involved  in  the  growth,  and  ulcerates,  an  occurrence 
usually  followed  by  the  sprouting  up  of  a  bleeding  fungating  mass, 
similar  in  character  to  that  formed  by  any  other  rapidly  growing 
malignant  tumour.  Dissemination  of  the  growth  throughout  the 
viscera  follows,  death  resulting  from  exhaustion  and  cachexia. 

The  Treatment  consists  in  the  removal  of  the  mass,  where 
practicable,  without  delay.  If,  however,  extensive  adhesions 
exist,  this  becomes  absolutely  impossible. 

Secondary  Growths  in  Lymphatic  Glands  are  a  special  feature  of 
all  cancerous  tumours.  In  the  sarcomata  they  are  less  common, 
but  are  always  present  in  the  case  of  melanotic  sarcoma,  lympho- 
sarcoma, and  usually  in  sarcoma  of  the  testis,  tonsil,  and  thyroid. 
The  special  characteristics  of  these  are  noted  elsewhere. 


CHAPTER   XIII. 
AFfECTIONS    OF    NERVES. 

Injuries  of  Nerves. 

The  simplest  and  most  common  forms  of  injury  to  which  nerves 
are  liable  are  Contusions  and  Strains,  causing  a  sensation  of  tingling, 
or  pins  and  needles,  which  usually  wears  off  in  the  course  of  a 
few  hours.  In  severe  cases  variable  degrees  of  loss  of  power  and 
sensation  may  ensue,  and  in  hysterical  women  more  or  less 
neuralgia.  In  patients  suffering  from  gout,  syphilis,  or  rheuma- 
tism, a  chronic  peripheral  neuritis  is  readily  induced,  often  of 
a  somewhat  intractable  type,  and  this  even  occurs  in  healthy 
individuals.  Treatment  consists  in  gentle  friction  with  stimu- 
lating liniments. 

Rupture  of  nerves  without  an  external  wound  only  occurs  in 
connection  with  severe  injuries,  such  as  dislocations  or  fractures, 
and  even  then  total  division  is  rare,  the  sheath  retaining  its 
integrity,  although  the  axis  cylinders  may  have  given  way.  Im- 
mediate paralysis  and  loss  of  sensation  usually  follow,  and  may 
persist  for  a  time,  although  repair  not  unlrequently  occurs, 
since  the  sheath  remains  intact.  The  doubt  always  existing  as 
to  the  condition  of  the  sheath  regulates  the  treatment  which  must 
be  followed,  viz.,  one  of  expectancy.  Friction  and  electricity 
should  be  applied  to  the  parts,  and  only  when  these  have  failed 
should  operation  be  undertaken.  Secondary  nerve  suture  under 
these  circumstances  is  not  a  very  successful  proceeding. 

Compression  of  a  nerve  is  usually  due  to  the  growth  of  tumours 
or  aneurisms,  or  to  some  displacement  of  bones,  as  in  fractures  or 
dislocations  ;  or,  again,  the  nerve  may  be  included  in  the  callus 
formed  in  the  repair  of  a  fracture,  e.g.,  the  musculo-spiral,  owing 
to  its  proximity  to  the  humerus,  the  symptoms  not  appearing  till 
four  or  five  weeks  after  the  injury  ;  or  it  may  be  met  with  in  the 
form  of  crutch  palsy,  or  as  a  result  of  splint  pressure,  as  when 
the  external  popliteal  nerve  is  compressed  against  the  neck  of  the 
fibula.  Those  nerves  also  which  traverse  bony  canals  in  the 
skull  are  liable  to  pressure  as  a  result  of  chronic  osteitis  and  con- 


AFFECTIONS  OF  NERVES 


327 


densation  of  the  surrounding  osseous  tissues.  Patients  who  have 
suffered  from  syphilis  are  more  liable  to  develop  chronic  neuritis 
from  slight  pressure  than  other  individuals.  The  early  symptoms 
are  those  of  irritation,  e.g.,  cramp  and  spasm  of  muscles,  or 
neuralgic  pain:  whilst  the  later  ones,  due  to  more  prolonged 
compression,  are  those  of  paralysis  and  anaesthesia,  combined 
sometimes  with  trophic  phenomena.  If  the  compressing  cause 
can  be  removed,  recovery,  at  any  rate  of  a  partial  character, 
follows  in  time  under  suitable  treatment,  such  as  massage, 
electricity,  and  the  administration  of  iodide  of  potassium  or 
nerve  tonics. 

Total   Division   of  a   Nerve.— The  Immediate  Effects  are:  (a) 
Paralysis  of  the  muscles  supplied  by  the  nerves;  (b)  complete 


Fig.  83. — Traumatic  Neuroma  of  Posterior  Tibial  Nerve  after 
Amputation  of  Leg.     (From  King's  College  Museum  ) 


anaesthesia  of  the  parts  supplied  by  it,  which,  however,  is  not 
necessarily  permanent,  since  sensation  may  be  conveyed  by  col- 
lateral trunks,  the  anaesthetic  area  passing  through  gradual  stages 
of  partial  sensation  before  recovery  is  complete,  (c)  Vasomotor 
paralysis  is  also  produced,  the  limb  becoming  hyperaemic  and 
warmer  for  a  few  days,  and  then  subsequently  colder  and  insuffi- 
ciently supplied  with  blood,  (d)  The  excito-secretory  nerves  are 
paralyzed  so  that  glands  lose  their  functions  for  a  time. 

The  Secondary  Effects  vary  with  the  character  of  the  nerve 
injured,  and  are  much  more  complicated  than  the  former.  We 
must  discuss  them  under  five  headings  : 

1.  Changes  in  the  Nerve. — Locally,  the  two  ends  retract  very 
slightly,  perhaps  not  more  than  the  twelfth  of  an  inch,  and  the 


328  A   MANUAL  OF  SURGERY 

space  thus  formed  fills  with  blood,  which  is  quickly  absorbed  and 
replaced  by  granulation  tissue,  and  this  in  turn  by  a  bulb-like 
mass  of  fibro-cicatrical  tissue  (traumatic  neuroma),  within  which 
are  found  spaces  filled  with  fine  nervous  fibrillae  coiled  up  in  loops 
and  developed  from  the  '  neurilemma  cells  which,  taking  on  an 
active  neuroblastic  function,  secrete  short  lengths  of  axis  cylinders 
and  of  medullary  sheaths ;  and  these,  linking  themselves  to- 
gether into  chains,  form  continuous  axis  cylinders  and  medullary 
sheaths.'*  After  an  amputation,  most  of  the  divided  nerves  are 
found  to  have  developed  these  typical  bulbous  ends  (Fig.  83), 
whilst  in  nerves  accidentally  severed  in  their  continuity  the 
bulbous  mass  which  forms  on  the  upper  end  is  separated  by  an 
interval  from  the  atrophied  lower  end,  though  there  is  usually  a 
fibrous  connection  between  the  two.  These  bulbs  are  often  the 
seat  of  severe  neuralgia.  In  a  few  rare  instances  immediate 
union  of  a  divided  nerve  is  supposed  to  have  occurred,  as  in- 
dicated by  total  and  rapid  restoration  of  function,  but  it  is  quite 
possible  that  the  phenomena  in  question  were  due  to  a  trans- 
mission of  nervous  stimuli  by  collateral  nerve  trunks. 

Peripherally,  an  almost  immediate  invasion  of  leucocytes  occurs 
as  the  result  of  the  traumatism,  and  these  are  followed  and 
replaced  after  a  few  days  by  proliferated  connective-tissue  cells. 
The  so-called  Wallerian  degeneration  commences  about  the  fourth 
day  after  the  accident,  in  consequence  of  the  separation  of  the 
nerve  from  its  trophic  centres.  It  first  shows  itself  in  the 
medullary  substance,  which  undergoes  a  kind  of  segmentation, 
becoming  broken  up  into  irregular  masses  of  myeline,  which  are 
absorbed  by  the  connective- tissue  cells  and  disappear  entirely  in 
about  a  month.  The  axis  cylinders  also  degenerate  and  disappear, 
being  lost  in  the  myeline  masses.  The  neurilemma  cells  pro- 
liferate in  columns  and  form  a  fibro-cellular  mass,  which  represents 
the  nerve,  and  has  long  lost  all  power  of  conducting  nervous  or 
electric  stimuli,  although  attempts  at  regeneration  are  made  at 
both  ends. 

Proximally,  degeneration  of  the  medullary  sheath  occurs,  similar 
to  that  which  is  seen  in  the  distal  portion,  but  only  extending  as 
far  as  the  next  node  of  Ranvier.     It  is  of  but  little  significance. 

2.  Changes  in  the  Muscles. —  Complete  paralysis  of  motion 
necessarily  occurs  when  a  motor  nerve  has  been  divided,  and  the 
muscles  involved  slowly  atrophy  and  undergo  degeneration.  The 
atrophy  is  not  noticed  at  first,  and  is  not  so  rapid  as  that  arising 
from  infantile  palsy,  since  it  is  simply  due  to  separation  from  the 
trophic  centres,  and  not  to  their  destruction.  As  a  result  of  the 
paralysis  and  atrophy,  deformity  may  ensue,  owing  to  a  disturb- 
ance of  the  equilibrium  normally  maintained  between  opposing 
groups  of  muscles.     The  electrical  changes,  too,  are  exceedingly 

*  See  Ballance  and  Purves  Stewart,  '  The  Healing  of  Nerves  '  ;  Macmillan 
and  Co.,  1901. 


AFFECTIONS  OF  NERVES  329 


important.  The  faradic  current  rapidly  loses  its  power  over  the 
affected  muscles,  and  its  effects  totally  disappear  in  two  or  three 
weeks,  whilst  the  galvanic  excitability  remains  for  weeks  or 
months,  and  even  then  only  slowly  diminishes,  so  that  a  condition 
develops  in  which  the  galvanic  current  produces  a  much  greater 
contraction  than  the  faradic  (reaction  of  degeneration) .  As  long  as 
this  phenomenon  remains,  there  is  a  hope  that  restoration  of  the 
continuity  of  the  nerve  may  be  followed  by  restoration  of  function ; 
but  when  the  muscles  react  neither  to  galvanic  nor  to  faradic 
stimuli,  the  case  may  be  looked  upon  as  beyond  repair. 

3.  Various  modifications  of  Sensation,  both  special,  general, 
and  muscular,  may  be  observed. 

4.  The  blood  supply  to  a  paralyzed  part  is  always  diminished, 
so  that  it  looks  blue  and  congested,  owing  to  the  weak  circulation; 
consequently  the  temperature  falls,  and  the  vitality  of  the  part  is 
decreased.  This,  associated  with  anaesthesia  and  the  loss  of  trophic 
influence  of  the  nerve  centres,  results  in  certain  conditions  which 
maybe  of  considerable  importance.  Thus  the  skin  becomes  thin, 
atrophic,  bluish-red,  and  shiny  ('  glossy  skin'  of  Weir- Mitchell), 
or  it  may  be  rough  and  covered  with  scales,  or  even  cedematous. 
Chilblains  are  readily  produced,  and  any  exposure  to  cold  or  heat 
may  result  in  vesication  or  even  sloughing.  Wounds  heal  badly, 
and  ulceration  from  slight  irritants  is  very  likely  to  occur,  e.g., 
corneal  ulceration  after  division  of  the  fifth  nerve,  and  perforating 
ulcers  of  the  foot.  The  cutaneous  appendages  are  also  involved, 
the  hairs  falling  out,  the  nails  becoming  rough,  brittle,  and  scaly, 
and  the  sebaceous  and  sweat  glands  either  discharging  an  abundant 
secretion,  or  remaining  absolutely  functionless.  Atrophy  of  the 
smaller  bones  may  follow,  and  ankylosis  of  the  terminal  joints  of 
the  fingers  or  toes.  In  a  growing  child  the  development  of  the 
part  is  always  more  or  less  impaired.  The  more  exaggerated 
forms  of  trophic  trouble  just  described  only  occur  in  irritative 
lesions  of  nerves,  e.g.,  when  a  foreign  body  is  left  in  contact  with 
them ;  simple  section  results  merely  in  simple  atrophy. 

5.  Finally,  in  a  few  cases  changes  have  developed  in  the  central 
nervous  system  which  are  of  extreme  interest.  In  the  early  stages 
reflex  spasms  or  paralyses  are  sometimes  met  with  as  temporary 
phenomena  ;  but  at  a  later  date  more  serious  symptoms  may  result. 
Thus,  in  a  glass  wound  of  the  median  nerve,  a  healthy  man  treated 
at  hospital  developed  a  typical  epileptic  fit  whenever  the  neuralgic 
bulbous  end  was  touched.  The  bulb  was  excised,  and  the  nerve 
cleanly  sutured,  but  without  effect,  the  epilepsy  and  pain  still 
remaining.  The  median  nerve  was  divided  in  the  upper  arm, 
and  a  portion  removed,  but  without  benefit.  Finally,  the  patient 
passed  into  a  condition  of  chronic  dementia,  and  died,  no  obvious 
lesions  being  found  on  post-mortem  examination. 

Regeneration  of  a  divided  nerve  must  necessarily  ensue  if 
restoration  of  function  is  obtained.     Attempts  at  regeneration  are 


333 


A   MANUAL  OF  SURGERY 


always  evident  in  the  distal  segment  whether  or  not  it  has  been 
sutured  to  the  upper  end,  but  in  the  latter  case  the  phenomena  are 
later  in  appearance  and  are  never  carried  to  perfection,  owing  to 
the  intervention  of  the  end-bulb.  Considerable  discussion  has 
arisen  as  to  whether  the  new  axis  cylinders  grow  downwards  from 
the  central  end  to  the  peripheral,  or  whether  they  are  developed 
in  the  distal  segment.  The  researches  of  Ballance  and  Purves 
Stewart  certainly  suggest  that  the  latter  theory  is  correct.  The 
proliferated  neurilemma  cells  always  retain  their  longitudinal 
direction,  and  about  3  or  4  weeks  after  the  operation  (a  little 
later,  if  no  operation)  thin  beaded  threads  begin  to  show  them- 
selves along  one  side  of  such  a  spindle-shaped  cell,  and,  gradually 
growing  downwards,  stretch  out  towards  their  nearest  neighbours. 
The  union  of  these  small  segments  constitutes  the  new  axis 
cylinder,  which  is  gradually  covered  in  by  a  medullary  sheath, 
also  apparently  the  product  of  the  neurilemma  cells.  The  process 
takes  some  months  to  reach  completion.  Clinically,  the  earliest 
evidence  of  regeneration  is  a  slight  return  of  sensation,  which  may 
be  at  first  abnormal,  and  only  slowly  becomes  of  a  normal  type. 
Motion  is  generally  much  later  in  its  restoration  than  sensation, 
and  may  never  be  entirely  recovered.  Under  very  favourable 
circumstances  it  is  possible  for  an  interval  even  as  great  as 
1  \  inches  to  be  bridged  over  by  this  process,  but  such  an  event 
is  very  unusual.  The  use  of  a  nerve  graft  under  these  conditions 
may  direct  the  energies  of  the  neuroblastic  cells,  but  the  graft  is 
itself  quite  passive,  being  invaded  by  neurilemma  cells  from  above 
and  below. 

The  Treatment  of  a  divided  nerve  depends  upon  its  size  and 
function.  If  small  and  of  slight  importance,  no  special  treatment 
is  required ;  but  in  any  of  the  main  nerves  of  the  extremities  it  is 
essential  to  deal  with  them  at  once  by  Primary  Nerve  Suture. 
This  is  best  accomplished  by  using  a  domestic  sewing  needle 
without  cutting  edges,  or  a  fine  Hagedorn  needle,  and  the  finest 
chromicized  catgut ;  one  or  more  stitches  should  pass  through  the 
nerve,  and  the  rest  merely  through  the  sheath.  Absolute  asepsis 
is  essential  in  order  to  obtain  satisfactory  results. 

If  the  wound  has  been  inflicted  months  before,  and  a  bulb  has 
formed,  Secondary  Nerve  Suture  must  be  employed.  The  nerve 
is  first  exposed  by  a  free  incision  through  the  cicatrix,  the  two 
ends  identified  and  isolated,  and  the  fibrous  tissue  of  the  bulb 
removed  to  a  sufficient  extent  to  expose  healthy  nerve  fibrillae ; 
the  divided  ends  are  then  brought  together  with  as  little  tension 
as  possible.  To  fill  up  the  gap  resulting  from  removal  of  the 
bulb,  traction  upon  each  end  of  the  nerve  should  be  employed  to 
stretch  it,  and  the  limb  subsequently  put  up  in  such  a  position  as 
to  relax  the  parts,  e.g.,  the  wrist  flexed  to  a  right  angle,  or  the 
elbow  bent  (except  when  dealing  with  the  ulnar  nerve  above  the 
elbow,  flexion  of  which  increases  the  tension  of  the  nerve).      In 


AFFECTIONS  OF  NERVES  331 


one  case  we  removed  an  inch  or  two  of  the  humerus  to  allow  the 
divided  ends  of  the  musculo-spiral  nerve  to  be  approximated.  In 
order  to  diminish  the  drag  on  the  fine  end-to-end  sutures,  a 
tension  stitch  should  be  passed  through  the  substance  of  the 
nerve,  about  ^  to  h  an  inch  from  the  divided  ends. 

Nerve  grafting,  in  order  to  bridge  over  a  defect,  has  not  up  to 
the  present  been  found  of  much  practical  value,  although  a  few 
cases  of  success  are  reported.  A  nerve  similar  in  size  to  that  to 
be  operated  on  is  removed  from  an  animal  just  previously  killed, 
and  carefully  stitched  in  position.  Since  it  merely  acts  as  a  carrier 
to  the  neuroblastic  cells  the  same  result  would  possibly  be  obtained 
by  passing  several  fine  strands  of  catgut  from  one  end  to  the  other. 

During  the  time  that  the  paralysis  continues  the  limb  itself 
must  be  well  massaged,  the  fingers  or  toes  worked  daily  to  keep 
them  from  getting  stiff,  and  the  muscles  treated  with  electricity, 
and  preferably  by  means  of  the  electric  bath,  one  electrode  being 
placed  in  a  basin  of  warm  saline  solution,  and  the  other  against 
the  patient's  back,  and  the  affected  limb  then  dipped  in  the  water 
till  it  becomes  of  a  bright  red  colour. 

In  many  cases  where  the  original  wound  has  been  complicated 
with  spreading  septic  inflammation  the  impaired  mobility  is  as 
much  due  to  the  inflammatory  adhesions  of  joints  and  tendons  as 
to  paralysis. 

Inflammation  of  Nerves. 

Acute  Neuritis  is  not  a  very  common  condition.  It  is  usually 
due  to  injury,  gout,  or  rheumatism,  but  is  occasionally  observed  in 
connection  with  septic  wounds.  The  nerve  may  sometimes  be 
felt  to  be  swollen  or  tender,  whilst  severe  pain  of  a  neuralgic 
type  is  often  complained  of  by  the  patient.  On  microscopic 
examination  the  ordinary  signs  of  inflammation  are  well  marked, 
though  mainly  evident  in  the  sheath.  The  Treatment  consists  of 
rest  to  the  limb,  together  with  leeching  or  dry  cupping  over  the 
course  of  the  nerve,  combined  with  belladonna  fomentations,  and 
suitable  general  therapeutic  measures. 

Chronic  Neuritis,  or  Perineuritis,  is  much  more  common  than 
the  former.  It  consists  pathologically  in  an  increase  of  all  the 
connective  tissue  of  a  nerve,  both  around  it  and  between  the 
fasciculi,  with  compression  of  the  vessels  and  nerve  fibres.  It 
may  result  from  injury,  such  as  sprains,  strains,  or  pressure, 
especially  when  the  patient  is  suffering  from  syphilis,  rheumatism, 
or  gout,  and  is  met  with  after  influenza  and  in  various  toxic 
conditions,  e.g.,  alcoholism,  diabetes,  malaria,  etc.  It  is  very 
common  in  the  fifth  nerve,  and  in  the  branches  of  the  brachial 
plexus.  The  Symptoms  vary  a  good  deal  with  the  nerve  affected. 
Occasionally  it  can  be  felt  thickened  and  tender  on  pressure, 
whilst  more  or  less  severe  neuralgia  is  also  noticed,  accompanied 
perhaps   by  some  loss   of  power   in  the  muscles  supplied  by  it. 


332  A   MANUAL  OF  SURGERY 

Trophic  lesions  may  also  be  induced,  such  as  perforating  ulcer, 
or  ankylosis  of  the  terminal  joints  of  fingers  or  toes. 

The  Treatment  in  the  early  stages  consists  in  the  administration 
of  anti-diathetic  remedies,  and,  indeed,  iodide  of  potassium,  with 
or  without  mercury,  is  generally  applicable.  Locally,  prolonged 
rest  is  needed  with  counter-irritation  in  the  form  of  blisters,  and 
later  on  massage  with  suitable  liniments.  If  there  is  any  paresis, 
the  muscles  must  be  stimulated  daily  by  the  faradic  current  or 
electric  bath.  Excessive  pain  is  combated  by  administering 
hypodermically  morphia  or  atropine.  Failing  these,  other  means 
should  be  adopted,  such  as  acupuncture,  in  which  needles  are 
passed  into  the  substance  of  the  nerve,  and  allowed  to  remain  for 
a  few  moments ;  this  probably  acts  by  relieving  the  tension  and 
inflammatory  exudation  within  the  sheath.  Various  operative 
measures  dealt  with  under  neuralgia  may  be  called  for  in  severe 
and  protracted  cases. 

For  Tumours  of  nerves,  see  p.  167. 

Neuralgia. 

Neuralgia  is  a  condition  which  either  the  physician  or  the 
surgeon  may  be  called  upon  to  treat ;  it  is  exceedingly  common, 
and  may  be  one  of  the  most  terrible  afflictions  to  which  the 
human  frame  is  subject.  It  is  characterized  by  a  paroxysmal  or 
intermittent  pain  of  a  darting  or  stabbing  character,  which  follows 
the  course  of  some  particular  nerve  or  nerves,  especially  the 
trigeminal.  In  this  nerve  the  attack  commences  suddenly,  and 
the  pain  steadily  increases,  until  it  reaches  a  climax,  and  then 
gradually  or  rapidly  subsides.  These  paroxysms  may  last 
minutes  or  hours,  and  may  recur  at  varying  intervals,  either 
a  few  in  a  day,  or  many  in  an  hour  ;  they  may  be  induced  by 
sudden  noises,  a  draught  of  air,  etc.  Moreover,  pressure  over 
the  affected  trunks  may  originate,  relieve,  or  increase  the  pain, 
whilst  the  skin  affected  by  them  is  often  intensely  tender,  and 
even  hyperaemic  and  cedematous  (the  points  douloureux  of  Valleix). 
Occasionally  adjacent  muscles  become  spasmodically  and  sym- 
pathetically contracted  during  the  attack,  whilst  excessive 
secretion,  such  as  from  the  lachrymal  or  sweat  glands,  is  also 
induced.  Herpes  is  sometimes  met  with  in  the  area  of  distribution 
of  the  affected  nerve  (e.g.,  shingles  in  connection  with  intercostal 
neuralgia).  Neuralgic  manifestations  may  occur  in  any  sensory 
or  mixed  nerve,  such  as  the  intercostals  or  sciatic,  or  in  complex 
bodies,  such  as  the  breast,  testis,  or  the  larger  joints. 

The  Causes  of  neuralgia  are  very  diverse,  and  the  surgeon  often 
has  to  look  far  afield  in  order  to  find  them.  Thus,  as  predisposing 
causes  may  be  mentioned  the  hysterical  temperament,  anaemia, 
and  depressing  circumstances  of  all  kinds,  especially  mental 
anxiety  and  worry.  The  direct  causes  may  be  toxic,  e.g.,  malaria, 
influenza,  lead,  or  mercury  ;  reflex,  e.g.,  ovarian  disease,  worms, 


AFFECTIONS  OF  NERVES 


333 


etc.  ;  central,  from  disease  of  the  spinal  cord  or  brain ;  radical, 
from  pressure  on  the  nerve-roots  as  they  emerge  from  the  spinal 
canal  or  cranium  ;  or  peripheral,  owing  to  lesions  of  the  trunks 
induced  either  by  trauma,  inflammation,  or  new  growths. 

Treatment  consists  primarily  in  attention  to  the  general  health, 
and  the  local  application  of  counter-irritants  and  sedatives.  Iron 
and  arsenic  may  be  given  to  anaemic  patients ;  anti-spasmodics, 
such  as  valerianate  of  zinc,  to  hysterical  women ;  quinine  or 
arsenic  for  malaria ;  whilst  sea-bathing  or  change  of  air  is  often 
advisable.  Iodide  of  potassium  and  mercury  are  beneficial  in  all 
cases  due  to  syphilis.  When  the  pain  is  excessive,  morphia, 
even  in  large  doses,  may  be  called  for.  Empirical  remedies,  such 
as  antipyrine,  phenacetin,  menthol,  and  croton-chloral  hydrate 
will  sometimes  do  good. 

When,  however,  medicinal  agents  fail,  surgical  measures  are 
indicated  in  order  to  allay  the  patient's  sufferings.  The  following 
are  the  more  usual  methods  adopted : 

i.  In  purely  Sensory  Nerves,  such  as  the  trigeminal,  simple 
division  or  neurotomy  has  often  been  resorted  to,  but  the  relief 
gained  is  of  a  most  temporary  nature,  since  sensory  nerves  readily 
unite  after  division,  and  sensation  is  rapidly  restored  even  when 
union  is  incomplete,  probably  by  transmission  through  collateral 
branches  ;  hence  the  operation  has  fallen  into  discredit.  A  much 
more  satisfactory  proceeding  is  neurectomy,  or  the  removal  of  a  por- 
tion of  the  nerve-trunk,  after  which  union  of  the  divided  ends  is  less 
likely  to  occur.  Many  of  these  cases,  however,  are  due  to  central 
disease,  and  it  is  an  interesting  question  how  the  trouble  can  be 
benefited  by  such  proceedings  ;  probably  the  explanation  is  that 
the  centre  is  placed  in  a  condition  of  rest  by  the  exclusion  of 
afferent  stimuli.  Acting  on  this  theory,  most  surgeons  nowadays 
endeavour  to  remove  as  large  a  portion  of  the  affected  nerve  as 
possible,  and  Thiersch  suggested  a  plan  of  nerve-extraction  in 
which  the  trunk  is  laid  bare  at  a  suitable  spot,  and  then  grasped 
with  forceps,  and  forcibly  extracted  by  torsion.  An  outline  of 
the  various  methods  employed  on  separate  nerves  is  given  below. 

Finally,  if  all  such  measures  have  failed,  the  roots  of  the  nerves 
may  be  divided  either  within  the  skull  or  in  the  spinal  canal. 

2.  In  a  Mixed  Nerve,  conveying  motor  as  well  as  sensory 
stimuli,  nerue- stretching  has  to  be  mainly  relied  upon.  The  trunk 
is  laid  bare,  and  traction  exercised,  both  centrally  and  peripher- 
ally, by  means  of  a  blunt  hook  if  the  nerve  is  small,  or  of  the 
finger  placed  under  it  if  large.  The  clinical  effect  is  to  abolish 
the  conductivity  of  the  nerve  for  a  time,  either  completely  or 
partially  ;  but  since  it  is  not  divided,  repair  and  restoration  of 
function  follow.  The  elasticity  and  extensibility  of  the  nerves 
are  considerable,  and  the  pressure  needed  to  cause  their  rupture 
has  been  accurately  estimated.  It  varies  much  in  different  indi- 
viduals, and  allowance  must  be  made  for  this  in  all  operations. 


334  A  MANUAL  OF  SURGERY 

Thus,  the  sciatic  nerve  will  stand  about  as  much  traction  as  an 
ordinary  man  can  make  with  his  finger  and  thumb  ;  it  should  be 
applied  steadily  and  continuously,  not  in  a  series  of  jerks.  The 
effect  of  stretching  is  to  free  the  nerve  from  external  inflam- 
matory adhesions,  and  to  alter  the  relations  between  the  sheath 
and  its  contents.  The  perineurium  has  its  fibrillar,  which  are 
naturally  wavy,  straightened  out,  thereby  compressing  the  lym- 
phatic spaces  between  the  fibres,  and  possibly  rupturing  the  nervi 
nervorum.  The  nerve  becomes  hyperaemic,  and  the  medullary 
sheath  of  the  tubules  may  be  irregularly  broken  up. 

Affections  of  Special  Nerves. 

The  Cranial  Nerves. — The  Olfactory  Nerve  may  be  involved  in 
fractures  extending  across  the  cribriform  plate  of  the  ethmoid,  or 
in  severe  cases  of  contusion  of  the  anterior  lobes  of  the  brain 
without  fracture,  resulting  in  loss  of  smell  (anosmia). 

The  Optic  Nerve  is  sometimes  ruptured  in  fractures  of  the  base 
of  the  skull  running  into  the  optic  foramen,  leading  to  sudden  irre- 
mediable blindness ;  or  it  may  be  compressed  by  effused  blood 
or  inflammatory  exudation,  either  within  or  outside  of  its  sheath, 
causing  more  or  less  complete  loss  of  vision  preceded  by  optic 
neuritis  (i.e.,  inflammation  of  the  intraocular  termination  of  the 
nerve,  or  papillitis) ;  but  if  the  haemorrhage  has  not  been  very 
extensive,  vision  may  be  in  measure  restored.  Orbital  cellulitis 
not  unfrequently  causes  pressure  on  the  nerve,  either  immediately 
as  a  result  of  the  inflammation,  or  subsequently  by  cicatricial  con- 
traction. Syphilitic  disease  of  the  sheath  or  the  formation  of  a 
gumma  in  its  neighbourhood,  or  intraorbital  aneurisms  or  tumours, 
may  likewise  induce  amblyopia  from  pressure  on  the  trunk. 

The  Third  Nerve  (motor  oculi)  being  entirely  motor,  paralytic 
symptoms  are  those  to  be  looked  for.  They  may  arise  from 
central  causes,  such  as  syphilitic  or  degenerative  changes  in  the 
floor  of  the  third  ventricle ;  or  from  peripheral  lesions,  such  as 
aneurisms,  tumours,  trauma,  etc.,  either  in  the  orbit,  sphenoidal 
fissure,  or  base  of  the  skull.  The  Symptoms  of  complete  paralysis 
are  as  follows  :  (a)  Ptosis,  or  drooping  of  the  upper  eyelid,  from 
loss  of  power  in  the  levator  palpebrae  superioris ;  (b)  external 
strabismus,  or  squint,  from  paralysis  of  the  inner,  upper,  or  lower 
recti,  the  eye  being  also  directed  a  little  downwards  from  paralysis 
of  the  inferior  oblique ;  (c)  mydriasis,  or  dilatation  of  the  pupil, 
from  palsy  of  the  iris  ;  (d)  loss  of  accommodation,  from  the  ciliary 
muscle  being  paralyzed  ;  and  (e)  some  slight  protrusion  of  the 
eyeball  (exophthalmos),  owing  to  most  of  its  muscles  being 
flaccid  and  relaxed.  In  consequence,  however,  of  its  close 
proximity  to  the  fourth,  fifth,  and  sixth  nerves  in  the  walls  of 
the  cavernous  sinus  and  sphenoidal  fissure,  symptoms  referable 
to   these   trunks   are   often   associated    with   the  above,  as  also 


AFFECTIONS  OF  NERVES 


venous  congestion  of  the  eye  and  orbit  from  pressure  on  the 
sinus.  Should  the  eyeball  be  totally  immobilized  from  paralysis 
of  all  its  muscles  without  venous  congestion,  the  condition  is 
known  as  ophthalmoplegia  externa,  and  is  always  due  to  central 
disease  affecting  the  floor  of  the  third  ventricle,  and  probably  of 
syphilitic  or  tabetic  origin.  The  Treatment  in  most  cases  consists 
in  the  administration  of  mercury  and  iodide  of  potassium. 

Paralysis  of  the  Fourth  Nerve  (Pathetic),  which  supplies  the 
superior  oblique  muscle,  results  in  defective  movement  of  the 
eyeball  downwards  and  outwards. 

The  Fifth  or  Trigeminal  Nerve  is  occasionally  torn  in  head 
injuries,  giving  rise  to  anaesthesia,  with  perhaps  ulceration  of  the 
cornea;  but  such  cases  are  exceedingly  rare.  Much  more  common 
is  the  disease  known  as  trigeminal  neuralgia,  or  tic  douloureux,  which 
is  more  frequently  observed  in  women  than  in  men.  It  is  to 
be  clearly  distinguished  from  the  simpler  forms  of  neuralgia  due 
to  some  local  irritation  or  general  weakness  by  the  paroxysmal 
character  and  violence  of  the  pain  ;  hence  the  term  '  epileptiform 
tic  '  has  been  applied  to  it,  and  not  inaptly  represents  the  terrible 
nature  of  the  affection.  As  a  rule,  it  commences  in  the  infra- 
orbital or  inferior  dental  branches,  radiating  thence  to  all  the  other 
divisions  of  the  nerve.  The  paroxysms  are  not  very  frequent  at 
first,  but  they  rapidly  increase  both  in  number  and  severity,  until 
at  last  the  patient  becomes  utterly  prostrate,  and  may  be  so 
depressed  as  to  contemplate  or  even  attempt  suicide.  The  con- 
dition is  often  influenced  considerably  by  the  general  health,  and 
intermissions  of  varying  length  occur.  The  attacks  are  accom- 
panied by  twitching  of  the  muscles  of  the  face,  and  even  of  the 
neck ;  also  by  unilateral  sweating  and  hyperaemia  of  the  head, 
and  the  development  of  such  marked  'points  douloureux,'  that 
possibly  the  patient  cannot  brush  his  hair  or  wash  his  face  on 
the  affected  side,  which  becomes  dirty  and  is  often  shiny  from 
trophic  changes.  Lachrymation  is  a  marked  feature  during  the 
attacks,  and  there  may  be  a  considerable  increase  in  the  salivary 
secretion,  as  also  in  that  of  nasal  mucus. 

As  to  the  Cause  of  tic  douloureux,  but  little  can  be  said  for  certain,  although 
many  conditions  may  contribute  to  its  production,  viz.:  (a)  Central  causes,  such 
as  changes  of  a  sclerosing  type  in  the  deep  centres  of  the  fifth  nerve,  or  in  the 
Gasserian  ganglion ;  (b)  radical,  or  those  due  to  compression  or  disease  of  the 
roots  of  the  nerve,  reaching  from  the  ganglion  to  the  cranial  foramina  ; 
(c)  cranial  conditions,  such  as  diminution  in  the  size  of  the  foramina  of  exit  of 
the  nerves,  which  not  only  vary  immensely  in  different  skulls,  being  generally 
smaller  in  women,  but  also  may  be  encroached  upon  by  callus,  inflammatory 
swellings,  or  tumours  ;  (d)  peripheral  causes,  e.g.,  dental  caries,  narrowing  of  the 
walls  of  the  bony  canals,  etc.  ;  (e)  toxic  agents,  e.g.,  malaria,  which  especially 
tends  to  affect  the  supra-orbital  nerve,  constituting  the  so-called  '  brow  ague  '; 
and  (/)  reflex  phenomena,  e.g.,  ovarian  disease,  errors  of  refraction,  etc. 

In  the  Treatment  of  tic  douloureux,  innumerable  remedies  have  been  used, 
with  a  varying  degree  of  success,  e.g.,  quinine,  where  there  is  a  malarial  history ; 
iodides  and  mercury  for  syphilis ;  iron  and  arsenic  for  anaemic  patients  ;  and, 


336 


A   MANUAL  OF  SURGERY 


failing  these,  croton-chloral,  paraldehyde,  etc.  All  sources  of  reflex  irritation 
should  be  removed  or  treated,  such  as  carious  teeth,  errors  of  refraction,  intra- 
nasal trouble,  ovaritis,  etc.  If  the  pain  persists,  Operative  Measures  will, 
sooner  or  later,  be  required.  Neurotomy  and  nerve-stretching  may  give 
temporary  relief,  but  most  surgeons  have  been  led  by  experience  to  the  con- 
clusion that  the  greatest  measure  of  success  follows  neurectomy,  and  that  the 
larger  the  portion  excised,  and  the  nearer  that  portion  is  to  the  central  organs, 
the  better  the  results  attained.  Hence  much  more  extensive  operations  are 
now  undertaken  than  formerly,  even  extending  to  the  Gasserian  ganglion  itself. 
The  operations  which  have  been  utilized  in  dealing  with  this  nerve  are  so 


Fig.  84. — a,  Incision  for  division  of  supra-orbital  nerve  ;  b,  line  indicating 
position  of  supra-trochlecir  nerve,  passing  from  angle  of  mouth  through 
the  inner  canthus ;  the  short  cross-line  at  its  upper  end  is  the  incision 
required  to  expose  it;  c,  position  of  infra-orbital  nerve  and  incision; 
d,  Carnochan's  incision  for  neurectomy  of  the  second  division. 

numerous  and  often  so  complicated  that  we  can  merely  give  the  briefest 
description  here  of  those  which  we  usually  employ.*  All  purely  subcutaneous 
or  submucous  methods  are  to  be  condemned  for  their  inaccuracy  and  in- 
efficiency, as  also  on  account  of  the  bleeding  which  is  likely  to  result  from  the 
closely  contiguous  bloodvessels. 

The  Supra-orbital  Nerve  does  not  very  commonly  require  division  or  extrac- 
tion, since  neuralgia  of  this  trunk  is  certainly  more  amenable  to  therapeutic 

*  Owing  to  necessary  limitations  of  space  we  must  refer  readers  for  further 
details  to  Rose  on  '  Trigeminal  Neuralgia '  (Bailliere,  Tindall  and  Cox,  1892). 


AFFECTIONS  OF  NERVES  337 

measures  than  other  forms.  The  pain  usually  recurs  about  the  same  time 
each  day,  and  may  be  treated  by  giving  a  pill  containing  ferri  sulph.,  1  grain, 
quiniae  disulph.,  2  grains,  and  morphinse  hydrochlor.,  T\  grain,  four  hours 
before  the  attack  is  expected,  and  repeating  it  every  hour  till  six  pills  in  all 
have  been  taken.  At  the  same  time  attention  must  be  directed  to  any  local 
cause  of  irritation.  Should  the  pain  persist  in  spite  of  treatment,  neurectomy 
may  be  undertaken.  The  nerve  emerges  from  the  orbit  through  the  supra- 
orbital notch,  lying  at  the  junction  of  the  inner  and  middle  thirds  of  the  upper 
margin,  and  is  reached  by  an  incision  following  the  course  of  the  eyebrow, 
through  which  the  orbicularis  is  divided  along  the  line  of  its  fibres  (Fig.  84,  a). 
By  incising  the  periosteum  and  depressing  it,  together  with  the  orbital  fat, 
the  nerve  can  be  followed  back  for  some  distance,  and  a  considerable  portion 
removed. 

The  Supra-trochlcar  Nerve  has  been  stretched  (somewhat  empirically,  it  is 
true)  for  sundry  obscure  neuralgic  affections  of  the  eyeball,  and  occasionally 
with  considerable  success.  It  emerges  from  the  orbit  along  a  line  drawn  from 
the  angle  of  the  mouth  through  the  inner  canthus  (Fig.  84,  b).  An  incision  is 
made  at  right  angles  to  this  course  just  below  the  eyebrow,  and  the  nerve, 
which  is  found  in  several  filaments,  stretched  or  divided. 

The  Infra-orbital  Nerve  emerges  from  the  foramen  of  the  same  name  at  a  spot 
about  h  inch  below  the  centre  of  the  lower  margin  of  the  orbit.  It  can  be 
reached  and  divided  by  a  horizontal  or  curved  incision  placed  over  this  site 
(Fig.  84,  c) ;  but  since  such  an  operation  is  unlikely  to  give  more  than  temporary 
relief,  the  root  of  the  second  division  should  be  at  once  attacked  if  operative 
procedures  are  necessary.  It  is  most  desirable  to  divide  the  nerve  behind 
Meckel's  ganglion,  and  hence  the  operations  which  are  performed  from  the 
face  (either  Wagner's,  which  follows  the  floor  of  the  orbit,  or  Carnochan's, 
which  traverses  the  antrum)  are  objectionable,  whilst  they  are  almost  certain 
to  leave  ugly  cicatrices  (Fig.  84,  d). 

Thz  pterygoid  method,  or,  as  it  called,  the  Braun-Lossen  operation,  is  without 
doubt  the  best  for  dealing  with  the  root  of  the  second  division.  Our  experience 
of  this  proceeding,  which  is  now  extensive,  has  induced  us  to  modify  the 
original  plans  considerably,  and  our  usual  method  of  procedure  is  as  follows  : 
The  incision  commences  at  the  external  angular  process  of  the  frontal  bone, 
follows  the  upper  border  of  the  zygoma,  and  curves  downwards  in  front  of  the 
ear  to  reach  the  angle  of  the  lower  jaw  (Fig.  72,  F).  The  flap  thus  marked  out, 
consisting  only  of  skin  and  subcutaneous  fat,  is  dissected  forwards,  temporarily 
fixed  by  a  suture  to  the  nose,  and  protected  with  gauze.  The  zygoma  is 
exposed  by  a  horizontal  incision  through  the  periosteum,  which  is  cleared 
from  the  bone  by  a  suitable  raspatory,  and  drilled  front  and  back  so  as  to 
carry  silver  wires  in  the  subsequent  suturing  up  (Fig.  85)  ;  it  is  then  sawn 
through  and  turned  down,  together  with  the  masseter.  The  mouth  is  slightly 
opened  with  a  gag,  and  the  temporal  tendon  pulled  well  backwards  from  the 
front  of  the  temporal  fossa  by  retractors,  exposing  thereby  the  pterygo- 
maxillary  fissure,  although  the  coronoid  process  is  sometimes  so  large  as  to 
need  removal.  The  internal  maxillary  vessels  are  then  looked  for,  and,  if 
possible,  secured  by  ligatures  and  divided.  The  root  of  the  second  division 
of  the  fifth  nerve  can  then  be  hooked  up  on  an  aneurism  needle  as  it  emerges 
from  the  foramen  rotundum,  and  divided — a  proceeding  much  facilitated  by 
chiselling  away  a  bony  prominence  which  rises  from  the  base  of  the  great  wing 
of  the  sphenoid,  on  the  posterior  aspect  of  the  junction  of  the  two  limbs  of  the 
pterygo-maxillary  fissure.  By  also  dividing  the  nerve  as  it  emerges  from  the 
infra-orbital  foramen  through  an  incision  in  the  face,  the  whole  trunk  is  set 
free,  and  can  be  removed  by  traction,  all  the  dental  branches  being  torn  across 
The  displaced  structures  are  then  put  back  in  position,  the  zygoma  is  sutured 
with  silver  wire,  and  the  incision  in  the  skin  closed.  The  results  gained  by 
this  method  have  been  very  satisfactory,  scarcely  any  scar  persisting,  and  the 
freedom  from  pain  being  usually  prolonged  and  complete. 

The   third   division   of   the   trigeminal   nerve  has  many  branches,   but    the 

22 


338 


A   MANUAL  OF  SURGERY 


lingual  and  inferior  dental  are  those  mainly  affected  with  neuralgia  sufficiently 
severe  to  call  for  operative  interference.  For  purely  local  lesions  they  can 
be  divided  separately  in  the  peripheral  portions  of  their  course,  but  for 
epileptiform  tic  it  is  best  to  deal  with  them  at  the  same  time  close  to  the 
foramen  ovale. 

The  Lingual  Nerve  can  be  divided  from  within  the  mouth  by  a  simple 
incision  down  to  the  bone,  as  it  crosses  the  junction  of  the  upper  and  middle 
thirds  of  a  line  drawn  from  the  crown  of  the  last  lower  molar  toofh  to  the 
angle  of  the  jaw  ;  or  it  may  be  sought  for  more  carefully  after  division  of  the 
mucous  membrane.  Such  methods,  however,  lack  precision,  and  are  net  only 
useless,  but  dangerous,  owing  to  the  necessary  occurrence  of  sepsis. 

The  Inferior  Dental  Nerve  is  sometimes  the  seat  of  neuralgia,  due  to  com- 
pression in  its  bony  canal  as  a  result  of  dental  troubles.     It  may  then  suffice 


Fig.  85. — Zygoma  and  Lower  Jaw  in  situ  to  show  Position  of  Saw-cuts 
and  Drill-holes  in  the  Braun-Lossen  Operation,  and  in  that  for 
Removal  of  the  Gasserian  Ganglion. 


to  trephine  the  inferior  maxilla,  making  the  necessary  incision  along  its  lower 
border,  and  remove  half  its  thickness,  so  as  to  expose  the  nerve  in  its  canal. 

Section  of  the  third  division  of  the  fifth  nerve  at  the  foramen  ovale  is  best  accom- 
plished in  the  following  manner :  A  flap  of  skin  and  subcutaneous  tissue  is 
reflected  forwards  from  the  parotid  region,  extending  from  the  zygoma  above 
to  the  angle  of  the  jaw  below  (Fig.  72,  F),  exposing  thus  the  parotid  gland 
with  the  socia  parotidis  and  the  masseter  muscle,  covered  by  fascia  If  the 
incision  is  kept  strictly  to  the  subcutaneous  tissues,  the  facial  nerve  is  in 
no  way  endangered.  The  masseter  is  then  divided  transversely  immediately 
below  the  socia  parotidis,  and  the  vertical  ramus  of  the  inferior  maxilla  cleared 
of  muscle  and  periosteum  to  a  sufficient  extent  to  allow  the  application  of  a 
j-inch  trephine  just  below  the  sigmoid  notch,  the  remaining  bridge  of  bone 
being  subsequently  removed  by  cutting  pliers;  enough  bone  is  left  in  front  and 
behind  to  preserve  the  continuity  of  the  jaw  with  the  articuiar  and  coronoid 


AFFECTIONS  OF  NERVES  339 


processes.  The  fibres  of  the  external  pterygoid  muscle  can  now  be  seen  cross- 
ing the  upper  part  of  the  wound  horizontally,  and  over  it  the  internal  maxillary 
artery  sometimes  courses,  giving  rise  to  considerable  haemorrhage  if  it  is 
wounded.  The  lingual  and  dental  nerves  are  usually  found  close  together, 
emerging  from  under  the  outer  pterygoid  muscle,  and  lying  between  the 
internal  pterygoid  and  the  bone.  The  peripheral  portions  should  be  twisted 
or  pulled  up,  and  divided  below  as  far  down  as  possible,  whilst  by  drawing 
the  external  pterygoid  outwards  with  retractors,  the  foramen  ovale  can  be 
seen,  if  electric  illumination  is  employed,  and  the  nerve  trunks  divided  at  the 
point  of  exit.  The  wound  usually  heals  well,  and  leaves  but  little  scar, 
although  some  impairment  in  the  mobility  of  the  jaw  may  result,  partly  from 
the  cicatrization  following  disturbance  of  the  muscles  and  tissues,  but  mainly 
from  paralytic  atrophy  of  the  muscles  supplied  by  the  divided  nerve. 

In  cases  where  such  measures  have  been  adopted  and  have  failed,  or  where 
the  pain  is  referred  to  the  whole  nerve,  removal  of  the  Gasserian  ganglion  has 
been  successfully  performed,  but  should  never  be  undertaken  until  the  extra- 
cranial proceedings  have  been  very  thoroughly  carried  out.  The  operations 
are  so  elaborate  and  recondite  that  we  can  only  give  a  bare  outline  of 
them  here. 

Rose's  operation  approaches  the  ganglion  through  the  pterygoid  region,  taking 
the  third  division  as  its  guide.  An  incision  (Fig.  72,  F)  similar  to  that  for 
exposing  the  foramen  ovale  is  made  through  the  skin,  and  the  flap  thus  marked 
out  is  drawn  forwards  and  stitched  out  of  the  way.  The  zygoma  is  drilled, 
divided  (Fig.  85),  and  turned  down  together  with  the  masseter ;  the  coronoid 
process  is  then  divided  or  removed,  and  together  with  the  temporal  muscle 
turned  upwards  ;  the  internal  maxillary  artery  is,  if  possible,  secured,  and  the 
sphenoidal  attachment  of  the  external  pterygoid  scraped  away  so  as  to  allow 
of  the  exposure  of  the  foramen  ovale,  which  lies  just  behind  the  base  of  the 
pterygoid  processes.  A  ^-inch  trephine  is  now  applied  immediately  outside 
the  foramen  ovale,  and  the  bone  around  the  opening  thus  made  is  also 
removed  by  forceps  or  chisel  so  as  to  give  more  space.  The  trunk  of  the  third 
division  is  traced  upwards,  the  sheath  of  the  ganglion  opened,  the  second 
division  cut  through  by  means  of  a  sharp  cutting-hook,  and  the  ganglion  torn 
away  piecemeal,  or,  at  any  rate,  broken  up.  There  is  likely  to  be  a  good  deal 
of  bleeding,  especially  in  the  earlier  stages  of  this  operation,  chiefly  derived 
from  veins  ;  it  can,  however,  be  usually  restrained  by  packing  the  wound  for 
a  few  moments  with  sponges  wrung  out  of  very  hot  lotion.  Efficient  electric 
illumination  is  absolutely  essential,  since  the  wound  is  a  very  deep  one. 

A  modification  of  and  improvement  upon  this  plan  has  been  introduced  by 
Doyen.*  The  earlier  steps  are  alike,  though  the  incision  differs  somewhat. 
The  zygoma  with  the  masseter  is  turned  down,  and  the  coronoid  process  divided 
and  together  with  the  bulk  of  the  temporal  muscle  removed.  The  great  wing 
of  the  sphenoid  is  cleared  and  a  trephine  applied  just  above  the  pterygoid 
ridge.  The  dura  mater  is  then  detached  and  the  bone  nibbled  away  with  a 
rongeur  from  all  round  the  opening,  and  downwards  so  as  finally  to  reach  the 
foramen  ovale.  The  temporo-sphenoidal  lobe  of  the  brain  is  held  up  under  a 
retractor  so  that  the  second  and  third  divisions  of  the  nerve  can  be  recognised, 
divided  peripherally  and  cleared.  The  dural  sheath  of  the  ganglion  (cavum 
Meckelii)  is  then  opened,  and  the  greater  portion  of  it  can  be  removed  ;  the 
innermost  portion  is  so  adherent  to  the  cavernous  sinus  that  it  is  better  not  to 
attempt  its  removal.  The  zygoma  is  wired  back  into  place,  and  the  wound 
can  then  be  closed. 

The  Hartley-Krause  operation  was  devised  independently  by  the  two  surgeons 
whose  names  are  associated  with  it.  An  ft-shaped  flap  is  marked  out  in  the 
temporal  region,  the  base  situated  just  above  the  zygoma.  Through  this  the 
subjacent  bone  is  divided  by  chisel  or  electric  saw,  and  the  whole  flap  of  skin, 

*   For  Doyen's  operation,  see  Practitioner,  May,  1902. 

22 — 2 


340  A  MANUAL  OF  SURGERY 

muscle,  and  bone  is  turned  down  en  bloc,  exposing  the  dura  mater,  which  is 
gently  stripped  up  from  the  middle  fossa  of  the  skull  as  far  as  the  cavernous 
sinus.  Profuse  haemorrhage  is  likely  to  be  caused  by  this  proceeding,  derived 
mainly  from  the  middle  meningeal  trunk  or  its  branches,  and  must  be  con- 
trolled by  pressure,  or  possibly  by  plugging  the  foramen  spinosum  with  puri- 
fied sponge.  The  second  and  third  divisions  of  the  nerves  are  readily  found 
beneath  the  periosteum,  and  are  traced  back  to  the  ganglion  as  it  lies  on  the 
apex  of  the  petrous  bone,  and  it  is  then  dealt  with  as  in  the  last  operation. 

As  far  as  we  can  see,  the  freedom  from  pain  is  certainly  more  prolonged 
than  after  any  of  the  operations  upon  the  peripheral  portions  of  the  nerve 
trunks,  and  may  possibly  be  permanent;  certainly  some  of  the  cases  on  which 
we  have  operated  have  remained  seven  or  eight  years  without  recurrence. 
At  the  same  time  we  cannot  but  admit  that,  with  a  mortality  which  amounts 
to  about  10  or  15  per  cent.,  it  is  very  desirable  to  perform  the  extracranial 
operations  very  thoroughly  before  resorting  to  such  a  serious  measure. 
During  the  last  few  years  we  have  been  working  along  these  lines,  taking 
the  greatest  precautions  to  excise  very  extensive  portions  of  the  nerves,  and 
have  been  much  gratified  with  the  results. 

The  Sixth  Nerve  may  be  torn  or  compressed,  either  in  its  intra- 
cranial course  along  the  inner  wall  of  the  cavernous  sinus,  or  as  it 
passes  through  the  sphenoidal  fissure,  or  in  the  orbit,  as  a  result 
of  penetrating  wounds  or  blows.  Its  division  causes  paralysis  of 
the  external  rectus  and  consequent  internal  strabismus. 

The  Seventh  or  Facial  Nerve  may  be  paralyzed  from  a  great 
variety  of  causes,  which  may  be  described  under  the  following 
headings : 

(a)  Intra-cranial  lesions. — If  simply  cortical,  as  from  pressure, 
haemorrhage,  degeneration,  etc.,  a  limited  portion  of  the  opposite 
side  of  the  face  is  usually  involved.  If  sub-cortical,  or  in  the 
corona  radiata,  or  corpus  striatum,  as  from  haemorrhage,  or 
softening  due  to  carotid  thrombosis  or  embolus,  the  paralysis 
appears  on  the  opposite  side  together  with  hemiplegia,  but  only 
the  lower  half  of  the  face  is  palsied,  the  associated  movements 
of  the  eyelids  being  left.  If  the  lesion  is  situated  in  the  pons, 
the  deep  facial  centres  may  be  implicated,  and  then  paralysis 
with  rapid  atrophy  of  the  facial  muscles  ensues  on  the  same  side 
as  the  lesion,  together  with  loss  of  power  of  the  opposite  arm 
and  leg  (crossed  paralysis).  If  the  wot  of  the  nerve  between  the 
centres  and  the  internal  auditory  meatus  is  involved,  the  whole 
of  the  same  side  of  the  face  is  paralyzed,  accompanied,  as  a  rule, 
by  deafness. 

(b)  Cranial  lesions.  —  There  are  two  not  uncommon  causes 
grouped  under  this  heading,  viz.,  (i.)  fracture  of  the  base  of  the 
skull,  involving  the  petrous  portion  of  the  temporal  bone,  the 
paralysis  supervening  either  immediately  after  the  injury  from 
laceration,  a  rare  phenomenon,  or  some  weeks  later  from  implica- 
tion in  the  callus,  the  usual  cause ;  or  (ii.)  as  a  complication  of 
chronic  otorrhcea,  and  then  due  to  compression  or  inflammation 
of  the  nerve  in  the  aqueductus  Fallopii.  In  both  these  forms  the 
palsy  is  complete  on  the  side  affected,  and  owing  to  the  com- 


AFFECTIONS  OF  NERVES 


341 


munication  of  the  facial  with  the  petrosal  nerves  in  this  part  of 
its  course  there  may  be  unilateral  drooping  of  the  velum  palati, 
the  uvula  being  deflected  towards  the  sound  side. 

(c)  Extra-cranial  lesions  from  injury,  inflammation  from  exposure 
to  cold,  or  the  pressure  of  a  tumour,  e.g.,  malignant  disease  of  the 
parotid.  This  variety  has  been  called  '  Bell's  palsy,'  and  is 
usually  characterized  by  the  whole  side  of  the  face  being  affected, 
but  without  implication  of  the  palate  or  uvula. 

The  general  Signs  of  facial  paralysis  (Fig.  86)  are  as  follows  : 
The  side  of  the  face  is  immobile  and  expressionless,  all  the  natural 


■r" 


-Facial  Paralysis.       (From  Photographs.) 

On  the  left  side  the  face  is  in  a  position  of  rest ;  on  the  right  side  an  attempt 
has  been  made  to  close  the  eyes,  that  on  the  paralyzed  side  remaining  open, 
and  the  eyeball  rolling  upwards  and  outwards,  whilst  the  asymmetry  of  the 
face  becomes  more  manifest. 


folds  and  wrinkles  being  lost ;  the  eye  cannot  be  completely  closed, 
and  on  attempting  to  do  so  the  eyeball  is  usually  seen  to  roll 
upwards  and  outwards ;  ulceration,  and  even  perforation,  of  the 
cornea  may  result  from  this  exposure.  From  the  drooping  and 
relaxation  of  the  lower  eyelid,  the  apposition  of  the  punctum 
lachrymale  to  the  conjunctiva  is  imperfect,  and  thus  tears  escape 
over  the  face  (epiphora),  a  condition  aggravated  by  the  loss  of  the 
suction-like  action  of  the  lachrymal  sac,  owing  to  the  associated 
paralysis  of  the  tendo  oculi  and  tensor  tarsi.  On  attempting  to 
move  the  face,  as  in  laughing  or  showing  the  teeth,  the  muscles 
on  the  non-paralyzed  side  are  alone  contracted,  and  marked 
asymmetry  results  from  the  drawing  over   of  the  opposite  side. 


342  A  MANUAL  OF  SURGERY 


The  iips  cannot  be  closed  firmly,  and  hence  whistling  and  such- 
like actions  are  prevented.  Food  collects  between  the  cheek  and 
the  teeth,  owing  to  paralysis  of  the  buccinator,  and  the  patient 
after  a  meal  has  to  clear  out  the  debris  with  a  spoon  or  his  fingers. 

The  Treatment  of  facial  paralysis  necessarily  depends  upon  its 
cause.  In  the  majority  of  cases  medical  treatment  (including  the 
administration  of  perchloride  of  mercury  and  iodide  of  potassium) 
will  suffice,  together  with  massage  and  electricity ;  in  others, 
surgical  measures  with  a  view  to  remove  some  obvious  cause  of 
pressure  may  be  necessary. 

Facial  Tic  (or  histrionic  spasm)  consists  of  a  clonic  contraction 
of  the  facial  muscles,  due  to  some  lesion  of  the  centre  in  the  pons 
or  cortex.  The  condition  causes  great  discomfort  to  the  patient, 
and  may  involve  the  whole  side  of  the  face,  or  merely  one  part  of 
it,  such  as  the  orbicularis  oculi.  Treatment  consists  in  the  admin- 
istration of  nerve  tonics  or  anti-spasmodics,  and,  failing  that, 
stretching,  or  even  in  severe  cases  division,  of  the  facial  nerve  has 
been  employed,  but  is  most  unsatisfactory. 

Operation. — The  nerve  is  exposed  immediately  below  the  ear,  its  position 
being  indicated  by  a  horizontal  line  drawn  from  the  middle  of  the  anterior 
border  of  the  mastoid  process,  and  usually  corresponding  to  the  point  where 
the  mastoid  meets  the  lobule  of  the  ear.  The  incision  extends  from  just 
behind  the  external  meatus  along  the  anterior  border  of  the  sterno-mastoid 
muscle  to  the  level  of  the  angle  of  the  jaw.  The  parotid  gland  is  separated 
from  the  muscle,  and  both  are  well  retracted,  exposing  by  this  means  the 
posterior  belly  of  the  digastric.  The  facial  nerve  is  found  above  this, 
running  directly  forwards  from  the  centre  of  the  mastoid  process.  The  great 
auricular  nerve  is  divided  in  the  superficial  incision,  and  the  posterior  auricular 
vessels  will  require  a  ligature.  The  internal  jugular  vein  is  close  to  the 
posterior  margin  of  the  wound.  The  operation  is  a  deep  one,  and  by  no 
means  easy  in  a  patient  with  a  thick  neck.  The  effect  of  stretching  the 
nerve  is  to  temporarily  paralyze  it,  but  the  ultimate  results  have  been  by 
no  means  encouraging,  only  one  case  out  of  twenty  collected  by  Godlee  being 
successful. 

The  Auditory  Nerve  may  be  injured  in  fractures  of  the  base  of 
the  skull,  either  one  or  both  sides  being  involved.  Incurable 
deafness  usually  results,  often  associated  with  facial  palsy. 

It  is  a  little  doubtful  what  effect  would  be  produced  by  injury 
of  the  Glosso -pharyngeal  Nerve,  but  in  one  case  in  which  it  was 
supposed  to  be  compressed  the  patient  suffered  from  difficulty  in 
swallowing  and  speaking,  together  with  persistent  ulceration  of 
the  tongue  ;  death  resulted  from  oedema  of  the  glottis. 

A  severe  injury  to  the  Pneumogastric  Nerve  may  prove  rapidly 
fatal,  but  less  serious  lesions  result  in  palpitation,  vomiting,  and 
a  sense  of  suffocation ;  such  phenomena  sometimes  manifest 
themselves  after  head  injuries,  especially  fractures  involving  the 
posterior  fossa,  and  indicate  that  the  jugular  foramen  has  been 
encroached  on.  The  nerve  is  also  exposed  to  injury  in  operations 
about  the  neck,  e.g.,  ligature  of  the  carotid,  or  removal  of  tuber- 
culous glands.    Irritation  causes  vomiting  and  temporary  inhibition 


AFFECTIONS  OF  NERVES  343 

of  the  heart's  action  ;  one-sided  division  sometimes  does  compara- 
tively little  harm,  but  if  both  nerves  are  divided,  death  results  from 
laryngeal  paralysis  or  from  such  complications  as  cedema  or 
congestion  of  the  lungs.  When  the  vagus  is  injured  in  the  lower 
part  of  the  neck  or  compressed  by  an  aneurism,  or  if  the  recurrent 
laryngeal  nerve  is  divided  or  compressed,  hoarseness  or  partial 
aphonia  is  produced,  from  paralysis  either  of  all  the  muscles  on 
one  side  of  the  larynx,  or  in  slighter  cases  only  of  the  abductor 
(crico-arytenoideus  posticus). 

The  Spinal  Accessory  Nerve  may  be  irritated,  either  at  its  exit 
from  the  skull  by  a  fracture  running  through  the  jugular  foramen, 
or  in  its  peripheral  course  by  inflamed  lymphatic  glands,  etc. 
Clonic  spasm  of  the  sterno-mastoid  and  trapezius  is  usually  due 
to  central  changes,  and  it  is  for  this  form  of  spasmodic  torticollis 
that  stretching  or  division  of  the  spinal  accessory  nerve  is  employed. 

Operation. — The  nerve  runs  downwards  and  backwards  at  right  angles  to 
the  centre  of  a  line  passing  from  the  angle  of  the  jaw  to  the  apex  of  the 
mastoid  process  ;  it  enters  the  deep  aspect  of  the  sterno-mastoid  about 
3  inches  below  that  spot.  An  incision  is  made  along  the  anterior  border  of 
the  sterno-mastoid,  reaching  from  the  ear  to  the  cornu  of  the  hyoid  bone. 
The  fascia  is  divided,  and  the  muscle  drawn  backwards  to  expose  the  posterior 
belly  of  the  digastric,  from  under  the  lower  border  of  which  the  nerve  emerges, 
passing  first  in  front,  and  then  below  the  transverse  process  of  the  atlas, 
which  can  be  readily  felt.  The  operation  has  not  given  good  results,  since, 
even  if  the  twitching  of  the  head  and  neck  ceases,  the  spasmodic  phenomena 
often  recur  elsewhere. 

The  Hypoglossal  Nerve  may  be  accidentally  divided  in  an 
operation,  or  compressed  by  an  aneurism  of  the  external  carotid, 
or  by  a  new  growth.  Unilateral  paralysis  or  weakness  of  the 
tongue  results,  the  organ,  when  protruded,  being  directed  towards 
the  paralyzed  side. 

The  Spinal  Nerves. 

The  nerves  constituting  the  Cervical  Plexus  are  exposed  to 
injury  either  from  blows,  dislocations  of  the  cervical  spine,  pene- 
trating wounds,  or  during  operations.  No  very  serious  results 
follow,  except  in  the  case  of  the  Phrenic  Nerve,  division  of  which 
may  cause  instant  death  by  paralysis  of  the  diaphragm,  although 
when  but  one  nerve  is  divided  the  patient  can  survive.  Irritation 
of  the  nerve  gives  rise  to  spasmodic  cough  or  hiccough. 

The  Brachial  Plexus  may  be  injured  from  exactly  similar  causes, 
paralysis  or  spasm  of  the  muscles  of  the  arm  arising  from 
division  or  irritation  of  the  motor  branches,  whilst  hyperesthesia 
or  anaesthesia  may  follow  from  damage  to  the  sensory  trunks. 
Thus  a  blow  on  the  back  of  the  neck  opposite  the  fifth  or  sixth 
vertebrae  caused  paralysis  of  the  serratus  magnus  and  rhomboids 
(winged  scapula)  ;  an  old  unreduced  unilateral  dislocation  of  the 
seventh  cervical  vertebra  produced  intense  neuralgia  along  the 


344 


A   MANUAL  OF  SURGERY 


course  of  the  ulnar  nerve,  and  many  similar  instances  might  be 
mentioned. 

One  special  form  of  injury  may  be  alluded  to  in  which  the  roots 
of  the  fifth  and  to  a  less  extent  of  the  sixth  cervical  nerves  are 
wrenched  or  torn  as  a  result  of  a  fall  on  the  shoulder,  which  is 
pressed  downwards,  whilst  the  head  is  forced  over  to  the  opposite 
side,  a  type  of  accident  which  is  liable  to  follow  a  spill  from  a  high 
dog-cart.  The  result  is  paralysis  of  Erb's  pre-axial  group  of 
muscles,  including  the  biceps,  deltoid,  and  supinator  longus,  arising 
from  the  fifth  nerve,  whilst  the  extensors  of  the  fingers  and  wrist 
are  involved  when  the  sixth  nerve  is  also  injured.  Sensory  lesions 
are  usually  slight,  and  recovery,  though  slow,  ensues  after  a  time. 

The  Treatment  is  mainly  symptomatic,  including  the  adminis- 
tration of  iodide  of  potassium  and  the  local  application  of  blisters 
or  other  counter-irritants  and  of  electricity.  In  cases  where  there 
is  severe  and  intractable  neuralgia,  not  referred  to  any  discoverable 
lesion,  or  where  clonic  spasm  of  the  muscles  of  the  arm  and 
shoulder  are  met  with,  stretching  of  the  brachial  plexus  may  be 
required. 

Operation. — The  patient  lies  on  his  back,  with  the  head  directed  to  the 
opposite  side,  and  the  arm  well  drawn  down  ;  a  cushion  is  inserted  under  the 
shoulder  to  steady  it.  An  incision  is  made  above  the  centre  of  the  clavicle, 
3  or  4  inches  in  length,  parallel  to  the  anterior  border  of  the  trapezius.  The 
platysma  and  deep  fascia  are  divided,  and  the  deep  cellular  tissue  opened  up 
by  retracting  the  margins  of  the  wound.  The  posterior  belly  of  the  omo- 
hyoid is  thus  exposed,  and  the  posterior  border  of  the  scalenus  anticus 
defined.  The  cords  of  the  plexus  are  found  emerging  between  the  latter 
muscle  and  the  medius  ;  they  are  carefully  isolated  by  division  of  the  sheath 
covering  them,  and  pulled  upon  by  the  finger  or  an  aneurism  needle  passed 
under  tnero.  Special  care  must  be  taken  of  the  lowest  cord  of  the  plexus, 
which  passes  behind  the  subclavian  artery.  The  nerves  are  stretched  both 
centripetally  and  centrifugally.  Excellent  results  have  followed  this  opera- 
tion, although  in  a  few  cases  the  necessary  cicatrization  which  followed  led  to 
a  recurrence  of  the  symptoms. 

The  Circumflex  Nerve  is  liable  to  injury  from  its  exposed  posi- 
tion, winding  round  the  outer  side  of  the  neck  of  the  humerus 
about  a  finger's  breadth  above  the  middle  of  the  deltoid.  Blows 
upon  the  shoulder  may  in  this  way  cause  paralysis  ;  it  is  some- 
times torn  or  compressed  in  fractures  of  the  surgical  neck  of  the 
humerus,  or  in  dislocation  of  the  shoulder,  or  it  may  be  impacted 
in  the  callus  arising  from  the  former  injury.  Paralysis  of  the 
deltoid  and  teres  minor  follows,  evidenced  by  inability  to  raise  the 
arm  from  the  side,  whilst  the  wasting  of  the  former  muscle  causes 
undue  prominence  of  the  acromion.  There  may  be  temporary 
anaesthesia  over  the  posterior  fold  of  the  axilla,  but  this  does  not 
last  long.  No  operative  treatment  has  been  adopted,  although  we 
see  no  reason  why  it  should  not  be  attempted  in  suitable  cases. 

The  Musculo-Spiral  Nerve  is  not  unfrequently  damaged  in 
fractures  and  dislocations  of  the  upper  extremity  of  the  humerus, 


AFFECTIONS  OF  NERVES  345 


but  is  especially  exposed  to  injury  in  the  musculo-spiral  groove 
where  it  lies  close  to  the  bone.  It  is  implicated  with  or  without 
other  nerves  in  crutch  palsy  (p.  433),  or  by  lying  asleep  in  bed 
with  the  arm  under  the  body,  as  so  frequently  occurs  in  drunken 
people  (commonly  called  '  Saturday-night  paralysis  '). 

The  Symptoms  arising  from  its  total  division  are  as  follows : 

A.  Anaesthesia  over  the  front  and  back  of  the  outer  side  of  the 

elbow  and  fore-arm  (external  cutaneous  branches), 
over  the  radial  side  of  the  dorsal  aspect  of  the  wrist 
and  hand,  and  over  the  back  of  the  thumb,  index, 
middle,  and  half  of  the  ring  fingers,  to  a  variable 
extent  (Fig.  88,  B,  ra). 

B.  Paralysis  of  the  following  groups  of  muscles  : 

(i.)  Of   the   extensor   of   the   forearm   (triceps)  ;    hence    the 

forearm  can  only  be  extended  by  its  own  weight, 
(ii.)  Of  the  long  and  short  supinators ;    hence  the   hand  is 
pronated,  the  only  supinator  remaining  being  the  biceps. 


Fig.  87. — Wrist-drop  from  Paralysis  of  the  Musculo-Sfiral  Nerve. 

(TlLLMANNS.) 

(iii.)  Of  the  radial  and  ulnar  extensors  of  the  wrist ;  hence 
wrist-drop  (Fig.  87),  a  condition  also  present  in  certain 
lesions  of  toxic  or  central  origin,  e.g.,  lead  palsy,  and 
progressive  muscular  atrophy. 

(iv.)  Of  the  extensors  of  the  fingers  and  thumb,  which  either 
hang  limp  and  motionless,  or  may  be  bent  up  into  the 
palm  from  the  unopposed  action  of  the  flexor  muscles. 
If,  however,  the  wrist  and  proximal  phalanges  are 
supported  and  extended,  the  termin.il  phalanges  can 
be  straightened  by  the  action  of  the  interossei  and 
lumbricales. 
Treatment  consists  in  massage  and  electricity  applied  to  the 
muscles,  but  in  some  cases  an  operation  is  necessary. 

Operation. — The  nerve  can  be  exposed  on  the  outer  side  of  the  arm  after  it 
has  traversed  the  external  intermuscular  septum,  where  it  lies  between  the 
brachialis  anticus  and  supinator  longus.  To  define  this  intersection  the  fore- 
arm is  semiflexed  and  pronated,  and  an  incision  made  extending  from  the 
centre  of  the  crease  of  the  elbow  upwards  and  outwards  along  a  line  made  by 


346 


A   MANUAL  OF  SURGERY 


prolonging  upwards  the  radial  border  of  the  forearm,  which  in  this  position 
corresponds  with  the  supinator  longus  muscle.  The  interspace  is  opened  up, 
and  the  nerve  found  together  with  the  termination  of  the  superior  profunda 
artery.  From  this  point  the  nerve  may  be  traced  upwards,  if  necessary,  by 
dividing  the  intermuscular  septum,  and  retracting  or  dividing  the  triceps. 
Where  there  has  been  considerable  loss  of  substance  of  the  nerve,  so  that  the 
ends  cannot  be  approximated,  an  inch  or  two  may  be  excised  from  the  shaft 
of  the  humerus  with  advantage,  the  bone  being  subsequently  wired,  and  the 
nerve  sutured.     We  have  performed  this  operation  with  a  successful  result. 

To  expose  the  upper  part  of  the  nerve  as  it  enters  the  groove,  the  arm  is 
placed  over  the  body,  and  the  posterior  border  of  the  deltoid  defined.  An 
oblique  incision  is  made  a  finger's  breadth  behind  this,  and  the  intersection 
between  the  long  and  outer  heads  of  the  triceps  found.  By  opening  up  this 
space  the  finger  can  be  passed  down  to  the  bone,  and  the  nerve,  together  with 
the  superior  profunda  artery,  readily  exposed. 

Where  the  nerve  is  impacted  in  the  callus  arising  from  a  fracture  of  the 
middle  of  the  shaft  of  the  humerus,  it  is  often  best  to  expose  it  by  a  median 
incision  down  the  back  of  the  arm,  splitting  the  triceps,  the  centre  of  the 
wound  being  opposite  the  insertion  of  the  deltoid. 


Fig.  88. — Distribution  of  Sensory  Nerves  of  Hand   from   Froni    and 

Back.     (Tillmanns.) 

vie,  Median  nerve  ;  u,  ulnar  ;  ra,  radial. 

The  Median  Nerve  may  be  damaged  in  fractures  and  dislocations 
of  the  humerus,  but  is  most  frequently  injured  just  above  the 
wrist  by  glass  wounds,  due  either  to  bursting  of  bottles,  etc.,  or 
to  thrusting  the  hand  and  arm  through  a  window.  Paralysis 
necessarily  results  in  these  cases  with  the  following  symptoms  : 

If  divided  just  above  the  wrist : 

A.  Anaesthesia  over  the  palmar  aspect  of  the  radial  side  of  the 

hand,  over  the  front  of  the  thumb,  index,  middle,  and 
half  the  ring  fingers,  and  over  varying  portions  of  the 
dorsum  of  the  same  (Fig.  88,  A,  B). 

B.  (i.)  Paralysis  of  the  outer  group  of  the  short  muscles  of  the 

thumb  (i.e.,  abductor,  opponens,  and  outer  half  of  the 


AFFECTIONS  OF  NERVES  347 

flexor   brevis  pollicis),   so  that  the  thenar   eminence 
wastes,  and  the  movement  of  '  opposition  '  is  impaired, 
the  thumb    remaining   extended    by  the  side    of   the 
fingers  (Duchenne's  '  ape-hand  '). 
(ii.)  Paralysis  of  the  outer  two  lumbrical  muscles,  causing 
loss  of  power  of  flexion  at  the  metacarpo-phalangeal 
joints  of  the  index  and  middle  fingers. 
The  great  impairment   of  mobility  in  the  hand  and  fingers  so 
often  seen  in  these  cases  depends  not  so  much  on  paralysis  of 
muscles  as  on  the  fact  that  in  the  majority  of  cases  the  synovial 
sheaths  of  the  wrist  are  also  laid  open,  and  involved    in  septic 
inflammation,  which  leads  to  the  formation  of  diffuse  adhesions. 
Hence  the  prognosis  is  often  unsatisfactory,  even  when  the  nerve 
has  been  skilfully  sutured  at  a  secondary  operation. 

//  divided  at  the  bend  of  the  elbow  or  in  the  arm,  to  the  above- 
described  symptoms  are  added  : 

(i.)  Loss  of  pronation  from  paralysis  of  the  two  pronators, 
(ii.)  Paralysis  of  the  flexor  carpi  radialis,   causing  defective 
wrist  flexion  on  the  radial  side,  and  impaired  radial 
abduction. 
(iii.)  Paralysis   of  the  flexor   longus   pollicis,    of  the   flexor 
sublimis,  and  the  outer  half  of  the  flexor  profundus 
digitorum,  leading  to  loss  of  power  in  the  hand-grasp, 
especially    on  the    radial    side,    and    perhaps   hyper- 
exrension  of  the  wrist. 
(iv.)  Paralysis  of  the  palmaris  longus. 

Operations. — When  the  nerve  has  been  divided,  primary  or  secondary  nerve 
suture  should  always  be  undertaken.  In  the  latter  case  incisions  are  made 
through  the  old  scars,  which  may  be  removed  with  advantage,  the  ends  of  the 
nerve  clearly  defined,  and  the  bulb  removed.  Suture  is  often  very  difficult 
from  lack  of  material,  and  to  assist  in  the  apposition  of  the  segments  the  hand 
is  flexed  to  a  right  angle,  and  also  the  elbow,  and  maintained  in  that  position 
by  a  poroplastic  or  plaster  of  Paris  splint. 

In  order  to  stretch  the  nerve,  it  may  be  exposed  in  the  arm  by  an  incision 
similar  to  that  for  ligature  of  the  brachial  artery,  or  at  the  wrist  by  an  incision 
placed  to  the  ulnar  side  of  the  flexor  carpi  radialis  tendon,  between  that 
structure  and  the  palmaris  longus  or  flexor  sublimis  tendons. 

The  Ulnar  Nerve  is  exposed  to  injury  at  the  wrist,  as  also  in 
the  hollow  between  the  olecranon  and  the  inner  condyle  of  the 
humerus,  and  paralysis  may  be  caused  by  wounds,  fractures, 
blows,  implication  in  callus,  etc.  The  symptoms  are  very  charac- 
teristic. 

If  divided  at  the  elbow  : 

A.  Anaesthesia  of  the  ulnar  side  of  the  front  of  the  wrist  and 
palm  (palmar  cutaneous  branch),  over  the  back  of  the  hand,  and 
of  the  little  and  half  the  ring  fingers,  back  and  front  (Fig.  88, 
A,  B). 

B.  (i.)  Paralysis  of  the  flexor  carpi  ulnaris,  causing  weakness 

in  flexion  and  in  ulnar  adduction  of  the  wrist. 


348 


A   MANUAL  OF  SURGERY 


(ii.)  Paralysis  of  the  inner  half  of  the  flexor  profundus,  with 
weakened  hand-grasp,  especially  in  the  ring  and  little 
fingers, 
(iii.)  Paralysis  of  the  two  inner  lumbricales  and  of  all  the 
interossei ;  hence,  loss  of  adduction  and  abduction  of 
the  fingers,  with  flexion  of  the  two  last  phalanges  in 
each  finger  and  hyper-extension  at  the  metacarpo- 
phalangeal joint  (main-en-griffe  or  claw-hand,  Fig.  89). 
The  interosseous  spaces  also  become  very  evident 
from  atrophy  of  these  muscles. 

(iv.)  Paralysis      of     the      short 
muscles  of  the  little  finger, 
of     the    inner    group    of 
short  thumb  muscles  (ad- 
ductor transversus,  adduc- 
tor    obliquus     and     deep 
portion    of  flexor  brevis), 
and  of  the  palmaris  brevis. 
If  divided  just  above  the   wrist,  the 
anaesthesia  only  involves  the  palmar 
aspect    of    the    hand,   and    back    of 
the    terminal    phalanges,   whilst    the 
paralysis    merely    affects    the    short 
palmar  muscles.     Additional  impair- 
ment  of  movement    may,    however, 
arise  from  septic  inflammation  of  the 
long  tendons  and  their  sheaths. 

Treatment. — If  divided,  the  nerve 
must  be  dealt  with  (according  to  the 
rules  already  given)  at  the  injured 
spot. 


Fig.  89. — Claw-hand  (Main- 
en  -  Griffe)  from  Ulnar 
Paralysis.  (After  Byrom 
Bramwell.) 


To  expose  the  nerve  for  the  purpose  of 
stretching  for  neuralgia,  or  suturing,  the 
following  methods  may  be  adopted  :  (a)  In 
the  upper  arm  an  incision  is  made  similar  to  that  for  tying  the  brachial  artery, 
but  half  an  inch  behind  it.  (b)  At  the  elbow,  cut  down  just  behind  the  internal 
condyle,  and  find  the  nerve  behind  the  internal  inter-muscular  septum  with 
the  inferior  profunda  artery,  (c)  Just  above  the  wrist  it  lies  to  the  radial  side 
of  the  flexor  carpi  ulnaris  between  the  tendon  and  the  ulnar  vessels ;  the  skin 
and  deep  fascia  alone  need  division. 

The  Intercostal  Nerves  are  frequently  the  seat  of  severe  neuralgia, 
either  from  a  chronic  neuritis,  probably  of  toxic  origin,  from  com- 
pression by  tumours,  or  inflammatory  lesions  of  the  ribs,  or 
from  injury  or  pressure  directed  to  the  nerve  roots  as  they  emerge 
from  the  spine.  Herpes  zoster  or  shingles  is  a  very  frequent 
sequela  to  such  pain,  and  may  be  followed  by  some  amount  of 
anaesthesia. 

Sciatica,  or  neuralgia  of  the  great  sciatic  nerve,  is  a  most 
painful  affection,  and  often  exceedingly  intractable.     It  may  arise 


AFFECTIONS  OF  NERVES  349 

from  the  following  Causes  :  (a)  Inflammation  of  the  neurilemma 
(acute  or  chronic),  the  result  of  cold,  injury,  gout,  rheumatism, 
syphilis,  and  many  toxic  agents  ;  (b)  pressure  upon  the  extra- 
pelvic  portion  of  the  nerve,  as  by  aneurisms,  tumours,  or  old- 
standing  dislocations  of  the  head  of  the  femur  on  the  dorsum 
ilii ;  (c)  similar  pressure  upon  the  nerve  in  the  pelvis,  or  as  it 
emerges  through  the  sacro-sciatic  notch,  as  from  sarcoma  or 
osteoma  of  the  pelvic  bones,  rectal  or  uterine  cancer,  a  pregnant 
uterus,  or  uterine  fibroids ;  (d)  pressure  upon  the  nerve-roots  in 
the  spinal  canal,  as  from  caries  or  sarcoma  ;  (e)  chronic  diseases 
of  the  spinal  cord,  such  as  tabes. 

The  Symptoms  are  very  evident,  the  pain  shooting  down  the 
back  of  the  thigh  and  often  referred  to  the  toes.  It  is  of  a 
paroxysmal  nature,  and  may  be  brought  on  by  pressure  over 
almost  any  part  of  the  nerve  or  by  movements  of  the  thigh,  and 
hence  the  patient's  gait  is  stiff  and  shambling.  Tenderness  in 
the  line  of  the  nerve  is  felt  when  the  cause  is  a  peripheral 
neuritis,  and  the  trunk  may  sometimes  be  detected  on  palpation 
as  a  thickened  cord.  The  limb  is  often  kept  slightly  flexed,  but 
complete  flexion  of  the  thigh  on  the  pelvis  is  an  impossibility  ; 
and  if,  when  the  patient  is  standing  against  a  wall,  the  limb  can 
be  raised  to  a  right  angle  with  the  knee  extended,  it  is  certain 
that  sciatica  is  not  present. 

The  Treatment  necessarily  varies  with  the  cause.  If  due  to 
neuritis  or  perineuritis,  general  anti-syphilitic  or  anti-rheumatic 
measures  may  be  adopted,  and  blisters  or  sedative  remedies  in  the 
more  acute  cases  applied  to  the  back  of  the  thigh.  Hypodermic 
injections  of  morphia  and  atropine  may  also  be  useful ;  but  if  all 
the  usual  anti-neuralgic  remedies  have  been  exhausted  without 
benefit,  stretching  of  the  nerve  may  be  employed. 

Stretching  of  the  sciatic  nerve  may  be  required  for  :  (i.)  neuralgia 
of  an  intractable  type  ;  (ii.)  paralysis  or  spasm  of  muscles  supplied 
by  it,  owing  to  adhesions  contracted  between  it  and  surrounding 
parts,  the  result  of  injury,  cellulitis,  or  perineuritis  ;  (iii.)  in 
paralysis  or  spasm  due  to  some  forms  of  tabes.  The  nerve  may 
also  be  exposed  in  order  to  suture  it  after  it  has  been  divided. 
Nerve-stretching  may  be  accomplished  without  operation  by 
flexing  the  thigh  upon  the  abdomen  and  then  extending  the 
knee ;  in  cases  of  sciatica  an  anaesthetic  will  be  required  for  this, 
but  it  may  be  attempted  before  undertaking  further  measures. 

The  nerve  is  best  exposed  for  stretching  at  the  point  where  it  emerges  from 
under  cover  of  the  gluteus  maximus,  midway  between  the  tuber  ischii  and  the 
great  trochanter.  The  patient  lies  in  the  prone  position  with  the  limb  slightly 
flexed,  and  a  4  or  5  inch  incision  is  made  vertically  downwards  from  the  gluteal 
fold  in  the  middle  line  of  the  thigh.  The  lower  border  of  the  gluteus  maximus 
is  first  exposed,  and  its  fibres  seen  running  downwards  and  outwards.  The 
hamstring  muscles  emerging  from  under  it  are  drawn  inwards,  and  the  nerve 
is  found  ensheathed  in  loose  connective  tissue  ;  it  is  stretched,  by  a  finger 
hooked  under  it,  both  peripherally  and  proximally. 


350  A   MANUAL  OF  SURGERY 


The  Anterior  Crural  Nerve  may  be  paralyzed  as  a  result  of 
injury  or  pressure,  and  may  be  the  seat  of  neuralgia  or  spasm. 
Its  division  causes  paralysis  of  the  quadriceps  extensor,  pectineus, 
and  sartorius,  and  the  most  marked  effect  will  be  secondary 
flexion  of  the  knee-joint  from  the  unopposed  action  of  the  ham- 
strings ;  anaesthesia  extends  over  the  front  of  the  thigh  and  along 
the  inner  side  of  the  leg  and  foot  as  far  as  the  ball  of  the  great 
toe.  The  nerve  may  be  exposed  on  the  outer  side  of  the  femoral 
vessels,  just  below  Poupart's  ligament,  by  a  vertical  incision  half 
an  inch  outside  the  line  of  the  artery. 

The  External  Popliteal  Nerve  may  be  divided  during  a  sub- 
cutaneous tenotomy  of  the  biceps,  to  which  it  lies  immediately 
internal ;  or  compressed,  as  it  winds  round  the  neck  of  the  fibula, 
by  strapping,  bandages,  or  splints ;  or  it  may  be  injured  in 
fractures  of  the  neck  of  the  fibula.  Total  division  causes 
anaesthesia  over  the  dorsum  of  the  foot,  together  with  paralysis 
of  the  extensor  and  peroneal  groups  of  muscles  ;  and  from  the 
contraction  of  the  unbalanced  opposing  groups,  the  paralytic 
form  of  talipes  equino-varus  results.  The  nerve  may  be  ex- 
posed by  making  an  incision  i|  inches  long  to  the  inner  side  of 
the  biceps  tendon,  terminating  at  the  neck  of  the  fibula.  The 
knee  is  then  flexed,  and  the  nerve  is  readily  found  embedded  in 
the  loose  cellular  tissue  of  the  popliteal  space. 

The  Internal  Popliteal  Nerve  is  much  less  exposed  to  injury 
owing  to  its  more  sheltered  position.  Division  results  in  anaes- 
thesia of  the  back  of  the  calf  and  sole  of  the  foot,  and  in  paralysis 
of  the  calf  muscles,  flexors  of  the  foot  and  toes,  and  of  the  short 
muscles  of  the  sole.  Paralytic  talipes  calcaneo-valgus  is  very 
likely  to  ensue.  The  nerve  is  laid  bare  by  a  vertical  incision  in 
the  middle  of  the  popliteal  space,  which  should  avoid  the  short 
saphena  vein.  After  division  of  the  deep  fascia,  the  nerve  is  the 
most  superficial  structure. 

If  the  Tibial  Nerves  are  divided,  the  resulting  effects  are  more 
limited  ;  thus,  paralysis  of  the  extensors  of  the  foot  and  paralytic 
talipes  equinus  result  from  division  of  the  anterior  tibial  ;  and 
paralysis  of  the  short  and  long  flexors  of  the  foot  and  of  the  inter- 
ossei,  with  resulting  talipes  calcaneo-valgus,  follow  lesions  of  the 
posterior  tibial.  The  nerves  may  be  exposed  in  the  same  way  as 
the  accompanying  arteries  (p.  296). 

The  Sympathetic  Nerve  Trunk  in  the  neck  is  occasionally  com- 
pressed by  aneurisms  or  tumours.  If  merely  irritated,  dilatation 
of  the  pupil  on  the  same  side  and  unilateral  sweating  of  the  head 
and  face  are  produced  ;  but,  if  divided,  the  pupil  is  contracted 
from  unbalanced  action  of  the  third  nerve.  It  has  also  been 
intentionally  divided  and  portions  excised  in  the  treatment  of 
Graves'  disease,  glaucoma,  and  epilepsy ;  but  such  practice  is  still 
onlv  in  the  experimental  stage. 


CHAPTER  XIV. 

SURGICAL  DISEASES  OF  THE  SKIN  AND  OF  THE 
CUTANEOUS  APPENDAGES. 

A  Boil  or  Furuncle  is  a  limited  form  of  infective  gangrene  involving 
merely  a  small  portion  of  skin  and  subcutaneous  tissue,  usually 
round  a  hair  follicle.  Experimentally,  a  plentiful  crop  of  boils  can 
be  produced  by  rubbing  a  culture  of  staphylococci  into  the  skin, 
and  clinically  it  is  supposed  that  a  similar  infection  through  the 
hair  follicles  is  the  most  common  cause  of  this  condition.  The 
secondary  boils  around  a  primary  one  are  without  doubt  due  to 
the  friction  upon  the  healthy  integument  of  dressings,  covered 
with  pus  and  microbes. 

People  with  a  coarse  skin  and  a  tendency  to  comedones  are 
specially  liable  to  the  occurrence  of  boils.  A  gangrenous  inflam- 
mation ensues  after  infection,  resulting  in  the  death  of  the  hair 
follicle,  or  of  the  sweat  or  sebaceous  gland  involved,  and  of  the 
surrounding  connective  tissue,  and  the  slough  thus  formed  is  cast 
off  by  a  process  of  suppuration.  A  matured  or  ripe  boil,  therefore, 
consists  of  a  central  slough  or  core,  a  zone  of  pus  around  it,  and 
external  to  this  granulation  tissue  merging  into  healthy  skin  and 
connective  tissue.  Although  infection  from  without  is  the  local 
exciting  cause,  there  is  frequently  present  some  depression  of  the 
vital  powers,  which  may  lead  to  crops  of  boils  recurring  again 
and  again. 

Signs. — A  boil  commences  as  a  small  red  irritable  pimple,  from 
which  a  hair  may  often  be  seen  to  protrude,  which  increases 
gradually  in  size,  becoming  more  and  more  painful,  until  it  forms 
a  conical  tumour,  deep  red  in  colour  and  exquisitely  tender.  A 
small  whitish  spot  appears  in  the  centre,  and  around  this  so-called 
core  yellow  pus  can  be  seen.  Finally  it  bursts,  discharging  the 
pus,  and  subsequently  the  core  or  slough  comes  away.  The 
process  is  then  at  an  end,  and  the  wound  rapidly  heals  by  granu- 
lation. Occasionally  the  inflammation  extends  more  deeply  into 
the  subcutaneous  tissues,  constituting  a  '  carbuncular  boil.'  The 
neighbouring  lymphatic  glands  become  sympathetically  enlarged 
and   painful,   but  rarely  suppurate.     A   boil   sometimes  subsides 


352  A  MANUAL  OF  SURGERY 

without  suppuration,  leaving  the  parts  thickened  and  infiltrated, 
the  condition  then  being  known  as  a  '  blind  boil.' 

Treatment. — Locally,  many  boils  may  be  left  to  burst  naturally, 
though  possibly  the  process  may  be  checked  by  surrounding 
them  with  a  piece  of  ordinary  adhesive  plaster,  with  a  hole  over 
the  apex  of  the  swelling.  Poultices  are  generally  applied,  and 
the  boil  is  incised  when  mature.  The  pus  should  be  received 
on  portions  of  wool  soaked  in  carbolic  lotion  (i  in  20),  and  the 
cavity  lightly  swabbed  out  with  pure  carbolic  acid.  A  small 
collodion  dressing  is  then  applied.  Constitutionally,  tonics,  such 
as  iron  and  quinine,  are  usually  required,  except  in  plethoric  indi- 
viduals, in  whom  a  spare  diet  and  abstinence  from  stimulants  may 
be  recommended.  A  change  of  air  to  a  bracing  seaside  place  is 
often  advisable,  especially  when  a  succession  of  boils  has  appeared 
from  time  to  time  for  weeks  or  months. 

A  Carbuncle  is  a  more  extensive  infective  gangrene  of  the  subcu- 
taneous tissues,  due  to  a  local  invasion  with  pyogenic  microbes, 
the  commonest  being  the  Staphylococcus  pyogenes  aureus.  It  occurs 
in  individuals  run  down  by  any  general  debilitating  condition,  such 
as  albuminuria  or  diabetes,  in  whom  the  germicidal  powers  of 
the  tissues  are  much  depreciated ;  it  is  also  occasionally  met  with 
as  a  sequela  of  acute  fevers.  The  exciting  cause  may  be  some 
blow  or  squeeze,  resulting  in  extravasation  of  blood  or  some  local 
diminution  of  vitality ;  into  this  area  cocci  are  implanted  either 
by  auto-infection,  or  more  usually  through  the  sweat-glands  or 
hair  follicles,  or  through  some  slight  superficial  abrasion. 

Signs. — A  carbuncle  commences  as  a  hard,  painful  infiltration 
of  the  subcutaneous  tissues,  the  skin  over  which  becomes  red  and 
dusky.  The  swelling  gradually  increases  in  size  in  all  directions, 
until  even  a  diameter  of  six  or  more  inches  is  reached.  As  it  ex- 
tends peripherally,  the  central  parts,  which  were  formerly  brawny, 
become  soft  and  boggy,  and  the  overlying  skin  shows  evidences 
of  yielding  to  the  pressure  within.  Vesicles  form  on  the  surface, 
and  finally  pustules ;  these  in  turn  burst,  and  allow  a  tardy  exit 
to  the  ashy-grey  sloughs  and  purulent  discharge  accumulated 
below.  Fresh  openings  gradually  develop,  leading  to  a  cribriform 
condition  of  the  cutis,  due  probably  to  the  passage  of  the  pus 
along  the  lines  of  least  resistance,  viz.,  the  perforations  of  the 
cutis  at  the  sites  of  the  sebaceous  glands  and  hair  follicles.  Some 
of  these  apertures  enlarge  and  run  into  one  another,  producing  a 
central  irregular  crateriform  opening,  at  the  bottom  of  which  lies 
the  necrotic  tissue.  As  the  violence  of  the  inflammation  subsides, 
the  sloughs  gradually  separate,  leaving  a  clean  granulating  wound. 
Carbuncles  most  frequently  occur  on  the  back,  the  nape  of  the 
neck,  the  shoulders,  and  nates,  where  the  vitality  of  the  tissues  is 
never  very  active ;  when  they  form  on  more  vascular  parts,  such 
as  the  face  and  lips,  the  consequences  may  be  even  more  serious, 


SURGICAL  DISEASES  OE  THE  SKIN  353 

since  infective  thrombosis  of  the  large  veins  may  follow,  and 
this  may  quickly  spread  up  to  the  cavernous  sinus.  The  soft 
and  spongy  tissue  of  the  cheek  is  a  very  favourable  place  for  the 
extension  of  the  necrotic  process,  and  there  may  be  a  wide  area  of 
mischief  under  an  apparently  insignificant  superficial  lesion.  A 
carbuncle  is  usually  single,  and  may  be  accompanied  by  a  painful 
enlargement  of  the  nearest  lymphatic  glands. 

There  is  often  considerable  constitutional  disturbance  of  an 
asthenic  type,  although  the  temperature  is  not  necessarily  much 
raised.  Sometimes  the  gravest  symptoms  of  blood-poisoning 
(pyaemia  or  septicaemia)  may  supervene. 

Diagnosis. — 1.  From  Boils. — Pathologically,  a  boil  is  an  infective 
gangrene  of  a  small  portion  of  the  skin.  A  carbuncle  affects  the 
subcutaneous  tissues  primarily,  and  the  skin  secondarily.  Clini- 
cally, boils  are  multiple,  conical  in  shape,  more  localized,  and 
when  suppuration  has  occurred  the  process  is  terminated  by  the 
discharge  of  the  pus  and  slough  through  a  single  opening. 
Carbuncles,  on  the  other  hand,  are  usually  single,  much  larger, 
flatter,  and  the  sloughing  process  may  continue  peripherally, 
whilst  the  central  part  is  discharging  its  sloughs  through  several 
openings.  2.  From  Gummata. — Cutaneous  gummata  are  frequently 
multiple,  occurring  in  patients  with  a  distinct  syphilitic  history. 
They  are  not  very  painful,  and  do  not  as  a  rule  attain  any 
great  size.  They  usually  ulcerate  early,  leaving  circular  sores, 
or  if  multiple  and  confluent,  sores  with  serpiginous  outlines ; 
there  is  generally  but  little  definite  sloughing.  The  deeper 
gummata  are  also  less  painful,  have  but  one  opening,  and  leave 
excavated  sores,  in  the  bases  of  which  are  yellowish  sloughs  like 
wet  wash-leather.  The  discharge  is  not  distinctly  purulent,  but 
more  like  bloodstained  gum,  unless  the  sore  becomes  septic. 

The  Prognosis  of  a  carbuncle  mainly  depends  upon  the  condition 
of  the  internal  organs.  If  the  patient  is  a  confirmed  sufferer  from 
diabetes  or  albuminuria,  there  is  always  considerable  risk  of  his 
sinking  from  exhaustion.  The  vascularity  of  the  parts  also  influ- 
ences the  result,  as  although  there  is  more  reparative  power  about 
a  vascular  region  like  the  face,  yet  the  implication  of  large  veins 
may  lead  to  embolic  pyaemia. 

Treatment  must  always  be  of  a  tonic,  supporting  character. 
Good  food,  iron,  quinine,  and  alcohol  according  to  judgment, 
must  be  administered,  whilst  appropriate  medicine  (e.g.,  codeia  or 
opium)  and  limitation  of  diet  are  necessary  in  diabetic  patients. 
Locally,  many  different  forms  of  treatment  have  been  suggested. 
The  most  thorough  and  satisfactory  is  to  lay  the  carbuncle  freely 
open  under  an  anaesthetic,  and  scrape  with  a  sharp  spoon  or  cut 
away  all  sloughs  until  healthy  tissue  is  reached,  and  then  to 
thoroughly  disinfect  the  cavity  with  pure  carbolic  acid  or  peroxide 
of  hydrogen  (10  volumes).  The  hollow  thus  formed  is  stuffed 
with  antiseptic  dressings,  such  as  gauze  soaked  in  an  iodoform 

23 


354  A  MANUAL  OF  SURGERY 


emulsion  (10  per  cent.),  and  the  case  will  then  probably  do  well. 
Another  less  radical  proceeding  is  to  make  a  free  crucial  incision, 
and  allow  the  sloughs  to  separate  naturally,  assisting  matters  by 
antiseptic  poultices. 

In  the  early  stages,  it  has  been  proposed  to  inject  the  surround- 
ing tissues  with  pure  carbolic  acid  in  the  hope  of  destroying  the 
organisms,  and  thus  preventing  suppuration.  In  a  certain  number 
of  cases  this  object  will  be  successfully  accomplished,  but  where 
the  organisms  are  at  all  virulent,  it  will  probably  fail. 

A  Corn  (clavus)  is  a  localized  outgrowth  of  the  epidermic 
layer  of  the  skin,  together  with  a  central  ingrowth  of  a  hard, 
horny  plug,  which  compresses  and  causes  atrophy  of  the  under- 
lying papillae,  constituting  a  cup-shaped  hollow,  whilst  the 
surrounding  papillae  are  hypertrophied.  It  is  the  presence  of 
this  central  plug  that  constitutes  the  difference  between  a  true 
corn  and  a  simple  callosity  or  diffuse  overgrowth  of  the  epidermis. 
Any  abnormal  pressure  is  capable  of  producing  either  condition, 
granting  that  it  is  not  sufficiently  severe  or  intense  to  lead  to 
ulceration  ;  but  it  is  rare  to  find  corns  except  on  the  feet,  and  the 
chief  cause  is  badly-fitting  boots.  Two  kinds  of  corns  are  de- 
scribed, viz.,  the  hard  and  the  soft. 

The  hard  corn  usually  occurs  on  the  little  toe,  or  over  the  head 
of  the  metatarsal  bone  of  the  great  toe,  or  over  the  heads  of  the 
first  phalanges  of  the  other  toes,  especially  if  there  is  any  tendency 
to  hammer-toe.  They  form  more  or  less  conical  swellings,  with  a 
dark,  dry,  central  plug,  and  are  often  very  painful,  especially 
when  rain  is  threatening.  Suppuration  sometimes  occurs  beneath 
a  corn,  and  the  pain  then  becomes  acute.  Treatment  consists  in 
paring  the  corn  down,  after  softening  with  hot  water  or  treating 
with  salicylic  acid  plaster  (10  or  20  per  cent.),  or  painting  with  a 
solution  of  salicylic  acid  in  collodion.*  A  circular  ring  of  felt 
plaster  may  subsequently  be  worn,  but  attention  must  be  directed 
to  the  boots,  and  the  cause  of  the  trouble  removed.  Occasionally, 
where  the  toe  is  deformed,  it  is  necessary  to  perform  amputation. 

A  soft  corn  occurs  between  the  toes,  and  owing  to  the  absorp- 
tion of  sweat  the  surface  looks  white  and  sodden ;  it  is  often 
extremely  painful.  Treatment  consists  in  removing  the  thickened 
cuticle  after  the  use  of  salicylic  acid.  The  parts  are  very  care- 
fully cleansed  night  and  morning,  and  spirits  of  camphor  painted 

*  The  following  is  a  useful  formula : 

]£.  Acidi  salicylici,  gr.  xv. 
Ext.  cannabis  ind.,  gr.  viii. 
Sp.  vini  rect.,  tilxv. 
jEtheris,  ttixl. 
Collodion  flexile,  nilxxv. 
M.  Ft.  pigm. 
Sig.  :  '  To  be  painted  on  with  a  brush  three  times  a  day  for 
a  week.' — R.  Crocker. 


SURGICAL  DISEASES  OF  THE  SKIN  355 

on  at  night,  whilst  cotton-wool  is  worn  between  the  toes  during 
the  day. 

Perforating  Ulcer  of  the  Foot  forms  on  some  part  of  the  sole 
and  progresses  deeply  so  as  to  involve  sooner  or  later  the  bones 
and  joints.  It  is  usually  due  to  two  main  factors,  viz.,  anesthesia 
of  the  soles,  and  more  or  less  persistent  traumatism,  such  as  arises 
from  wearing  a  tight  boot  or  from  the  presence  of  a  nail,  which  is 
not  noticed  owing  to  the  concurrent  anaesthesia.  It  is  therefore 
likely  to  be  met  with:  (1)  In  certain  central  nervous  diseases,  e.g., 
tabes  dorsalis,  syringomyelia,  spina  bifida,  etc. ;  (2)  in  diseases  such 
as  diabetes,  syphilis,  alcoholism,  etc.,  which  lead  to  peripheral 
neuritis  ;  and  (3)  as  a  sequence  of  traumatic  lesions  of  the  nerves 
affecting  any  portion  of  their  course  from  the  spinal  cord  down- 
wards. Thus,  a  short  time  back  one  of  us  amputated  a  foot 
which  was  painful  and  deformed  as  the  result  of  a  healed  per- 
forating ulcer  which  had  involved  bones  and  joints,  and  was  due 
to  a  severe  lesion  of  the  lower  lumbar  region,  involving  the 
cauda  equina,  received  thirty  years  previously.  (4)  Perforating 
ulcer  is  occasionally  due  to  pure  plantar  lesions,  apart  from  any 
nervous  influence,  e.g.,  a  suppurating  wart  or  corn,  or  even  a 
chronic  epithelioma.  The  skin  under  the  head  of  the  first  metatarsal 
is  the  part  most  frequently  affected,  but  any  spot  to  which  undue 
pressure  is  directed  may  become  involved,  and  not  uncommonly 
several  such  sores  may  be  seen  on  the  same  foot.  A  corn  or 
callosity  first  forms,  and  under  this  a  bursa,  in  which  suppuration 
takes  place,  the  pus  tending  to  travel  not  only  to  the  surface,  but 
also  deeply,  so  as  to  involve  bones  and  joints.  A  typical  per- 
forating ulcer  presents  the  appearance  of  a  sinus  passing  down 
to  the  deeper  parts  of  the  foot,  the  orifice  of  which  is  surrounded 
by  heaped-up  and  thickened  cuticle.  There  is  usually  but  little 
discharge  and  often  no  pain.  If  allowed  to  progress  without 
treatment,  the  bones  and  joints  of  the  foot  may  be  extensively 
destroyed,  or  may  be  welded  together  into  a  solid  painful  mass, 
in  either  case  necessitating  amputation  ;  but  if  taken  in  hand 
early,  a  cure  can  in  some  cases  be  established  by  carefully  paring 
away  the  thickened  mass  of  cuticle,  purifying  the  sinus,  and  pro- 
tecting the  parts  from  pressure. 

A  Wart  (verruca)  is  a  papillary  overgrowth  of  the  skin,  which 
may  manifest  itself  in  many  different  appearances.  The  common 
wart  is  a  horny  projection  about  the  size  of  a  split  pea,  usually 
seen  on  the  hands  of  young  people ;  its  surface  may  be  smooth 
or  irregularly  filiform,  and  its  colour  varies  with  the  amount  of 
dirt  ingrained  on  the  surface.  When  smooth-topped,  they  are 
sometimes  extremely  numerous,  and  may  be  a  little  difficult  to 
distinguish  from  lichen  planus.  In  parts  where  there  is  a  certain 
amount  of   moisture  warts   become  soft   in  character,  and  form 


356  A   MANUAL  OF  SURGERY 


large  vascular  masses,  e.g.,  venereal  warts.     The  best  method  of 
treating  ordinary  warts  is  to  paint  them  with  glacial  acetic  acid, 
or  some  other  caustic,  every  two  or  three  days,  after  softening  and 
removing  the  horny  crust  with  salicylic  acid. 
Verruca  Necrogenica  (see  p.  206). 

Tuberculous  Affections  of  the  Skin. — Lupus. — Although  the  term 
1  lupus '  is  usually  and  correctly  applied  to  a  tuberculous  affection 
of  the  skin,  yet  it  is  also  sometimes  employed  to  indicate  any 
chronic  inflammation  of  the  skin  which  tends  to  spread,  and 
results  in  replacement  of  the  cutaneous  structures  by  fibro- 
cicatricial  tissue  with  or  without  ulceration.  In  this  place  we 
shall  deal  with  the  ordinary  Lupus  Vulgaris,  which  is  universally 
acknowledged  at  the  present  day  to  be  of  tuberculous  origin. 

It  is  met  with  in  children  and  young  adults,  rarely  commencing 
after  the  age  of  thirty.  Its  most  common  situation  is  the  face, 
usually  starting  on  the  nose  or  cheek.  It  is  rare  on  the  scalp, 
but  fairly  frequent  on  the  trunk  and  extremities.  The  mucous 
membrane  of  the  nose  and  mouth  is  also  attacked,  but  in  such 
cases  the  disease  usually  spreads  to  it  from  the  skin.  It  is  rarely 
symmetrical,  except  when  commencing  on  the  nose. 

Clinical  Features. — The  earliest  manifestation  of  lupus  consists 
in  the  formation  of  one  or  more  shot-like  nodules  in  the  deeper 
layers  of  the  skin,  which  are  surrounded  by  a  zone  of  hyperemia 
and  infiltration.  These  nodules  are  not  particularly  hard  to  the 
touch,  but  when  of  any  size  can  be  demonstrated  to  be  of  a 
brownish-yellow  tint,  especially  if  they  are  compressed  by  a 
glass  slide,  appearing  then  somewhat  of  the  colour  of  apple  jelly. 
Gradually  the  process  extends,  and  usually  more  rapidly  in  one 
special  direction,  following  the  course  of  the  vessels.  At  the 
same  time  the  integument  becomes  infiltrated  and  transformed 
into  granulation  or  cicatricial  tissue,  covered  by  a  layer  or  two  of 
epithelium,  and  owing  either  to  degeneration  of  the  tuberculous 
nodules,  or  to  a  lack  of  vitality,  arising  from  compression  of 
the  vessels  by  the  contraction  of  this  new  formation,  ulceration  is 
very  liable  to  follow.  In  the  extremities  the  lupoid  growth  not 
unfrequently  takes  on  a  warty  aspect,  somewhat  similar  to  the 
'  anatomical  wart '  occasionally  seen-  on  the  knuckles  of  post- 
mortem porters,  (p.  206). 

A  Lupoid  Ulcer  usually  spreads  at  one  margin  as  it  heals  at 
the  other,  and  hence  under  typical  circumstances  is  more  or  less 
crescentic  in  shape,  although  this  is  frequently  interfered  with 
by  various  causes.  The  surface  is  covered  with  granulations, 
often  of  a  protuberant  nature.  The  edges  are  raised  and  infil- 
trated, and  scattered  lupoid  tubercles  are  readily  distinguishable, 
extending  into  the  healthy  tissues,  which  are  usually  red  and  con- 
gested. A  considerable  amount  of  sero-pus  is  often  secreted,  and 
this  by  drying  forms  thick  scabs.    Any  cicatrix  which  results  from 


SURGICAL  DISEASES  OF  THE  SKIN 


357 


natural  processes  of  cure  is  thin  and  vascular,  easily  breaking 
down  from  any  slight  irritation.  The  process  extends  gradually, 
with  or  without  intermissions,  from  the  seat  of  its  first  appearance, 
being,  as  a  rule,  distinctly  limited  to  the  cutaneous  tissues ;  but 
when  it  attacks  the  nose,  the  cartilages  are  often  involved  and 
destroyed,  whilst  if  it  extends  to  the  palate  or  septum  nasi, 
perforation  is  very  likely  to  ensue.  The  disease  is  practically 
painless,  and  does  not  at  first  affect  the  general  health.  Neigh- 
bouring lymphatic  glands  may  become  inflamed,  and  in  some  few 
instances  are  the  seat  of  a  tuberculous  deposit.  Even  if  left  to 
itself,  it  tends  sooner  or  later  to  come  to  an  end,  the  ulcerated 
parts  cicatrizing,  but  leaving  indelible  traces  of  its  ravages  in  the 
shape  of  obvious  scars,  with  often  considerable  loss  of  substance. 


;■  •     r, 

Fig.  90. — Spreading  Margin  of  a  Patch  of  Lupus.     (Ziegler.) 

a,  Normal  epidermis  ;  b,  normal  corium  with  sweat  gland  (/)  ;  c,  focus  oi 
lupoid  tissue ;  A,  vascular  nodule  surrounded  by  diffuse  cellular  infiltra- 
tion ;  e,  non-vascular  nodule  ;  /,  strings  of  cells  in  course  of  lymphatics ; 
g,  lupoid  ulcer;  h,  proliferating  epithelium. 

Occasionally  it  persists,  in  spite  of  treatment,  and  then  an 
epithelioma  may  in  time  develop  on  the  site  of  the  mischief, 
running  a  rapid  course  owing  to  the  vascularity  of  the  part. 

Pathological  Anatomy. — The  characteristic  microscopical  feature 
of  lupus  lies  in  the  formation  of  nodules  around  the  smaller  vessels 
of  the  skin,  consisting  chiefly  of  a  mass  of  round  cells,  within 
which  may  perhaps  be  observed  a  giant  cell  and  epithelioid  cells, 
arranged  in  the  same  way  as  in  tubercle.  The  structures  around 
are  infiltrated  and  hyperaemic,  and  as  the  disease  progresses,  the 
original  tissue  of  the  part  disappears,  and  is  replaced  by  granula- 
tion or  fibro-cicatricial  tissue.  The  bacilli  are  by  no  means 
readily  found,  and  are  always  few  in  number  (Fig.  go). 


358  A  MANUAL  OF  SURGERY 

The  Diagnosis  of  lupus  from  syphilitic  and  other  destructive 
affections  of  the  skin  turns  on  the  presence  of  outlying  nodules 
beyond  the  spreading  edge  of  the  lesion,  together  with  the  apple- 
jelly-like  granulations,  and  the  thin,  congested  character  of  any 
cicatricial  tissue  present,  whilst  the  slow,  though  continuous, 
progress,  and  the  tendency  to  heal  at  one  part  as  it  spreads  at 
another,  are  also  suggestive  of  its  presence.  The  age  and  con- 
stitution of  the  individual,  and  the  persistence  of  the  disease  in 
spite  of  treatment,  must  also  be  taken  into  account. 

The  Treatment  of  lupus  is  often  a  matter  of  considerable 
difficulty.  Theoretically,  it  consists  in  the  free  removal  of  all 
the  diseased  tissue,  either  by  the  knife,  sharp  spoon,  or  caustics. 
Wherever  possible,  excision  of  the  whole  mass  should  be  per- 
formed, the  wound  being  either  closed  by  sutures,  or  allowed  to 
heal  by  granulation,  or  covered  by  skin-grafts.  The  last  is  the 
best  plan  to  adopt,  if  practicable,  when  dealing  with  the  face. 
More  commonly  one  has  to  depend  on  scraping  and  the  use  of 
caustics.  This  must  be  undertaken  with  a  free  hand  if  the  whole 
disease  is  to  be  eradicated,  since  the  growth  extends  beneath  the 
layer  of  fibro-cicatricial  tissue  exposed  by  the  spoon.  Hence 
scraping  should  always  be  accompanied  by  the  subsequent  appli- 
cation of  caustics,  e.g.,  solid  nitrate  of  silver,  a  paste  composed 
of  chloride  of  zinc,  pyrogallic  acid  (5  to  10  per  cent.),  or  even 
the  actual  cautery.  The  wound  thus  produced  should  be  dressed 
with  an  ointment  containing  iodoform,  and  allowed  to  heal  by 
granulation.  Outlying  nodules  may  be  removed  with  a  sharp 
lupus-spoon,  and  the  little  cavity  formed  in  this  way  covered  with 
chloride  of  zinc  paste;  or  they  may  be  dug  out  with  the  sharpened 
end  of  a  match  dipped  in  acid  nitrate  of  mercury. 

Recently  excellent  results  have  been  obtained  by  exposing  lupus 
patients  to  concentrated  electric-  or  sun-light  from  which  the 
heat  rays  have  been  eliminated  by  being  passed  through  a  glass 
chamber  full  of  cold  running  water  (Finsen  light  cure).  The  rays 
are  passed  through  what  is  practically  a  telescope  focussed  on  the 
patient's  skin.  Each  sitting  lasts  for  an  hour  or  more,  and  the 
constant  attention  of  an  assistant  is  required  to  slightly  shift  the 
lens  so  as  to  bring  all  parts  of  an  area  about  the  size  of  a  shilling 
under  treatment.  Inflammatory  phenomena  supervene,  and  the 
lupoid  tissue  disappears.  The  process,  though  satisfactory,  is  very 
slow,  owing  to  the  limited  surface  that  can  be  exposed  to  the  light 
at  any  sitting. 

Lupus  Erythematosus  is  a  disease  the  nature  of  which  is  not  yet 
satisfactorily  determined.  The  appearance  of  the  affection  is 
tolerably  characteristic  ;  it  is  usually  situated  on  the  face,  and  in 
the  most  typical  cases  symmetrical  patches  are  formed  over  the 
root  of  the  nose  and  cheeks,  correspoding  in  appearance  to  a 
butterfly  with  outspread  wings.  There  is  a  considerable  tendency 
for  it  to  evade  the  forehead,  ears,  and  scalp,  and  it  occasionally 


SURGICAL  DISEASES  OF  THE  SKIN  359 


appears  on  the  trunk,  and  may  then  be  unilateral.  It  appears 
as  a  smooth  hyperaemic  surface,  covered  with  a  branny  desquama- 
tion ;  the  scales  consist  of  inspissated  sebum,  and  are  continuous 
with  deep  plugs,  which  can  be  traced  into  the  mouths  of  enlarged 
sebaceous  follicles.  As  the  disease  spreads  peripherally,  the  older 
and  central  portions  are  transformed  into  cicatrical  tissue  of  a 
pale,  thin  and  white  type,  in  marked  contrast  to  the  hyperaemic 
condition  of  the  advancing  margin.  It  is  usually  seen  in  adults, 
and  more  frequently  in  women  than  men.  Progress  is  ex- 
ceedingly slow,  and  ulceration  uncommon,  except  when  the  ears 


«/ 


M 


LlViitif  / 1       mmwzmm 


91. — Tuberculous  Ulceration  of  Large  Intestine. 
(Ziegler.) 

a,  Mucosa  ;  b,  submucosa  ;  c,  inner  transverse  muscular  coat ;  d,  outer  longi- 
tudinal muscular  coat ;  e,  serosa  ;  /,  tuberculous  focus  in  solitary  gland  ; 
g,  mucosa  infiltrated  with  cells  ;  h,  tuberculous  ulcer  ;  hu  focus  of  soften- 
ing or  tuberculous  abscess  ;  i,  early  tubercle,  with  giant  cell  in  centre  ; 
iv  caseous  tubercle. 

or  scalp  are  involved ;  in  the  latter  region  the  hair  is  often  lost. 
Epithelioma  has  also  been  known  to  follow  this  affection. 

The  Treatment  consists  in  attention  to  the  general  health,  together 
with  the  local  application  of  weak  tarry  and  mercurial  preparations. 
The  light-cure  acts  rapidly,  but  must  be  used  with  caution,  since 
the  inflammatory  disturbance  caused  by  it  is  considerable. 

The  so-called  Tuberculous  Ulcers  differ  from  the  lupoid  in  the 
fact  that  they  always  result  from  the  breaking  down  of  a  sub- 
cutaneous focus,  and  hence  may  be  connected  with  diseases  of 
bones,  joints,  lymphatic  glands,  or  simply  of  the  connective 
tissues.     A  similar  condition  is  found  in  connection  with  mucous 


360  A   MANUAL  OF  SURGERY 

membranes,  the  tuberculous  foci  starting  in  the  submucosa,  and 
subsequently  bursting  through  the  mucous  membrane  (Fig.  91). 
Whatever  their  location,  the  ulcers  are  characterized  by  the  same 
features,  viz.,  an  irregular  and  ragged  margin  with  undermined 
and  congested  edges  ;  the  base  is  formed  by  pulpy  granulation 
tissue  containing  caseous  masses  of  tubercle  (z'x). 

The  Treatment  necessarily  consists  in  the  removal  both  of  the 
unhealthy  and  undermined  skin,  and  of  the  tuberculous  granula- 
tion tissue  beneath  it,  the  wound  being  purified  by  some  strong 
antiseptic,  and  then  dressed  with  gauze  covered  with  iodoform. 

Other  cutaneous  manifestations  of  tubercle  are  recognized,  but 
need  scarcely  be  mentioned  here. 

Affections  of  the  Nails. 

Onychia  is  almost  always  due  to  the  infection  with  pyogenic  or 
other  organisms  of  the  matrix,  starting  at  the  side  or  base  of  the 
nail  under  the  semilunar  fold.     Two  varieties  are  described  : 

1.  Onychia  Purulenta  (Peri-onychia,  or  Ungual  Whitlow)  is  an 
affection  of  the  matrix  commonly  seen  in  surgeons  and  nurses,  in 
which  suppuration  occurs  beneath  the  nail,  which  is  thereby 
loosened  ;  the  individual  attacked  is  generally  out  of  health.  The 
condition  usually  starts  on  one  side,  and  gradually  extends  round 
the  semilunar  fold  and  beneath  the  nail,  until  the  whole  matrix 
may  be  affected.  When  the  loosened  nail  is  cut  away,  it  is  found 
that  the  diseased  portion  of  the  matrix  is  converted  into  granula- 
tion tissue.  The  process  is  extremely  painful  and  somewhat 
tedious.  The  only  hope  of  checking  its  progress  lies  in  removing 
with  fine  scissors,  possibly  under  an  anaesthetic,  all  the  loosened 
portion  of  the  nail,  and  then  touching  the  exposed  granulations 
with  nitrate  of  silver,  whilst  the  most  comforting  applications  are 
without  doubt  linseed-meal  poultices,  possibly  made  with  hot 
carbolic  lotion  (1  in  40),  and  frequently  repeated.  At  the  same 
time  the  general  health  must  be  attended  to. 

2.  Onychia  Maligna  is  the  term  applied  to  a  somewhat  similar 
condition  met  with  in  badly  nourished  children,  w  ho  are  perhaps 
syphilitic.  The  whole  matrix  is  transformed  into  granulation 
tissue,  whilst  the  digit  becomes  swollen  and  club-shaped.  Treat- 
ment consists  in  avulsion  of  the  nail  from  its  bed,  and  the  applica- 
tion of  antiseptic  fomentations  or  poultices,  together  with  iodoform. 

Ingrowing  Toenail  is  an  ulcerative  condition  of  the  soft  parts 
curling  over  the  side  of  one  of  the  toenails  (usually  that  of  the 
great  toe),  and  due  either  to  the  pressure  of  pointed  or  badly- 
fitting  boots,  or  to  neglect  in  trimming  the  nails.  The  fold  of 
skin  is  thus  pressed  by  the  boot  over  and  against  the  nail  when 
the  patient  walks,  and  in  order  to  diminish  the  pain  and  irritation 
caused  thereby,  he  often  cuts  away  the  projecting  angle  of  the 
nail,  but  leaves  a  deep  corner  which  still  further  irritates  the  soft 


SURGICAL  DISEASES  OF  THE  SKIN  361 


parts.  Ulceration  ensues,  accompanied  by  an  offensive  discharge 
and  so  much  pain  as  to  prevent  the  patient  from  walking.  The 
matrix  of  the  nail  may  also  become  inflamed,  and  onychia  result. 
In  the  earliest  stages,  further  progress  can  often  be  prevented 
by  careful  attention  to  the  nails,  by  the  use  of  square-toed  boots 
fitting  easily,  and  by  introducing  small  plugs  of  aseptic  wool 
to  press  back  the  overhanging  fold  of  skin.  When  ulceration  is 
actually  present,  the  best  plan  to  adopt  is  the  removal  of  the 
affected  half  of  the  nail  under  local  or  general  anaesthesia,  giving 
special  attention  to  the  extraction  of  the  projecting  angle.  If 
there  is  much  discharge,  it  is  also  wise  to  cut  away  the  over- 
hanging fold  of  skin  with  scissors,  and  scrape  away  any  granula- 
tions present.  The  parts  are  then  dressed  antiseptically,  and  in 
a  few  days  the  patient  is  able  to  walk  about. 

The  term  Onychogryphosis  is  applied  to  a  hypertrophic  condi- 
tion of  the  nails,  which  become  distorted  and  bent,  or  twisted  up, 
perhaps  simulating  a  ram's  horn.  It  is  usually  limited  to  the 
great  toes  of  elderly  people,  and  is  due  to  neglect.  The  nails  are 
very  rough,  and  often  covered  with  grooves  or  ridges,  whilst 
beneath  them  is  an  accumulation  of  soft,  offensive  epithelium. 
The  only  treatment  is  removal. 

Affections  of  the  Sebaceous  Glands. 

Sebaceous  Cysts  occur  on  any  part  of  the  surface  of  the  body, 
but  especially  the  scalp,  and  are  due  to  obstruction  of  the  duct  of 
a  sebaceous  gland.  They  are  rounded  swellings,  firm  and  elastic 
to  the  touch,  moveable  on  the  deeper  structures,  and  always 
attached  at  one  spot  to  the  skin.  On  careful  examination,  the 
obstructed  mouth  of  a  sebaceous  follicle  can  usually  be  seen,  and 
possibly  some  of  the  contents  of  the  sac  squeezed  through  this 
opening.  The  cyst  wall  is  formed  by  several  layers  of  epithelium, 
surrounded  by  dense  fibro-cicatricial  tissue,  and  if  exposed  to 
irritation  or  pressure,  as  when  situated  on  the  back  or  shoulder, 
and  rubbed  by  the  braces,  becomes  very  firmly  adherent  to  the 
surrounding  parts.  The  material  contained  within  is  of  a  cheesy, 
pultaceous  consistency,  with  a  peculiar  stale  odour,  yellowish- 
white  in  colour,  and  under  the  microscope  is  seen  to  be  composed 
of  fatty  and  granular  debris,  epithelial  cells,  and  cholesterine. 
Sometimes  a  distinctly  adenomatous  element  is  present,  so  that 
the  cyst  walls  are  thick  and  firm.  Left  to  themselves,  the  cysts 
may  attain  considerable  dimensions,  whilst  the  walls  and  contents 
sometimes  become  calcified.  Occasionally  the  exudation  oozes 
through  the  duct,  and  dries  on  the  surface,  with  just  sufficient 
cohesion  to  prevent  it  from  falling  off;  layer  after  layer  of  this 
desiccated  material  is  deposited  from  below,  finally  giving  rise  to 
what  is  known  as  a  Sebaceous  Horn.  These  become  dark  in 
colour  from  admixture  with   dirt,  and  are  always  more  or  less 


362  A  MANUAL  OF  SURGERY 

fibiillated  in  texture  ;  the  base  to  which  they  are  firmly  adherent  is 
infiltrated  and  hyperaemic.  Sebaceous  cysts  sometimes  inflame 
and  suppurate.  When  the  skin  has  given  way  over  them,  the 
contents  are  only  partly  discharged,  and  the  remainder  undergoes 
putrefactive  changes,  giving  rise  to  an  offensive  ulcerated  surface 
with  raised  edges,  which  may  readily  be  mistaken  for  epithelioma. 
It  is  sometimes  known  as  Cock's  Peculiar  Tumour.  True  malig- 
nant disease  of  an  epitheliomatous  nature  is  said  occasionally 
to  supervene. 

Diagnosis. — From  a  dermoid  cyst  it  is  known  by  the  facts  that 
the  dermoid  is  congenital  in  origin,  that  it  is  limited  to  certain 
localities,  whilst  it  is  hardly  ever  directly  attached  to  the  skin. 
From  a  fatty  tumour  it  is  recognised  by  the  absence  of  lobulation, 
and  by  its  more  solid  character,  whilst  a  lipoma  is  softer  and 
more  moveable  From  a  chronic  abscess  it  is  distinguished  by  the 
existence  of  the  dilated  orifice,  by  its  firmer  consistency,  and  by 
the  history,  but  it  is  sometimes  impossible  to  be  certain  before 
incising  it. 

Treatment. — A  sebaceous  cyst  should  be  entirely  and  completely 
removed  if  giving  rise  to  any  inconvenience  or  pain.  In  the  scalp 
all  that  is  needed  is  to  transfix  the  tumour,  squeeze  out  the  cheesy 
contents,  and  then  the  cyst  wall  can  be  readily  removed  by 
grasping  it  with  dissecting  forceps  and  pulling  it  away.  In  other 
situations  the  cyst  wall  may  require  to  be  dissected  out ;  but  even 
then  it  is  advisable  to  open  it  by  transfixion,  and  to  deal  with  the 
sac  from  below  rather  than  from  above.  Horns  and  fungating 
ulcers  should  be  excised  with  the  surrounding  skin. 

Molluscum  Contagiosum. — This  affection  shows  itself  in  the 
form  of  a  number  of  firm  hemispherical  nodules,  a  little  larger 
than  a  split  pea,  usually  of  a  yellowish-white  colour,  and  very 
definitely  umbilicated.  The  depression  in  the  centre  may  be 
occupied  by  dry  debris,  and  from  the  larger  ones  a  waxy  mass 
may  be  expressed.  They  are  usually  seen  on  the  face,  but  may 
involve  any  part  of  the  surface  of  the  body.  There  seems  no 
doubt  as  to  their  contagious  properties,  this  being  perhaps  best 
seen  in  the  development  of  growths  of  this  nature  on  a  mother's 
breast,  secondary  to  those  on  the  face  of  her  baby.  The  cause 
of  the  contagion  is  by  no  means  certain,  whilst  the  exact  nature 
of  the  affection  is  also  more  or  less  in  dispute,  since,  although 
some  authorities  consider  it  sebaceous  in  origin,  others  are  equally 
insistent  that  it  commences  in  the  hair  follicles  or  deep  layers  of 
the  rete.  Pathologically,  the  tumours  consist  of  numerous  wedge- 
shaped  lobules  of  polygonal,  nucleated,  epithelial  cells,  supported 
by  a  fibrous  stroma.  The  cells  towards  the  centre  undergo  a 
waxy  or  hyaline  degeneration,  and  in  them  are  seen  numerous 
rounded  bodies,  which  have  been  supposed  to  resemble  psoro- 
sperms.  Treatment  consists  in  cutting  or  pulling  them  away,  or 
in  cutting  them  across,  and  squeezing  the  contents  out  from  the 
well-defined  capsule. 


CHAPTER  XV. 

AFFECTIONS  OF  MUSCLES,   TENDONS,  AND  BURSiE. 

Injuries  of  Muscles  and  Tendons. 

Contusion. — Muscles  are  bruised  as  a  result  of  blows  or  falls, 
leading  to  more  or  less  extravasation,  with  possibly  some  rupture 
of  the  fibres.  The  part  becomes  tender  and  swollen,  and  any 
active  contraction  gives  rise  to  pain  ;  passive  movement,  however, 
is  tolerated,  if  the  injured  fibres  are  not  thereby  put  on  the  stretch. 
Fomentations  and  rest  may  be  needed  for  a  few  days  ;  but  friction, 
with  stimulating  embrocations  and  liniments,  and  regular  massage 
of  the  parts,  are  subsequently  necessary. 

Sprains  and  Strains,  due  to  violent  efforts  or  falls,  result  in  the 
tearing  or  stretching  of  some  of  the  fibres.  Considerable  stiffness 
follows,  especially  in  rheumatic  and  gouty  patients.  Rest  and 
either  hot  or  cold  applications  may  be  used  at  first ;  but  friction 
with  liniments  and  passive  movements  will  be  needed  later.  In 
individuals  predisposed  to  the  development  of  tuberculous  disease, 
special  precautions  must  be  taken  to  ensure  complete  recovery. 

Rupture  of  the  Sheath  of  a  muscle  is  an  accident  occasionally 
met  with,  especially  in  the  biceps  cubiti  or  rectus  femoris.  The 
belly  of  the  muscle,  when  contracted,  protrudes  through  the  open- 
ing as  a  hernia,  constituting  a  soft  semi-fluctuating  swelling.  In 
treating  this  condition  the  limb  must  be  kept  at  rest  in  such  a 
position  as  to  relax  the  muscular  fibres  and  allow  the  rent  in  the 
fascia  to  heal.  In  old-standing  cases  it  is  justifiable  to  cut  down 
and  expose  the  opening  in  the  muscular  sheath,  the  edges  of  which 
are  sutured  together. 

Displacement  of  Tendons  rarely  occurs,  except  in  parts  where 
these  structures  pass  through  osseo-fibrous  canals,  and  particularly 
in  those  where  the  line  of  action  is  thereby  changed.  During  some 
violent  effort  the  patient  feels  a  sudden  localized  pain,  followed  by 
a  certain  amount  of  limitation  of  mobility.  This  accident  is  popu- 
larly known  as  a  '  rick.'  In  superficial  parts  the  displaced  tendon 
can  sometimes  be  distinctly  felt  in  an  abnormal  position,  and  this 
becomes  more  evident  on  attempting  to  move  it.     Thus  the  long 


364  A   MANUAL  OF  SURGERY 


tendon  of  the  biceps  may  be  dislocated  from  the  bicipital  groove ; 
and  various  tendons  about  the  wrist  or  ankle,  especially  that 
of  the  peroneus  longus,  may  similarly  suffer.  If  left  alone,  the 
parts  settle  down  more  or  less  comfortably,  but  some  permanent 
weakness  may  persist ;  whilst  recurrence  is  very  likely  to  ensue 
if  movement  is  permitted  before  the  newly-formed  connections 
have  had  time  to  consolidate. 

Treatment  consists  in  fully  relaxing  the  muscles  and  replacing 
the  tendon,  if  possible,  by  manipulation.  The  parts  are  then 
immobilized  and  well  supported,  as  by  a  plaster  of  Paris  splint  or 
strapping,  and  this  should  be  maintained  for  six  or  eight  weeks. 
If  the  displacement  recurs,  as  is  commonly  the  case  where  such 
treatment  has  not  been  adopted,  it  is  sometimes  advisable  to  cut 
down,  expose  the  tendon,  and  stitch  it  back  into  position,  using 
early  passive  movement  to  prevent  the  formation  of  troublesome 
adhesions.  This  is  required  most  frequently  in  the  case  ot 
the  peroneus  longus  tendon,  which  slips  forwards  from  its  groove 
behind  the  external  malleolus.  The  external  annular  ligament  is 
thereby  ruptured,  and  the  operation  consists  either  in  suturing 
the  divided  segments,  or  in  more  aggravated  cases  it  may  be 
necessary  to  turn  down  a  flap  of  periosteum  from  the  malleolus 
and  by  stitching  its  apex  to  the  outer  side  of  the  os  calcis  secure 
the  tendon  in  place. 

Eupture  of  Muscles  and  Tendons  is  by  no  means  an  uncommon 
accident,  resulting  from  any  excessive  violence  of  a  sudden  and 
unexpected  nature.  Most  frequently  the  tendon  gives  way  at  its 
union  with  the  muscular  belly  ;  less  often  the  belly  itself  yields, 
whilst  occasionally  the  tendon  may  snap,  or  the  point  of  bone  to 
which  it  is  attached  may  be  torn  off. 

Signs. — The  patient  at  the  moment  of  the  accident  experiences 
a  sharp  and  severe  pain,  as  if  he  had  been  struck  with  a  whip ;  he 
may  also  feel  or  hear  a  snap.  Loss  of  function  follows,  together 
with  a  certain  amount  of  swelling  and  bruising,  which  is  more 
evident  if  the  muscular  fibres  have  been  torn  across  than  if  the 
tendon  has  alone  been  lacerated.  On  attempting  to  contract  the 
affected  muscle,  the  belly  rises  up  as  a  soft,  rounded,  semi- 
fluctuating  tumour,  drawn  towards  the  uninjured  attachment,  if 
the  union  between  the  tendon  and  belly  has  given  way ;  whilst  if 
the  lesion  has  been  through  the  muscular  substance,  the  divided 
halves  of  the  belly  become  similarly  prominent,  and  a  distinct  gap 
or  sulcus  can  be  felt  between  them. 

Repair  is  established  in  the  usual  way  already  described  (p.  209), 
viz.,  a  cellulo-plastic  effusion  is  first  poured  out,  taking  the  place 
of  the  blood-clot,  which  is  absorbed  ;  this  becomes  vascularized 
into  granulation  tissue,  and  finally  cicatricial  tissue  is  developed. 
Where  a  muscular  belly  is  involved  and  the  ends  are  much 
separated,  a  lon<^  and  weak  bond  of  union  is  likely  to  form  ;  but 
when  they  are  closely  apposed,  the  cicatrix  is  a  short  one,  and  may 


AFFECTIONS  OF  MUSCLES,  TENDONS,  AND  BURS&         365 


sooner  or  later  be  replaced  by  true  muscular  tissue.  When  a 
tendon  has  been  divided  or  torn,  the  connecting  medium  is  at 
first  attached  to  the  sheath,  and  if  this  adhesion  persists,  it  may 
lead  to  much  pain  and  weakness.  It  is  an  exceedingly  interest- 
ing fact  to  note  how  rapidly  this  tissue  attains  a  considerable 
degree  of  strength ;  a  rabbit's  tendon  ten  days  after  division 
requires  a  weight  of  56  lbs.  to  break  it  (Paget). 

Treatment. — It  is  essential  to  relax  the  parts  fully  so  as  to 
prevent  separation  of  the  divided  ends,  and  to  maintain  them  in 
this  position  for  two  or  three  weeks.  Any  resulting  stiffness  is 
combated  by  passive  movements  and  mas- 
sage, whilst,  if  need  be,  adhesions  are 
broken  down  under  an  anaesthetic.  Tendons 
accidentally  divided  in  open  wounds  should 
be  sutured  together  by  catgut,  special  anti- 
septic precautions  being  adopted  to  prevent 
suppuration  along  the  tendon  sheaths. 
Where  there  has  been  actual  loss  of  sub- 
stance in  a  tendon,  it  is  possible  to  remedy 
the  defect  by  grafting  a  portion  of  tendon 
from  another  patient,  or  from  an  animal, 
between  the  two  ends ;  or,  again,  one  end 
may  be  split  longitudinally  in  such  a  way  as 
to  leave  a  thin  flap  attached  peripherally,  so 
that  the  free  end  (a)  can  be  turned  down  and 
united  to  the  other  segment  (Fig.  92).  Care 
must  be  exercised  to  prevent  opposing  mus- 
cles from  dragging  on  and  stretching  the  new 
bond  of  union,  as  thereby  considerable  func- 
tional disability  may  result.  Thus  a  young 
man  had  his  anterior  tibial  muscles  divided 
by  a  stab  with  a  knife  ;  they  were  carefully 
sutured  together,  but  during  convalescence 
the  foot  was  allowed  to  drop,  the  result 
being  that  the  muscles  and  tendons  Avere 
stretched,  and  hence  the  most  vigorous  contractions  had  no  effect 
in  raising  the  toes,  which  dragged  along  the  ground.  A  second 
operation  to  shorten  all  these  structures  was  required. 

When  muscular  bellies  have  been  divided,  it  is  not  difficult  to 
secure  them,  if  the  fibres  have  been  severed  longitudinally  or 
obliquely  ;  but  when  the  section  is  transverse,  there  is  a  great 
tendency  for  the  stitches  to  cut  out.  In  such  a  case  it  is  advisable 
to  encircle  with  a  ligature  a  bundle  of  muscular  fibres  on  either 
side  of  the  incision,  and  then  tie  the  two  threads  together.  This 
must  be  done  at  several  spots  in  the  cross-section. 

The  long  tendon  of  the  biceps  is  not  unfrequently  torn  from  the 
muscular  belly,  which,  on  attempting  to  bend  the  arm,  is  drawn 
down  towards  the  elbow,  constituting  a  soft  tumour,  somewhat 


Fig.  92.. — Method  of 
Uniting  Tendon 
after  Loss  of 
Tissue  by  Turning 
Down  a  Portion  of 
it  as  a  Flap. 


366  A   MANUAL  OF  SURGERY 

resembling  a  lipoma,  No  special  treatment  is  needed  beyond 
keeping  the  forearm  flexed  for  a  time.  If  the  tendo  A  chillis  is 
ruptured,  union  may  be  attained  by  keeping  the  knee  bent  and 
the  heel  raised,  as  by  securing  a  strap  to  the  back  of  a  slipper 
below,  and  to  a  dog-collar  passed  round  the  knee  above.  A  better 
result,  however,  would  follow  an  aseptic  incision  and  suture. 
Similarly,  if  the  ligamentum  patella  gives  way,  suture  through  an 
open  wound  is  more  satisfactory  than  mere  elevation  of  the  leg 
and  rest.  The  inner  head  of  the  gastrocnemius  is  sometimes  torn  in 
wrenches  or  slips,  as  at  lawn  tennis,  and  the  plantaris  is  similarly 
affected.  Cooling  lotions  are  applied  for  a  few  days,  and  the  parts 
are  kept  at  rest  until  the  tenderness  and  swelling  have  subsided 
in  part,  and  then  regular  massage  is  undertaken.  The  adductor 
longus  may  be  lacerated  in  violent  attempts  to  maintain  a  seat  on 
horseback,  and  constitutes  one  form  of  rider's  sprain  ;  it  is  treated 
by  rest  and  the  application  of  a  firm  spica  bandage. 

Diseases  of  Muscles. 

Inflammation  of  Muscles  (Myositis)  may  arise  from  a  variety  of 
circumstances,  but  the  chief  results  are  alike,  whatever  the  cause, 
viz.,  a  more  or  less  painful  infiltration  of  the  muscle,  with  in- 
creased discomfort  on  attempting  movement.  The  part  feels 
hard  and  rigid,  and  may  be  tender  to  the  touch.  If  suppura- 
tion ensues,  the  ordinary  signs  of  an  abscess  subsequently  make 
themselves  evident.  A  certain  amount  of  contractile  tissue  is 
thereby  destroyed,  and  the  cicatricial  changes  induced  will 
possibly  lead  to  deformity. 

Varieties. — i.  Simple  Traumatic  Myositis  results  from  contusion 
or  laceration  of  the  fibres,  and  is  merely  a  plastic  inflammation, 
with  or  without  haemorrhage,  running  on  to  resolution,  with 
perhaps  a  little  fibroid  thickening  of  the  part.  It  is  liable  in  some 
cases  to  become  chronic,  the  muscle  substance  becoming  shortened 
and  replaced  by  fibrous  tissue  (M.  fibrosa),  and  this  fibrosis  may 
extend  beyond  the  limits  of  the  original  lesion.  The  induration 
of  the  sterno-mastoid  muscle  met  with  in  children  is  of  this  type, 
and  may  lead  to  torticollis.  In  other  cases  ossification  of  a  limited 
portion  of  the  muscle  or  tendon  may  occur  from  long-continued 
and  frequently-repeated  irritation ;  thus,  in  riders  the  upper 
portion  of  the  adductor  tendons  may  in  this  way  become  bony, 
constituting  the  so-called  '  riders'  bone.' 

2.  Rheumatic  Myositis  usually  results  from  exposure  to  cold, 
e.g.,  wry  neck  from  sitting  in  a  draught.  It  is  treated  by  fomenta- 
tions, and  ordinary  saline  anti-rheumatic  remedies,  whilst  later 
on  friction  with  stimulating  embrocations  is  needed. 

3.  Acute  Suppurative  Myositis  is  the  outcome  of  infection  with 
pyogenic  organisms,  either  from  without,  as  after  operation 
wounds,  punctures,  gun-shot  injuries,  gangrene,  etc.,  the  pus  in 
such  cases  spreading  widely  up  and  down  the  muscular  planes  ; 


AFFECTIONS  OF  MUSCLES,  TENDONS,  AND  BURSA?        367 


or  from  within  the  body,  as  in  pyaemia ;  or  by  extension  from 
neighbouring  suppurative  foci,  as  from  sub-periosteal  abscesses  ; 
it  may  also  arise  after  a  contusion  or  sprain  by  auto-infection. 
Great  cicatricial  deformity  is  likely  to  follow. 

4.  Chronic  Tuberculous  Myositis,  with  the  formation  of  a  chronic 
abscess,  is  not  an  uncommon  secondary  consequence  of  a  similar 
affection  of  neighbouring  bones  or  joints — e.g.,  a  psoas  abscess. 

5.  Syphilitic  Disease  is  usually  met  with  in  the  tertiary  period, 
and  takes  the  form  either  of  a  diffuse  sclerosis  or  of  a  localized 
gumma.  Any  muscle  may  be  affected,  but  perhaps  the  tongue 
and  sterno-mastoid  are  those  most  frequently  involved.  Care  is 
needed  in  making  a  diagnosis,  since  these  conditions  resemble 
tumours  in  their  method  of  onset ;  but  the  presence  of  a  syphilitic 
history,  the  slow  growth,  the  hardness  with  subsequent  central 
softening,  and  the  rapid  disappearance  after  the  administration  of 
iodide  of  potassium,  should  suffice  to  determine  their  nature. 

Occasionally  gummata  appear  in  muscles  in  the  shape  of 
small  hard  and  shotty  nodules,  usually  arranged  more  or  less 
longitudinally,  which  are  painless  and  apparently  attached  to 
the  fascial  sheath.     They  react  readily  to  iodide  of  potassium. 

6.  Parasitic  Myositis,  arising  from  the  presence  of  either  the 
Trichina  spiralis  or  of  hydatids,  need  not  be  described  here. 

7.  Myositis  Ossificans  is  a  rare  disease,  in  which  various  muscles, 
especially  those  of  the  back,  are  transformed  into  bony  plates  or 
rods,  so  as  to  lead  to  extensive  ankylosis.  The  process  seems  to 
be  one  of  ossification  of  the  connective  tissue  associated  with 
atrophy  of  the  muscular  fibres,  and  is  sometimes  extremely 
painful.  It  is  most  commonly  seen  in  young  males,  and  is 
possibly  rheumatic  in  origin.  In  a  boy  recently  under  observa- 
tion the  arms  were  immobilized  by  ossification  of  the  Latissimus 
dorsi  muscles  on  either  side,  whilst  the  Pectoralis  major  was  also 
ossified  on  the  right  side.  The  Erector  spinas  was  involved,  the 
back  being  thus  rendered  rigid,  and  the  right  Trapezius  was 
undergoing  the  same  change.  This  disease  is  not  unusually  asso- 
ciated with  a  congenital  deformity  of  the  great  toes  in  which  the 
proximal  phalanx  is  absent  or  stunted.  No  treatment  has  proved 
of  any  value. 

Tumours  of  Muscles  are  not  very  common.  Primary  growths 
consist  of  angioma,  fibroma,  chondroma,  myxoma,  or  sarcoma, 
and  of  these  the  majority  start  in  the  fibrous  sheaths  or  the  inter- 
fibrillar  connective  tissue.  Secondary  deposits  of  both  carcinoma 
and  sarcoma  occur,  but  there  is  nothing  special  to  be  noted  about 
them. 

Treatment  must  be  determined  on  ordinary  surgical  principles. 
If  sarcomatous,  the  whole  thickness  of  the  muscle  should,  if 
possible,  be  excised  for  some  distance  from  the  growth,  the  sheath 
forming  a  natural  limit  not  early  overstepped.  Amputation  of 
the  limb  may,  however,  be  required. 


368  A  MANUAL  OF  SURGERY 


Diseases  of  Sheaths  of  Tendons. 

The  synovial  membranes  which  line  the  sheaths  of  tendons 
may  become  inflamed  as  a  result  of  injury  or  infection. 

1.  Acute  Simple  Teno  Synovitis  often  follows  sprains  and 
stiains,  and  is  most  commonly  seen  in  connection  with  the 
extensor  muscles  of  the  thumb.  A  puffy  swelling  in  the  course  of 
the  tendons  is  produced,  painful  on  movement  and  perhaps  tender 
to  the  touch,  giving  a  characteristic  fine  crepitus  whenever  the  parts 
are  moved.  All  that  is  needed  for  its  Treatment  is  to  immobilize 
the  limb  for  a  few  days,  and  apply  fomentations.  As  soon  as  the 
more  acute  symptoms  have  disappeared,  friction  with  stimulating 
embrocations  and  pressure  are  employed  to  hasten  the  absorption 
of  the  fluid  :  whilst  active  and  passive  movements  are  undertaken 
to  prevent  the  formation  of  adhesions. 

2.  Acute  Suppurative  Teno-Synovitis  may  result  from  a  punc- 
tured wound  of  the  synovial  sheath,  or  the  inflammation  may 
spread  to  it  from  neighbouring  tissues.  The  thecal  variety  of 
whitlow  (p.  208)  is  of  this  nature.  Suppuration  may  extend  both 
up  and  down  the  sheath,  and  gives  rise  to  both  local  and  con- 
stitutional symptoms.  Unless  promptly  treated  by  incision,  the 
tendon  will  slough,  or  may  contract  extensive  adhesions  to 
neighbouring  parts ;  in  either  case  considerable  impairment  of 
function  follows.  The  suppuration  may  extend  to  neighbouring 
articulations,  leading  to  their  disorganization,  especially  in  the 
case  of  the  tendon  sheaths  around  the  wrist-joint. 

3.  Chronic  Simple  "Teno- Synovitis  is  a  common  affection,  charac- 
terized by  a  passive  effusion  into  the  tendon  sheath  of  glairy 
synovia,  somewhat  resembling  uncooked  white  of  egg.  It  may  be 
limited  in  extent,  constituting  one  of  the  varieties  of  ganglion,  or 
diffuse.  An  elastic  fluctuating  swelling  forms  in  the  course  of  a 
tendon,  usually  associated  with  creaking.  There  is  no  pain  or 
tenderness,  but  the  affected  part  feels  weak.  Treatment  consists 
in  counter-irritation  and  pressure,  as  by  Scott's  dressing  ;  failing 
this,  the  part  may  be  freely  incised,  the  synovia  removed,  and,  if 
need  be,  the  cavity  washed  out.  In  the  more  localized  forms  it 
may  suffice  to  puncture  the  cyst-like  swelling  and  squeeze  out  the 
contents,  pressure  being  subsequently  applied. 

4.  Chronic  Tuberculous  Teno-Synovitis  is  of  two  types.  In 
one  the  sheath  fe  lined  by  cedematous  granulation  tissue  of 
some  thickness,  containing  tuberculous  foci,  giving  rise  to  a  soft 
elastic  swelling  along  the  course  of  a  tendon,  which  increases 
slowly  in  size,  and  is  but  slightly  painful  or  tender.  Suppura- 
tion may  follow,  and  subjacent  bones  or  joints  be  involved. 
Treatment  consists  in  immobilizing  the  part,  pressure,  and  im- 
provement   of    the    general    health.     If   a    cure    is    not    quickly 


AFFECTIONS  OF  MUSCLES,  TENDONS,  AND  BURSJE         369 

established,  a  free  incision  should  be  made  and  the  diseased 
tissue  removed. 

The  other  form  of  tuberculous  disease  consists  in  a  passive 
effusion  into  the  synovial  space,  the  lining  membrane  of  which 
becomes  thickened  by  the  deposit  thereon  of  fibrinous  material. 
At  the  same  time  there  is  usually  a  large  development  ot  the  so- 
called  melon-seed  bodies,  which  are  laminated  masses  of  fibrin, 
perhaps  containing  traces  of  tuberculous  giant-cell  systems.  When 
numerous  they  give  rise  to  a  curious  and  characteristic  form  of 
crepitus.  That  they  are  of  a  tuberculous  nature  can  be  demon- 
strated by  inoculation  experiments  ;  the  spores  or  bacilli  contained 
therein  are  not,  however,  in  a  very  active  state. 

If  Treatment  by  immobilization  and  pressure  (as  by  the  appli- 
cation of  Scott's  dressing)  fails,  the  part  should  be  laid  open, 
and  the  effused  fibrin  and  melon-seed  bodies  removed,  together 
with  as  much  of  the  thickened  membrane  as  possible. 

A  Ganglion  is  the  term  given  to  a  localized  cyst-like  swelling 
forming  in  connection  with  a  tendon  sheath.  It  is  most  commonly 
met  with  at  the  back  of  the  wrist,  arising  from  the  tendons  of  the 
thumb  or  index-finger,  but  it  sometimes  occurs  on  the  front  of  the 
wrist  or  in  the  foot.  It  varies  in  size  considerably,  and  contains 
a  clear,  transparent  gelatinous  or  colloid  substance,  like  white- 
currant  jelly.  A  rounded  firm  elastic  swelling  is  produced,  usually 
somewhat  moveable,  and  neither  painful  nor  tender  at  first, 
although  some  painful  weakness  of  the  part  may  be  experienced 
as  it  increases  in  size.  It  is  due  to  one  of  several  causes  :  thus, 
it  may  result  from  a  chronic  localized  teno-synovitis,  or  from 
a  hernial  protrusion  of  the  synovial  membrane  through  an  opening 
in  the  tendon  sheath.  Others  seem  to  originate  in  a  colloid  de- 
generation of  the  cells  lining  the  synovial  space ;  whilst  certainly 
some  few  arise  in  connection  with  subjacent  articulations,  in  the 
same  way  as  a  Baker's  cyst.  Little  difficulty  arises  in  the 
diagnosis,  although,  when  situated  deeply  and  lying  over  a  bone, 
they  have  been  mistaken  for  exostoses. 

Treatment. — A  ganglion  may  often  be  ruptured  by  manipulation 
and  pressure  with  the  thumbs,  or  by  a  forcible  blow  with  a  book, 
but  it  is  apt  to  fill  again.  Failing  this,  a  rapid  cure  is  usually 
obtained  by  an  aseptic  puncture  of  the  cavity,  and  the  subsequent 
application  of  firm  pressure.  In  some  cases  it  may  be  advisable 
to  lay  the  part  open  and  remove  the  cyst  wall ;  such  treatment 
requires  absolute  asepsis,  since,  if  infection  occurs,  most  serious 
consequences  may  ensue. 

A  Compound  Palmar  Ganglion  consists  in  a  tuberculous  affection 
of  the  common  synovial  membrane  surrounding  the  flexor  tendons 
of  the  wrist,  the  cavity  being  distended  with  synovia,  usually 
containing  many  melon-seed  bodies.  It  forms  a  large  swelling 
extending  above  and  below  the  wrist,  fluctuation  being  readily 
transmitted   from   one    part    to    the    other    beneath    the    annular 

24 


370 


A   MANUAL  OF  SURGERY 


ligament;  it  also  extends  amongst  the  muscles  of  the  thenar 
eminence  along  the  tendon  of  the  flexor  longus  pollicis.  In  the 
treatment  rest  and  pressure,  as  by  Scott's  dressing,  together  with 
suitable  constitutional  remedies,  may  first  be  tried ;  and  failing 
this,  an  incision  should  be  made  both  above  and  below  the 
annular  ligament,  the  cavity  being  well  washed  out,  and  all 
melon-seed  bodies  and  fibrinous  debris  removed  with  a  sharp 
spoon  ;  a  drainage-tube  is  subsequently  inserted.  In  a  few  cases 
it  may  be  necessary  to  divide  the  annular  ligament  in  order  to 
efficiently  deal  with  the  trouble.  The  results,  however,  are  not 
very  good,  as  the  tendons  get  matted  together  and  adherent  to 
the  skin,  and  the  movement  of  the  fingers  is  thereby  hampered. 

Operations  on  Tendons. 

i.  By  Tenotomy  is  meant  the  division  of  a  tendon  through  an 
open  or  subcutaneous  wound  with  the  object  either  of  remedying 
some  deformity,  such  as  talipes  or  torticollis,  or  of  assisting  the 
surgeon  to  reduce  some  displacement,  as  in  setting  a  fracture  ; 
thus,  the  tendo  Achillis  may  require  division  in  fractures  of  the 
leg  in  order  to  overcome  muscular  contraction. 

Division  of  tendons  is  accomplished  in  two  ways,  viz.,  by  sub- 
cutaneous or  open  incision.  The  subcutaneous  method  is  made 
use  of  where  there  is  little  likelihood  of  injuring  important 
structures.  The  strictest  attention  to  asepsis  is  desirable,  since 
the  character  of  the  wound,  viz.,  a  puncture,  and  the  entire 
absence  of  drainage,  are  most  favourable  to  the  development  of 
organisms,  if  entrance  is  once  given  to  them.  Moreover,  the 
synovial  tendon  sheath  is  often,  though  undesignedly,  wounded, 
and  septic  inflammation  would  rapidly  spread  along  this  structure, 
and  give  rise  to  the  most  serious  consequences.  The  operation 
consists  in  inserting  a  sharp-pointed  tenotome  through  the  skin 
down  to  the  tendon.  This  is  then  withdrawn,  and  a  blunt-pointed 
knife  passed  along  the  track  thus  made,  either  superficial  to  or 
beneath  the  tendon.  The  cutting  edge  is  turned  towards  it,  and 
the  tendon  divided  by  a  sawing  or  rocking  movement,  whilst  the 
structure  is  put  on  the  stretch  by  an  assistant.  Every  effort  must 
be  made  to  avoid  opening  the  sheath,  since  even  if  the  wound 
remains  aseptic,  the  tendon  often  retracts  more  than  is  desirable, 
and  in  healing  gains  adhesions  to  the  sheath  which  considerably 
limit  the  subsequent  freedom  of  movement  of  the  part.  Various 
opinions  are  entertained  as  to  whether  it  is  better  to  pass  the 
knife  above  or  below  the  tendon  ;  the  advantages  of  the  former 
method  are  that  there  is  no  likelihood  of  making  an  unduly  large 
wound  in  the  skin,  and  that  there  is  less  risk  of  dividing  the  lax 
subjacent  structures  if  the  knife  is  turned  towards  them.  On  the 
other  hand,  if  the  knife  is  at  once  passed  be1ow  the  tendon,  and 
any  such    subjacent   structures   are   by  mistake   included,   their 


AFFECTIONS  OF  MUSCLES,  TENDONS,  AND  BURS.E         371 

division  is  a  matter  of  certainty.  Where,  however,  there  is  any 
risk  of  dividing  important  structures,  such  as  the  external  popliteal 
nerve  in  tenotomy  of  the  biceps  cruris,  it  is  wiser  to  adopt  the 
open  method.  In  this  an  incision  about  1  inch  in  length  is  made 
over  the  tendon,  which  can  thereby  be  exposed,  lifted  on  an 
aneurism  needle,  and  severed  without  danger.  There  is  no 
haemorrhage  worth  mentioning,  and  the  wound  is  closed  by  a 
point  or  two  of  suture,  dressed  antiseptically,  and  firmly  bandaged 
to  prevent  extravasation.  The  malposition  is  at  once  corrected, 
and  the  part  immobilized  at  the  time,  or  in  the  course  of  forty- 
eight  hours,  in  plaster  of  Paris. 

Tenotomy  of  the  Tendo  A  chillis. — The  foot  is  placed  on  its  outer 
side,  and  the  tendon  relaxed  by  pointing  the  toes  downwards. 
The  tenotome  is  introduced  about  1  inch  above  its  insertion 
(Fig.  76,  F)  at  the  inner  margin  of  the  tendon,  either  superficial 
to  or  beneath  it,  and  it  is  readily  divided  when  the  foot  is  dorsi- 
flexed.  If  the  surgeon  cuts  towards  the  skin,  he  must  be  careful 
not  to  divide  the  last  few  fibres  too  rapidly,  otherwise  a  con- 
siderable external  wound  may  be  inflicted  by  the  suddenly 
liberated  knife. 

The  Tibialis  Anticus  is  usually  divided  about  1  inch  above  its 
insertion,  as  it  crosses  the  scaphoid  (Fig.  78,  C).  There  is  here 
no  synovial  sheath,  and  the  arteria  dorsalis  pedis  is  separated 
from  it  by  the  tendon  of  the  extensor  proprius  hallucis.  It  is 
first  relaxed  so  as  to  allow  of  the  introduction  from  the  outer  side 
of  the  sharp-pointed  tenotome  beneath  it  ;  this  is  then  replaced  by 
a  blunt-ended  instrument,  and  the  section  is  readily  accomplished 
when  the  foot  is  abducted.  The  open  method  may  be  adopted  in 
some  cases. 

The  Tibialis  Posticus  is  usually  divided  together  with  the  flexor 
longus  digitorum  just  above  the  base  of  the  inner  malleolus,  at  a 
spot  about  a  finger's  breadth  from  the  tip  of  that  process  in  an 
infant,  and  about  1^  inches  from  it  in  an  adult  (Fig.  76,  E).  A 
small  tubercle  can  usually  be  felt  at  this  spot,  and  the  section 
must  be  made  just  above.  The  knife  is  inserted  between  the 
tibia  and  the  tendon,  and  is  kept  as  near  the  bone  as  possible.  If 
correctly  placed,  it  remains  fixed  without  the  support  of  the  hand, 
being  grasped  between  the  tendon  and  the  bone.  The  blunt- 
ended  tenotome  is  then  introduced,  and  the  edge  being  turned 
towards  the  tendon,  the  latter  structure  is  divided  when  the  foot 
is  dorsiflexed.  The  posterior  tibial  vessels  may  be  wounded  if 
the  tendons  are  too  suddenly  severed,  but  even  should  this  occur, 
a  little  well-adjusted  pressure  will  suffice  to  prevent  any  serious 
consequences. 

The  Peronei  tendons  are  divided  just  above  the  base  of  the  outer 
malleolus,  at  a  spot  where  the  synovial  sheath  is  usually  absent 
(Fig.  77,  D).  The  tenotome  is  inserted  close  to  the  fibula, 
between  the  tendons  and  the  bone. 

24 — 2 


372 


A  MANUAL  OF  SURGERY 


The  Biceps  Cruris  tendon  is  best  divided  by  an  open  operation, 
on  account  of  the  close  propinquity  of  the  external  popliteal 
nerve,  which  has  often  been  wounded  in  the  subcutaneous 
operation.  An  incision  is  made  in  the  direction  of  the  tendon 
just  above  its  insertion  into  the  fibula.  It  is  then  lifted  upon  an 
aneurism  needle  and  divided  ;  muscular  fibres  will  probably  be 
found  quite  close  to  its  lower  end. 

The  Semimembranosus  and  the  Semitendinosus  tendons  are  dealt 
with  just  above  the  knee-joint,  and  the  subcutaneous  operation 
may  be  conveniently  adopted  when  they  are  prominent  and  tense. 

For  division  of  the  Stemo -mastoid,  see  p.  380). 

2.  Lengthening  a  Tendon  is  sometimes,  though  rarely,  required, 


ft 


n 


Fig.  93.  Fig.  94.  Fig.  95. 

Figs.  93,  94  and  95. — Z-Operation  for  Lengthening  or  Shortening 
of  Tendons. 

In  Fig.  93  the  method  of  dividing  the  tendon  is  shown.  In  Fig.  94  the  flaps 
are  slipped  downwards,  one  on  the  other,  so  as  to  lengthen  the  tendon. 
In  Fig.  95  equal  portions  have  been  cut  away  from  each  half,  and  the 
remainders  sutured,  so  as  to  shorten  it. 


in  order  to  overcome  the  deformity  which  results  from  a  con- 
tracted tendon.  It  may  be  possible  to  utilize  the  method  sug- 
gested on  p.  365  for  the  union  of  a  tendon  where  there  has  been 
loss  of  substance,  viz.,  by  bridging  the  interval  by  a  flap  turned 
down  from  one  end.  Perhaps  a  more  efficient  method  is  the 
so-called  Z-operation  (Fig.  93).  The  tendon  is  split  longi- 
tudinally into  two  halves  (be),  which  are  separated  one  from  the 
other  by  cross  cuts  made  on  opposite  sides,  one  at  each  end  (ab 
and  cd).  The  two  flaps  are  then  drawn  apart  for  a  distance 
corresponding  to  the  increase  in   length    required,   and   sutured 


AFFECTIONS  OF  MUSCLES,  TENDONS,  AND  BURSM         373 


together ;  the  resulting  bond  of  union  will  be  as  represented  in 
Fig.  94. 

3.  Shortening  a  Tendon  is  undertaken  in  some  forms  of  paralytic 
talipes.  The  Z-method  may  also  be  employed  here,  the  two 
halves,  after  they  have  been  separated,  being  shortened  to  the 
required  amount,  and  then  stitched  together  (Fig.  95).  This 
operation  will  probably  give  a  more  solid  bond  of  union  than  the 
simpler  proceedings  in  which  either  a  transverse  or  an  oblique 
section  is  removed,  and  the  ends  sutured  together  ;  in  such  the 
sutures  are  much  more  likely  to  cut  out. 

4.  Tenoplasty,  or  the  incorporation  of  a  strong  tendon  into  a 
weaker  one  in  order  to  strengthen  it,  is  rarely  undertaken  except 
in  talipes,  and  more  particularly  in  order  to  reinforce  a  weak 
tendo  Achillis  in  paralytic  talipes  calcaneus,  by  joining  to  it  a 
strong  and  healthy  peroneus  longus.  In  order  to  make  an 
effective  bond  of  union,  the  healthy  tendon  must  be  threaded 
through  the  weak  and  atrophic  one,  and  fixed  by  sutures  in 
several  places. 

Diseases  of  Bursae. 

Bursae  exist  as  normal  structures  in  many  parts  of  the  body 
exposed  to  pressure,  their  object  being  to  diminish  friction  and 
permit  of  a  gliding  movement.  Similar  cavities,  known  as 
abnormal  or  Adventitious  Bursae,  are  developed  in  regions  where 
exceptional  pressure  is  brought  to  bear  on  some  prominent 
structure ;  they  consist  of  a  fibrous  wall  lined  by  a  serous 
membrane,  contain  a  small  quantity  of  serum,  and  are  formed 
either  by  dilatation  of  lymphatic  spaces,  or  as  a  result  of  a 
localized  effusion  into  the  tissues.  Examples  of  this  are  met 
with  in  men  following  special  occupations ;  e.g.,  over  the  vertebra 
prominens  of  Covent  Garden  porters,  and  then  known  as  a 
'  hummy '  ;  Billingsgate  fish-carriers  occasionally  have  bursae 
under  the  centre  of  the  scalp  ;  and  deal  runners  often  present 
one  on  the  upper  part  of  the  shoulder.  They  occur  over  bony 
prominences  arising  from  malformation  or  displacement,  e.g.,  over 
the  cuboid,  in  talipes  equino-varus ;  over  the  internal  condyles  of 
the  femora,  in  bad  cases  of  genu  valgum ;  whilst  the  false  joint 
or  pseudarthrosis  which  occurs  in  unreduced  dislocations  or 
ununited  fractures  is  practically  of  this  nature. 

Wounds  of  bursae  may  be  caused  by  penetrating  injuries,  or 
sometimes  by  the  skin  over  them  splitting,  as,  e.g.,  in  a  fall  on 
the  point  of  the  olecranon.  The  escape  of  bursal  fluid  which 
results  often  prevents  healing,  and  then  it  will  be  necessary  either 
to  excise  the  bursa,  or  to  open  it  freely  so  that  it  can  be  stuffed 
and  made  to  granulate  from  the  bottom. 

The  following  are  the  morbid  conditions  which  arise  in  ad- 
ventitious as  well  as  normal  bursae  : 


374  A  MANUAL  OF  SURGERY 


i.  Acute  Simple  Bursitis  may  result  from  a  non-penetrating 
injury,  or  from  prolonged  irritation,  especially  in  gouty  or  rheu- 
matic individuals.  The  part  becomes  swollen,  painful,  and  tender, 
and  if  superficial  the  skin  over  it  may  be  hypersemic.  Effusion 
into  the  cavity  quickly  occurs,  the  fluid  being  spontaneously 
coagulable  in  the  early  stages,  and,  if  resulting  from  traumatism, 
mixed  with  blood.  Lymph  is  deposited  on  the  serous  surface, 
and  in  many  cases  results  in  the  formation  of  adhesions,  and 
possibly  obliteration  of  the  cavity.  Treatment  consists  in  keeping 
the  part  at  rest,  and  applying  fomentations,  whilst  suitable  con- 
stitutional remedies  are  administered.  If  the  effusion  persists, 
aspiration,  or  removal  with  trocar  and  cannula  under  strict 
asepsis,  may  be  employed,  or  even  the  whole  cavity  excised. 

2.  Acute  Suppurative  Bursitis  arises  from  infection  occurring 
either  from  without  or  within ;  it  not  uncommonly  follows  a 
subcutaneous  injury  of  a  chronically  inflamed  bursa,  leading  to 
its  distension  with  blood.  All  the  phenomena,  local  and  constitu- 
tional, usually  associated  with  the  formation  of  a  superficial  or 
deep  abscess  are  present.  The  pus,  formed  at  first  within  the 
bursa,  may  travel  directly  to  the  surface,  or  bursting  through  the 
capsule,  is  diffused  through  the  tissues.  Where  this  occurs,  the 
characteristic  features  suggesting  a  bursal  origin  of  the  abscess 
may  be  masked.  Thus,  in  suppuration  of  the  bursa  patellae,  the 
pus  often  finds  its  way  to  the  lateral  aspects  of  the  limb,  allowing 
the  patella  to  be  distinctly  felt  through  the  skin  ;  the  case  is  then 
liable  to  be  mistaken  for  suppuration  within  the  knee-joint,  from 
which,  however,  it  is  easily  distinguished  by  the  absence  of  the 
more  acute  arthritic  symptoms.  Implication  of  subjacent  bones 
and  joints  sometimes  occurs  ;  thus,  the  patella  or  olecranon  may 
become  carious,  or  necrose.  The  Treatment  of  suppurative  bursitis 
resolves  itself  into  an  early  free  incision,  and  drainage. 

3.  Chronic  Bursitis  with  Effusion  is,  perhaps,  the  most  common 
pathological  condition  met  with  in  connection  with  bursas.  The 
cavity  becomes  distended  with  a  serous  effusion  of  varying 
amount,  giving  rise  to  a  fluctuating  tumour.  The  walls  differ  in 
thickness  according  to  circumstances  ;  if  the  condition  is  one  of 
long  standing,  or  if  frequent  recurrences  have  been  present,  the 
bursal  wall  is  usually  reticulated  and  dense,  and  adhesions  or 
fibrous  cords  are  often  produced.  Subacute  exacerbations  are  fre- 
quently grafted  on  the  more  chronic  variety.  Treatment  con- 
sists in  rest  and  counter-irritation,  as  by  blistering  or  iodine  paint, 
and  if  this  fails,  the  bursa  should  be  dissected  out.  Special  care  has 
to  be  taken  in  dealing  with  bursas  communicating  with  joints,  such 
as  that  under  the  semimembranosus  tendon  ;  the  tumour  should 
not  be  opened  into,  if  possible,  but  its  neck  must  be  isolated,  and  its 
communication  with  the  joint  shut  off  by  a  catgut  or  silk  ligature. 

4.  Chronic  Fibroid  Bursitis. — -In  this  variety  the  walls  of  the 
bursa  become  chronically  thickened,  as  a  result  of  prolonged  irrita- 


AFFECTIONS  OF  MUSCLES,   TENDONS,  AND  BURS.E         375 


tion,  and  also  probably  from  the  effect  of  syphilis.  There  is  but 
little  effusion  ;  consequently  a  hard  fibroid  tumour  is  met  with  in 
the  region  of  the  bursa,  and  in  the  centre  of  this  is  a  small  cavity. 
The  only  Treatment  is  complete  removal. 

5~  Chronic  Tuberculous  Bursitis  occurs  either  in  the  form  of 
a  fibrinous  deposit  on  the  inner  wall,  together  with  effusion  and 
the  presence  of  melon-seed  bodies ;  or  the  lining  membrane 
undergoes  a  change  analogous  to  that  described  as  pulpy  de- 
generation of  a  joint,  and  perhaps  leading  to  the  formation  of  a 
chronic  abscess.  Either  condition  may  be  secondary  to  a  tuber- 
culous arthritis,  or  may  give  rise  to  it,  when  the  bursa  com- 
municates with  a  joint.  If  total  removal  is  impracticable,  the 
Treatment  consists  in  laying  the  part  freely  open,  scraping  away 
all  tuberculous  tissue,  and  stuffing  the  cavity  with  gauze  impreg- 
nated with  iodoform. 

6.  Syphilitic  Changes  may  also  occur  in  bursae,  in  the  shape 


Fig.  96 — Enlarged  Bursa  Patella.     (From  a  Photograph.) 

either  of  a  symmetrical  bursitis  in  the  early  stages,  or  later  on  as 
a  gummatous  peri-synovial  development. 

Occasionally  Gouty  Deposits  are  observed  in  the  walls  of  bursa, 
constituting  tophi,  the  irritation  of  which  may  predispose  to 
abscess  formation,  pus  mixed  with  urate  of  soda  crystals  being 
discharged.  The  bursa  over  the  olecranon  is  said  to  be  most 
frequently  affected  in  this  way. 


Special  Bursse. 

The  bursa  patella*  (Fig.  96),  which  lies  over  the  lower  half  of  the 
bone  and  not  over  its  centre,  is  very  liable  to  injury  and  inflam- 
mation from  its  exposed  situation,  and  especially  in  those  who 


376  A  MANUAL  OF  SURGERY 

kneel  much,  giving  rise  to  the  condition  known  as  '  housemaid's 
knee.'  Any  of  the  above-mentioned  varieties  of  bursitis  may  be 
met  with,  and  their  signs  are  so  evident  that  it  is  unnecessary 
to  again  mention  them  in  detail.  The  relation  of  the  bursa 
to  the  patella  explains  the  fact  that  acute  suppuration  sometimes 
gives  rise  to  caries  or  superficial  necrosis  of  that  bone,  whilst 
chronic  and  subacute  inflammations  may  lead  to  thickening  of 
the  bone  from  osteoplastic  periostitis. 

The  bursa  beneath  the  ligamentum  patella,  between  it  and  the  head 
of  the  tibia,  when  distended  with  fluid,  gives  rise  to  a  fluctuating 
swelling  felt  on  either  side  of  the  tendon,  more  especially  when 
the  limb  is  extended ;  when  the  leg  is  flexed,  the  swelling 
diminishes.  Chronic  enlargement  of  this  bursa  may  cause  the 
ligamenta  alaria  to  be  pushed  backwards  into  the  joint,  so  that 
they  are  nipped  between  the  bones  whenever  the  patient  attempts 
to  stand  with  the  leg  extended  ;  the  pain  thereby  induced  is  some- 
what similar  to  that  caused  by  a  displaced  semilunar  cartilage,  or 
by  a  loose  foreign  body  in  the  joint.  The  inability  to  stand  with 
a  straight  leg,  and  the  presence  of  the  enlarged  bursa,  are  suffi- 
cient, however,  to  guide  the  surgeon  to  a  correct  diagnosis. 

The  bursa  in  the  popliteal  space  are  often  enlarged,  especially  that 
between  the  inner  head  of  the  gastrocnemius  and  the  semi- 
membranosus, leading  to  a  rounded  fluctuating  swelling,  sharply 
limited  on  its  outer  aspect,  and  more  fixed  and  less  defined 
towards  the  inner.  The  sensation  imparted  to  the  fingers  varies 
according  to  the  position  of  the  limb,  the  swelling  being  tense  in 
extension  and  flaccid  in  flexion,  as  occurs  in  most  of  these  peri- 
articular bursas.  Owing  to  the  proximity  of  the  popliteal  vessels, 
pulsation  is  occasionally  detected  ;  but  it  is  only  heaving,  not 
expansile,  in  character.  The  fact  that  the  bursa  usually  com- 
municates with  the  joint  necessitates  considerable  caution  in  its 
treatment  ;  it  should  be  removed  by  a  careful  dissection,  the 
communication  with  the  joint  being  closed  by  ligature  or 
suture. 

The  bursa  beneath  the  insertion  of  the  semitendinosus  and  gracilis  is 
sometimes  inflamed,  and  is  very  liable  to  cause  osteoplastic 
periostitis  of  the  subjacent  inner  surface  of  the  tibia. 

The  bursa  beneath  the  tendo  Achillis,  if  enlarged,  presents  a 
fluctuating  swelling  on  either  side  of  that  structure,  somewhat 
simulating  disease  of  the  ankle-joint,  but  necessarily  limited  to 
the  posterior  aspect  of  the  joint.  The  enlargement  is  usually  due 
to  the  pressure  of  badly-fitting  boots. 

Distension  of  the  bursa  beneath  the  psoas  tendon  gives  rise  to  a 
fluid  swelling  which  usually  projects  anteriorly,  presenting  on  the 
inner  side  of  Scarpa's  triangle.  If  painful,  it  necessitates  flexion 
of  the  thigh,  and  thus  leads  to  symptoms  resembling  those  of  hip- 
joint  disease  or  of  a  psoas  abscess.  It  must  not  be  forgotten  that 
this  bursa  often  communicates  with  the  joint. 


AFFECTIONS  OF  MUSCLES,  TENDONS,  AND  BURSAz         377 


The  gluteal  bursa,  situated  between  the  insertion  of  the  gluteus 
maximus  and  the  great  trochanter,  is  not  uncommonly  the  seat  of 
tuberculous  disease.  It  presents  as  a  rounded  swelling,  obliterat- 
ing the  hollow  behind  the  trochanter,  and  in  its  more  acute 
manifestations  may  be  accompanied  by  abduction  and  eversion  of 
the  limb,  in  order  to  relax  as  far  as  possible  the  gluteus.  It  may 
thereby  somewhat  resemble  the  earlier  stages  of  hip  disease,  but 
is  known  from  it  by  the  absence  of  flexion,  and  the  fact  that 
passive  movements,  including  even  the  so-called  test-movement 
for  hip  disease,  can  be  undertaken  with  but  little  or  no  pain. 
Should  suppuration  occur,  the  pus  may  burrow  widely  beneath 
the  gluteus.  Treatment  consists  of  incision,  scraping  and  disin- 
fecting the  interior,  and  allowing  it  to  heal  from  the  bottom. 

The  bursa  over  the  tuber  ischii,  if  inflamed,  gives  rise  to  the  con- 
dition known  as  '  weavers'  bottom  ' ;  it  causes  great  discomfort  in 
sitting,  and  is  often  solid  and  symmetrical.  If  troublesome,  it 
should  be  removed. 

Enlargement  of  the  bursa  over  the  olecranon  constitutes  the  condi- 
tion known  as  '  miners'  or  students'  elbow  ' ;  suppuration  within 
it  is  not  uncommon,  leading  to  necrosis  of  the  underlying  bone ; 
the  elbow-joint  is  but  rarely  affected. 

The  large  multilocular  subdeltoid  bursa  is  occasionally  enlarged  ; 
it  leads  to  prominence  of  the  deltoid,  and  expansion  of  the 
shoulder.  (For  diagnosis  from  effusion  into  the  shoulder-joint, 
see  p.  574.)  Where  treatment  by  counter-irritation  and  rest 
fails,  the  cavity  should  be  incised  and  drained. 


CHAPTER    XVI. 


DEFORMITIES. 


Torticollis. 


Torticollis,  or  wry-neck,  is  a  deformity  produced  by  a  contrac- 
tion of  the  sterno-mastoid  muscle,  the  trapezius  and  deep  fascia 
being  also  frequently  affected,  and  occasi<  ndly  the  short  muscles 

at  the  back  of  the 
neck.  It  is  charac- 
terized by  the  affected 
side  of  the  head  being 
drawn  down  towards 
the  shoulder,  whilst 
the  face  is  turned 
towards  the  sound 
side,  as  shown  in 
Fig.  94.  When  this 
has  lasted  for  some 
time,  especially  in 
congenital  cases  and 
those  commencing  in 
childhood,  the  af- 
fected side  of  the 
head  and  face  be- 
comes atrophic.  The 
measurement  from 
the  external  canthus 
to  the  angle  of  the 
mouth  is  smaller,  the 
eyebrow  is  less 
arched,  the  nose  de- 
flected, and  the  cheek 
less  full  than  on  the 
sound  side.     No  very 


Fig.  97. — Torticollis. 
The  right  sterno-mastoid  is  contracted,  and  the  corre- 
sponding half  of  the  face  atrophic. 


satisfactory  explanation  of  these  phenomsna  is   forthcoming,  but 
they    are   probably    due    to    imperfect    vascular    supply.       The 


DEFORMITIES 


379 


cervical  spine  becomes  laterally  curved,  with  its  concavity  to  the 
affected  side,  and  a  secondary  compensatory  curve  is  also  present 
in  the  dorsal  region,  so  as  to  maintain  the  eyes  as  far  as  possible 
on  a  level. 

The  Causes  and  Varieties  of  torticollis  may  be  classified  as 
follows : 

i.  Congenital  torticollis,  the  result  of  malformation  or  malposi- 
tion in  utero,  or  of  some  intra-uterine  muscular  contraction  or 
nervous  lesion. 

2.  Muscular  torticollis,  due  to  intrinsic  contraction  of  the  sterno- 
mastoid,  apart  from  nervous  influences,  as  in  cicatricial  shortening 
after  intramuscular  abscess  or  gumma.  In  children  it  is  said  to 
follow  the  congenital  induration  of  the  muscle  so  often  seen,  and 
due  to  laceration  during  birth,  whilst  it  is  not  unfrequently  met 
with  as  a  temporary  deformity  resulting  from  cold  (rheumatic 
myositis,  or  stiff-neck). 

3.  Torticollis  arising  from  nervous  causes,  including  spasm  and 
paralysis.  Spasmodic  torticollis  (tonic  or  clonic)  may  result  (a) 
from  the  direct  irritation  of  the  nerve  trunk  or  its  roots,  as  by 
inflamed  cervical  glands  or  cervical  caries ;  (b)  possibly  from 
reflex  irritation,  as  by  carious  teeth,  and  worms  or  ovarian 
mischief;  and  (c)  from  irritation  of  the  deep  or  cortical  centres. 
This  latter  variety  is  usually  of  the  clonic  type,  and  often  involves 
the  posterior  muscles  as  well  as  the  sterno-mastoid.  The 
character  of  the  movements  varies  with  the  actual  muscles  in- 
volved. It  occurs  most  frequently,  though  not  exclusively,  in 
women  of  about  thirty  years  of  age,  and  there  is  often  a  family 
history  of  nervous  diseases,  such  as  epilepsy,  etc.  The  prognosis 
in  these  cases  is  almost  always  unfavourable,  since,  even  if  the 
localized  spasm  is  cured  by  appropriate  operative  treatment,  other 
parts  are  likely  to  become  affected.  Paralytic  torticollis  arises 
either  from  infantile  paralysis  of  one  muscle,  leading  to  unbalanced 
action  of  that  on  the  other  side,  or  from  some  peripheral  nerve 
lesion. 

4.  Hysteria  is  also  responsible  for  a  certain  number  of  cases. 
Most  commonly  the  sternal  portion  is  mainly  affected,  whilst 

the  clavicular  half  may  be  quite  relaxed.  In  congenital  and 
cicatricial  cases  the  muscle  stands  out  as  a  hard  tense  band,  an 
excess  of  fibrous  tissue  being  present,  or  the  muscular  substance 
almost  entirely  absent ;  but  in  spasmodic  cases  the  muscle 
may  be  well  developed  and  not  specially  prominent.  The  deep 
fascia  always  becomes  secondarily  contracted  and  shortened,  and 
if  the  deformity  has  lasted  long  the  posterior  cervical  muscles  are 
similarly  affected,  whilst  changes  in  the  shape  of  the  vertebrae 
may  also  be  induced,  the  bodies  becoming  wedge-shaped  and 
thickest  towards  the  convexity  of  the  curve. 

The  Diagnosis  of  torticollis  is  readily  made.  It  must  not  be 
confounded  with  cicatricial  contraction  of  the  skin  of  the  neck 


380  A   MANUAL  OF  SURGERY 

following  burns,  or  the  attitude  temporarily  assumed  by  a  patient 
with  an  acute  deep-seated  abscess  of  the  neck,  or  with  tuberculous 
caries  of  the  spine  associated  with  lateral  deviation.  The  rigidity 
of  the  neck  in  the  latter  case,  together  with  the  pain  caused  by 
movement  of  or  pressure  over  the  vertebrae,  should  suffice  to  make 
the  diagnosis  clear.  Rheumatic  inflammation  of  the  deeper  liga- 
ments and  muscles  of  the  cervical  spine  (rheumatic  spondylitis) 
may  also  be  mistaken  for  torticollis,  but  it  comes  on  rapidly,  and 
is  associated  with  tenderness  on  deep  pressure.  The  fact  that  in 
tonic  cases  the  muscle  is  evidently  contracted,  and  stands  out  as 
a  tense  band  in  the  neck,  is  sufficiently  characteristic.  Spasmodic 
torticollis,  again,  cannot  well  be  mistaken  for  any  other  condition, 
but  it  may  be  difficult  to  distinguish  its  cause  or  to  localize  the 
affected  muscles. 

The  Treatment  of  torticollis  necessarily  varies  with  the  cause, 
and  thus  either  anti-phlogistic,  anti-neurotic,  anti-rheumatic,  or 
anti-syphilitic  remedies  may  be  required.  When,  however,  it  is 
due  to  congenital  or  tonic  contraction  of  the  muscle  or  its  tendon, 
massage  and  manipulation  may  be  first  tried,  or  even  some  form 
of  mechanical  apparatus ;  but  in  the  majority  of  cases  tenotomy 
or  myotomy  will  give  a  more  satisfactory  result,  and  is  much  less 
tedious  and  troublesome. 

Two  methods  of  dividing  the  sterno-mastoid  have  been  em- 
ployed :  (i)  The  subcutaneous  operation  is  a  somewhat  undesirable 
proceeding,  on  account  of  the  important  structures  placed 
immediately  beneath  it.  There  is  but  little  danger  or  difficulty 
in  dealing  with  the  sternal  head,  a  tenotome  being  passed 
down  to  it  beneath  the  skin,  and  the  incision  made  from  before 
backwards ;  the  tension  to  which  it  is  exposed  suffices  to  draw  it 
well  forwards  out  of  harm's  way.  In  dealing  with  the  clavicular 
portion,  it  has  been  recommended  to  introduce  a  sharp-pointed, 
and  then  a  blunt-ended,  tenotome  beneath  the  muscle,  divid- 
ing it  from  within  outwards,  whilst  others  suggest  that  a  director 
should  first  be  passed  beneath  it,  and  then  the  muscle  divided. 
(2)  The  open  method  is  far  preferable  to  any  of  these  plans,  as 
thereby  all  danger  is  obviated.  The  skin  is  freely  incised  across 
the  muscle,  its  anterior  and  posterior  borders  defined,  and 
its  fibres  carefully  and  fully  divided.  No  attempt  should  be 
made  to  deal  with  the  portion  of  deep  cervical  fascia  which 
passes  beneath  it  and  securely  covers  in  the  important  under- 
lying structures.  Any  part  of  the  lower  half  of  the  muscle 
may  be  selected,  but  the  best  spot  is  about  ^  inch  above  the 
clavicle.  The  position  of  the  head  is  then  rectified,  and  fixed  by 
plaster  of  Paris  or  some  other  suitable  apparatus.  A  simple 
and  satisfactory  arrangement  consists  of  a  padded  leather  strap 
passed  round  the  forehead  and  occiput,  and  another  under 
the  axillae.  A  chain  or  elastic  band  is  secured  to  the  forehead 
strap  above  the  mastoid  process  of  the  side  which  is  not  affected, 


DEFORMITIES  381 


and  traction  made  by  fixing  it  to  the  front  of  the  lower  belt  on 
the  opposite  side  of  the  body.  Thus,  if  the  left  sterno-mastoid  is 
contracted  and  has  been  divided,  the  chain  is  attached  over  the 
right  mastoid  process  above,  and  below  over  the  front  of  the  left 
axilla,  traction  being  thus  made  in  the  direction  of  the  right  or 
weakened  sterno-mastoid  muscle.  In  some  cases  more  efficient 
support  is  necessary,  and  may  be  obtained  by  the  use  of  Chance's 
back  splint  (p.  387),  to  which  arms  are  attached  at  the  upper  end, 
bringing  pressure  to  bear  upon  each  side  of  the  head  in  suitable 
directions.  Where,  however,  osseous  changes  are  present,  the 
deformity  may  persist  to  a  great  extent,  in  spite  of  combined 
operative  and  mechanical  treatment. 

In  cases  of  clonic  torticollis  it  may  be  necessary  to  cut  down  on, 
and  stretch  or  excise,  the  spinal  accessory  nerve  (p.  343).  This 
is  not  attempted  until  hygienic  and  tonic  treatment  has  failed. 
Where  the  cause  is  peripheral,  good  results  may  follow ;  but 
when  due  to  central  lesions,  as  is  usually  the  case,  we  have 
already  stated  that  failure  is  not  uncommon.  In  such,  division 
of  the  posterior  cervical  nerves,  as  they  lie  on  the  semispinalis 
colli,  will  occasionally  bring  about  a  cure  ;  should  this  fail,  it  may 
be  justifiable  to  deal  with  the  cortical  centres. 

A  Cervical  Rib  is  a  deformity  of  somewhat  unusual  occurrence. 
It  arises  most  frequently  from  the  anterior  transverse  process  of 
the  seventh  cervical  vertebra,  but  a  similar  outgrowth  sometimes 
occurs  from  the  sixth.  It  is  mainly  composed  of  cartilage  at 
first,  but  as  age  advances  it  becomes  osseous.  It  passes  down 
behind  the  nerves  to  unite  with  the  central  portion  of  the  first  rib, 
and  occasionally  consists  of  two  portions,  an  upper  and  a  lower, 
united  together  by  a  synchondrosis.  No  symptoms  are  produced 
until  the  mass  by  its  growth  compresses  the  brachial  plexus,  or 
pushes  the  subclavian  vessels  forwards,  thus  leading  to  trophic 
and  vascular  disturbances,  as  well  as  to  neuralgia  and  some  weak- 
ness or  loss  of  power  in  the  arm.  Nothing  should  be  done  to  this 
condition  unless  pressure  symptoms  are  present,  when  removal 
may  be  required.  An  incision  is  made  parallel  to  the  anterior 
border  of  the  lower  portion  of  the  trapezius ;  the  nerves  and 
vessels  are  separated  from  the  mass  of  cartilage  and  drawn  aside, 
and  the  growth  carefully  excised  with  gouge,  chisel,  or  cutting 
pliers. 

Deformities  of  the  Spine. 

Scoliosis.  —  By  scoliosis  is  meant  a  lateral  curvature  of  the 
spine  accompanied  by  rotation  of  the  vertebrae.  Conditions  are 
met  with  in  which  the  spine  becomes  deflected  laterally  as  an 
occasional  result  of  Pott's  disease,  or  in  fractures  ;  such,  however, 
are  not  generally  considered  to  be  genuine  scoliosis. 

etiology. — The    following   are   the    chief  causes  of  scoliosis : 


382  A  MANUAL  OF  SURGERY 

i.  It  is  said  to  occur  very  rarely  as  a  congenital  deformity,  owing 
to  malformation  of  the  vertebrae.  2.  It  may  commence  in  children 
at  an  early  period  of  life  as  a  result  of  rickets,  owing  partly  to  the 
softened  and  rarefied  condition  of  the  bones,  partly  to  their  irregular 
and  uneven  growth.  It  is  probably  often  induced  by  the  method 
of  always  carrying  children  on  the  same  arm  in  vogue  with  nurse- 
maids. A  similar  change,  due  to  the  so-called  '  delayed  rickets,' 
may  also  occur  later  on  in  children  who  are  able  to  run  about  The 
primary  curve  in  this  type  is  usually  one  directed  towards  the  left 
in  the  dorsi-lumbar  region.  3.  Any  condition  of  asymmetry  of 
the  body  may  lead  to  what  is  known  as  statical  scoliosis,  e.g.,  con- 
genital shortness  of  one  leg,  unilateral  dislocation  of  the  hip, 
contractions  of  the  knee  or  hip  joints,  genu  valgum,  falling  in  of 
the  chest  wall  as  a  result  of  empyema,  and  even  old-standing 
torticollis.  If  the  cause  exists  in  one  of  the  lower  extremities, 
the  pelvis  is  tilted  down  on  the  shorter  side,  producing  a  lumbar 
curve  with  the  convexity  towards  the  side  of  the  shortened  leg, 
whilst  a  compensatory  dorsal  curve  in  the  opposite  direction  is 
subsequently  added  in  order  to  maintain  the  general  axis  of  the 
body.  When  due  to  empyema,  a  primary  dorsal  curvature  is 
produced,  with  its  convexity  towards  the  sound  side.  In  torti- 
collis the  cervical  curve  is  primary,  and  a  compensatory  curve  in 
the  opposite  direction  in  the  dorsal  region  usually  follows.  4.  The 
most  common  form  of  scoliosis,  however,  is  that  known  as  the 
scoliosis  of  adolescents,  met  with  in  young  people  about  the  age  of 
puberty,  or  a  little  older,  who  are  in  a  weak  and  asthenic  con- 
dition, often  as  a  result  of  rapid  growth,  ccmbined  possibly  with 
improper  food,  defective  hygienic  surroundings,  or  exposure  to 
hard  work,  whereby  muscular  fatigue  is  induced.  Young  women 
of  an  anaemic  type  who  suffer  from  amenorrhcea,  and  who  as 
housemaids  or  factory  hands  have  to  undertake  a  good  deal  of 
lifting,  are  especially  liable  to  this  condition.  It  is  due  to  a 
relaxed  state  of  the  ligaments  and  muscles,  which  have  not 
developed  pari  passu  with  the  weight  and  length  of  the  skeleton ; 
it  is  therefore  not  unfrequently  associated  with  flat  foot  and  genu 
valgum.  Prolonged  standing  in  a  position  of  ease  or  rest,  in 
which  the  weight  is  mainly  carried  on  one  leg,  may  determine  its 
occurrence,  as  also  faulty  positions  occupied  by  children  at  school, 
owing  to  low  desks  and  want  of  support  to  the  feet.  The  lumbar 
curve  usually  forms  first,  its  convexity  being  to  the  left  side,  a 
compensatory  dorsal  curve,  with  its  convexity  to  the  right,  being 
subsequently  developed. 

The  Phenomena  vary  considerably  according  to  the  character 
and  extent  of  the  lesion.  Sometimes  the  whole  spine  is  involved 
in  one  curve  (total  scoliosis)  ;  but  more  usually  two  curves  are 
present,  one  primary,  the  other  compensatory.  It  is  by  no  means 
uncommon  for  this  condition  to  be  associated  with  kyphosis, 
but  its  absence,  in  what  is  sometimes  termed  the  '  flat-backed  ' 


DEFORMITIES 


383 


type,  is  no  criterion  of  the  slightness  of  the  case.  The  most 
usual  variety  is  that  in  which  there  is  a  double  curve,  with  the 
dorsal  convexity  to  the  right  and  the  lumbar  to  the  left.  It  will 
be  desirable  to  describe  this  carefully,  whilst  for  the  opposite  condi- 
tion all  that  is  necessary  is  to  transpose  the  words  '  right '  and 
'  left,'  or,  as  Hoffa  has  put  it,  one  variety  is  the  '  mirror  picture  ' 
of  the  other. 

In  addition  to  the  lateral  displacement,  rotation  of  the  bodies  of  the 


Fig.  98. — Scoliosis  seen  from 
Behind.     (Tillmanns.) 


Fig.  99. — Spine  in  Scoliosis  seen 
from  in  Front.     (Tillmanns.) 

vertebra  (Fig.  99)  towards  the  convexity  of  the  curves  is  always 
present.  This  is  probably  a  purely  mechanical  act,  and  due  to 
the  more  firm  support  given  to,  and  the  interlocking  of,  the 
posterior  parts  of  the  vertebrae.  As  a  result,  the  spinous 
processes  are  directed  towards  the  concavity,  and  hence  will 
always  indicate  a  smaller  amount  of  distortion  than  really  exists. 
Occasionally  there  may  be  some  backward  projection  of  the 
spines  at  the  junction  of  the  two  curves. 

The  thoracic  walls  necessarily  participate  in  the  process.     The 


384 


A   MANUAL  OF  SURGERY 


ribs  on  the  right  side  become  to  some  extent  separated  from  one 
another,  and  project  posteriorly  on  account  of  the  rotation  of  the 
vertebrae  ;  the  amount  of  curvature  at  the  angle  is  consequently 
increased,  whilst  the  front  of  the  chest  on  this  side  of  the  body 
becomes  flattened.  On  the  left  side  the  ribs  are  huddled  together, 
and  the  curve  at  the  angle  diminished,  the  ribs  being  thereby 
opened  out;  consequently  the  thorax  is  flattened  posteriorly  on 
that  side,  but  projects  in  front ;  the  left  breast  may  thus  be 
rendered  prominent  (Fig.  ioo).  In  fact,  the  thorax  becomes 
more  or  less  rhomboidal  in  shape.  The  sternum  also  is  somewhat 
displaced  towards  the  concavity,  and  twisted  so  that  the  anterior 
surface  looks  towards  the  right.  The  capacity  of  the  thorax  is 
not  as  a  rule  affected  at  first,  but  in  the  later  stages  it  is  consider- 
ably diminished,  and  the 


may 
The 


Fig. 


ioo. —Section  of  Thorax  in  Scoliosis. 
(After  Holmes  and  Hulke.) 


abdominal  viscera 
even  be  displaced. 
scapula  follow  the  thor- 
acic wall,  and  hence  the 
right  shoulder  is  pushed 
upwards  and  outwards, 
and  this,  it  is  said,  in  the 
worst  cases  may  pro- 
gress to  such  an  extent 
as  to  cause  the  sternal 
end  of  the  clavicle  to  be 
spontaneously  dislocated 
backwards.  It  is  for  this 
'  growing  out  of  the 
shoulder'  in  young 
women  that  the  majority 
of  cases  come  under 
observation.  The  left 
scapula  is  generally 
The  effect  on  the  waist  varies 
if   the  dorsal  and 


somewhat  lower  than  the  right 
with  the  situation  and  extent  of  the  curves  ; 
lumbar  curves  are  nearly  equal,  then  the  true  waist  on  the  right 
side  becomes  more  marked  than  usual,  corresponding  to  the 
lumbar  concavity,  and  in  advanced  cases  a  distinct  sulcus  may  be 
present  between  the  lower  ribs  and  the  crest  of  the  ilium.  On 
the  left  side  the  hip  appears  to  project  ('growing  out'),  owing  to 
the  deflection  of  the  trunk  towards  the  right  side,  whilst  the 
dorsal  concavity  higher  up  may  simulate  a  false  waist.  In 
addition  to  the  above  phenomena,  the  buttocks  may  be  noticed  to 
be  asymmetrical,  if  the  scoliosis  is  of  statical  origin.  The  erector 
spinas  muscle  stands  out  unduly  on  the  left,  owing  to  the  rotation 
of  the  vertebrae,  whilst  the  transverse  processes  on  this  side  may 
be  unusually  evident. 

In  the  early  stages  the  characteristic  deformity  disappears  on 


DEFORMITIES  3S5 


extension  of  the  trunk,  as  by  hanging  from  a  trapeze,  or  on  bend- 
ing forwards  ;  but  as  it  progresses,  the  spine  becomes  more  and 
more  fixed,  and  but  little  alteration  is  produced  by  suspension  of 
the  patient.  In  the  worst  cases  the  deformity  becomes  so  marked 
as  to  simulate  the  '  hump '  formed  in  Pott's  disease,  especially 
when  associated  with  kyphosis,  and  the  patient's  stature  becomes 
dwarfed  and  stunted. 

Subjective  symptoms,  such  as  neuralgic  pain  and  weakness,  are 
also  present,  but  usually  they  are  not  very  prominent  features. 

Anatomical  Changes. — The  structure  of  the  spinal  column  is  at 
first  not  manifestly  altered,  but  as  soon  as  the  deformity  becomes 
chronic,  the  individual  vertebrae  become  mis-shapen.  The  bodies 
are  somewhat  wedge-like  on  section,  being  thicker  on  the  convex 
than  on  the  concave  side.  The  intervertebral  discs  are  similarly 
changed,  whilst  the  articular  processes  are  unduly  pressed  together  on 
the  concave  side,  and  separated  from  one  another  on  the  convex. 
The  transverse  and  spinous  processes  are  also  approximated  to 
one  another  on  the  side  of  the  concavity,  and  often  curved.  The 
ligaments,  which  in  the  early  stages  are  relaxed,  become  secondarily 
shortened  on  the  concave  side,  and  may,  indeed,  disappear,  the 
.bodies  of  the  vertebrae  being  ankylosed.  The  muscles  are  also 
relaxed  in  the  early  stages,  but  accommodate  themselves  after- 
wards to  the  altered  curves  of  the  spine,  and  hence  are  contracted 
on  the  concave  side,  and  stretched  on  the  convex. 

It  is  most  essential  that  a  correct  Diagnosis  be  made  as  soon  as 
possible,  since  so  much  depends  upon  early  treatment.  A  thorough 
examination  should  be  made  with  the  clothes  stripped  to  below  the 
waist,  so  that  the  whole  back  can  be  seen.  The  patient  should 
be  made  to  sit  straight  up  on  a  stool  or  chair  placed  sideways,  and 
the  surgeon  stands  behind  her.  The  general  appearance  is  first 
noted,  and  then  the  spinous  processes  are  marked  out  one  after 
another  with  a  spot  of  ink  or  with  a  flesh  pencil.  The  shape  of 
the  thorax,  the  curvature  of  the  ribs,  and  the  position  of  the 
scapulae,  are  also  ascertained.  The  patient  is  then  made  to  stand, 
to  hang  from  a  bar,  and  to  bend  forwards,  and  the  effects  of  these 
respective  movements  noted ;  by  this  means  some  idea  can  be 
obtained  of  the  extent  and  nature  of  the  deformity.  There  can  be 
but  little  risk  of  mistaking  it  for  Pott's  disease,  since  the  rigidity, 
deformity,  and  localized  pain  of  the  latter  are  so  characteristic  ; 
in  those  cases  of  scoliosis,  however,  where  there  is  a  projection  of 
the  spinous  processes  backwards,  a  mistake  might  easily  arise  if 
only  a  careless  examination  were  made. 

The  Prognosis  necessarily  varies  with  the  stage  which  the  affec- 
tion has  reached.  In  early  days,  before  the  deformity  has  become 
set,  and  when  it  disappears  on  extension  of  the  spine,  it  is  almost 
certain  to  be  entirely  cured,  if  suitable  precautions  are  taken. 
Later  on  it  can  be  improved  to  some  extent,  but  in  bad  cases  all 
that  can  be  expected  is  to  prevent  it  from  getting  worse. 

25 


386 


A   MANUAL  OF  SURGERY 


In  the  Treatment  of  scoliosis,  the  cause  of  the  trouble  must  not 
be  overlooked,  since  in  many  cases  the  deformity  may  be  remedied, 
or  at  any  rate  prevented  from  increasing,  by  attending  to  this. 
Thus,  inequality  in  the  length  of  the  limbs  necessitates  the  wear- 
ing of  a  high-heeled  boot,  whilst  contractions  of  the  knee  or  hip 
joints  should,  if  possible,  be  remedied.  In  that  variety  which 
occurs  in  young  people  from  constitutional  or  local  debility,  the 
general  health  must  be  improved  by  a  visit  to  the  seaside,  or  the 
administration  of  tonics,  such  as  iron  and  arsenic.  Carefully 
regulated  rest  and  exercise  must  also  be  recommended,  so  as  to 
improve  the  muscular  tone  of  the  back  without  unduly  fatiguing 
the  patient  ;  for  a  similar  reason  massage  and  cold  baths  are 
beneficial.  All  errors  of  position  must  be  corrected,  and  suitable 
desks,  forms,  and  chairs  utilized.  In  the  slighter  cases  it  often 
suffices  to  order  the  patient  to  rest  in  the  supine 
position  on  an  inclined  board  for  an  hour  or  two 
daily,  the  head  being  thus  raised  and  the  spine  ex- 
tended. Calisthenic  movements  and  gymnastic 
exercises,  especially  on  the  horizontal  bar  and 
trapeze,  are  also  valuable.  Of  course,  these  must 
be  arranged  so  as  to  exercise  the  weak  muscles  and 
counteract  the  deformity.  Space  forbids  us  describ- 
ing them  here,  and  we  must  refer  readers  to  special 
textbooks.  A  spinal  support  is  often  useful,  but 
should  not  be  worn  continuously,  except  in  bad  cases, 
as  it  renders  the  muscles  of  the  back  weak  from 
disuse.  All  that  is  needed  in  the  early  stages  is  the 
support  of  a  firm,  carefully-fitted  corset;  but  should 
the  deformity  increase,  stronger  steel  instruments 
may  be  employed  in  which  springs  are  incorporated, 
T  _       whereby  it  is  hoped  that  correction  of  the  curvature 

I  O  I. —  J  r 

may  be  brought  about.  In  the  more  severe  cases, 
which  are  often  associated  with  considerable  pain, 
such  a  contrivance  with  axillary  crutches  is  abso- 
lutely, essential.  Plaster  of  Paris,  applied  accotding 
to  Sayre's  method,  is  certainly  objectionable,  since  it  is  irremov- 
able, and  all  other  local  treatment  to  the  back  is  thus  prevented. 

Kyphosis. — By  this  term  is  meant  a  condition  of  increased 
dorsal  convexity  of  the  back  (Fig.  101),  which  is  often  associated 
with  loss  of  the  lumbar  concavity,  so  that  the  whole  spine  is 
arched  backwards.  Occasionally,  however,  a  marked  lumbar 
lordosis  is  present  as  a  compensatory  condition. 

The  chief  varieties  of  kyphosis  are  as  follows  : 

i.  Kyphosis  from  defective  growth  or  habit.  This  may  occur 
(a)  in  children  under  the  age  of  four,  resulting  from  rickets  ;  (b)  in 
adolescents  up  to  the  age  of  sixteen  (round  shoulders),  from  a  con- 
tinuous habit  of  stooping,  as  in  reading  or   writing,  and  is  not 


Fi  G. 
Kyphosis. 
(After 
Erichsen.) 


DEFORMITIES  387 


uncommon  in  those  suffering  from  myopia ;  (c)  various  forms  of 
occupation,  involving  the  carrying  of  heavy  weights,  or  stooping 
over  work,  will  lead  to  its  appearance  in  adults,  as  in  porters  and 
cobblers,  whilst  the  use  of  bicycles  which  necessitate  the  riders 
stooping  forwards  in  order  to  grasp  the  handles  is  becoming  a 
frequent  source  of  this  deformity  ;  (d)  in  old  men  it  results  from 
senile  atrophy. 

2.  Kyphosis  from  general  diseases  of  the  spine  is  a  marked 
feature  in  osteo-arthritis,  osteitis  deformans,  osteo-malacia,  hyper- 
trophic pulmonary  osteo-arthropathy,  and  acromegaly.  In  the 
latter  disease  the  condition  is  limited  to  the  dorsal  region. 

3.  Kyphosis  from  localized  disease  of  the  spine  is  sometimes 
described,  although  it  is  more  commonly  known  by  the  contradic- 
tory term  '  angular  curvature.'  It  results  from  fractures,  Pott's 
disease,  gumma,  or  cancer  {q.v.). 

Treatment  is  impossible  in  the  majority  of  cases,  but  the  round 
shoulders  of  young  people  come  so  commonly  under  the  observa- 
tion of  the  surgeon  that  a  little  more  notice  of  the  condition  is 
needed. 

Round  Shoulders  occur  most  frequently  in  girls  who  have  grown 
rapidly,  and  perhaps  developed  precociously.  The  condition  is 
often  due  to  defective  habits  of  sitting  and  standing,  especially  at 
school,  and  may  be  induced  by  faulty  desks  and  chairs,  whilst 
other  intrinsic  conditions,  such  as  myopia  or  adenoids,  may  also 
be  primarily  responsible.  The  spine  becomes  bent  forwards  in 
the  cervico-dorsal  region  ;  at  first  the  deformity  can  be  voluntarily 
corrected,  but  not  so  later  on. 

Treatment. — A  thorough  investigation  must  be  made  into  the 
question  of  causation,  and  all  removable  conditions  dealt  with. 
Special  attention  must  be  directed  to  the  chairs  and  desks  so  as 
to  ensure  that  the  child  sits  in  a  good  position.  The  essential 
point  in  the  treatment  is  to  increase  the  power  of  the  muscles  of 
the  back,  especially  the  trapezii,  the  erectores  spina?,  the  rhom- 
boidei,  and  the  serrati.  This  may  be  accomplished  by  massage, 
electricity,  and  exercises,  the  latter  necessarily  directed  towards 
extension  of  the  back.  The  girl  should  never  be  allowed  to 
fatigue  herself  unduly,  and  must  rest  on  her  back  two  or  three 
times  a  day  for  half  an  hour.  At  night  she  should  lie  on  her 
back,  without  a  bolster,  and  with  a  pillow  beneath  the  curve. 
The  general  nutrition  and  health  must  also  be  attended  to,  and  a 
course  of  suitable  tonics  prescribed.  In  bad  cases  where  the 
deformity  is  marked  and  it  is  feared  it  may  be  progressive,  a  light 
support  may  be  required  ;  a  Chance's  splint*  will  do  as  well  as 
any,  but  of  course  the  exercises  must  be  persisted  in. 

*  Many  modifications  of  Chance's  original  splint  have  appeared,  but  the 
essential  features  of  all  are  the  presence  of  a  metal  pelvic  band,  from  which 
rises  a  single  or  double  bar  of  malleable  iron,  fitted  to  the  back,  and  capable 
of  having  its  curve  altered.  Lateral  supports  spring  from  the  central  bar  or 
bars,  and  straps  to  fix  it  in  position  are  also  provided. 

25—2 


388 


A  MANUAL  OF  SURGERY 


Lordosis  (Fig.  102)  consists  in  an  increased  anterior  curvature 
of  the  spine  in  the  lumbar  region.  It  is  usually  produced  by 
continued  flexion  of  the  hip,  whether  due  to  congenital  displace- 
ment, to  unreduced  dislocation,  or  to  hip  disease,  and  in  such 
cases  it  is  irremediable  unless  the  malposition  of  the  femur  can  be 
corrected. 

It  is  seen  as  a  temporary  condition  in  pregnancy,  and  as  a  more 
constant  phenomenon  in  bad  cases  of  uterine  fibroids,  owing  to  the 
increased  weight  of  the  uterus  or  its  contents,  necessitating  back- 
ward displacement  of  the  upper  part    of   the  spine  in  order  to 
adjust  correctly  the  centre  of  gravity  of  the  body. 
The  same  may  be  noticed  in  persons  with  large,  fat, 
and  pendulous  abdomens. 

It  is  occasionally  present  in  progressive  muscular 
atrophy  where  the  lumbar  and  abdominal  muscles 
are  weakened,  and  usually  in  pseudo-hypertrophic 
paralysis  from  loss  of  power  in  the  gastrocnemii  and 
other  muscles  engaged  in  maintaining  the  erect 
posture.  In  both  cases  the  centre  of  gravity  of  the 
body  is  displaced  forwards,  necessitating  the  throw- 
ing backwards  of  the  head  and  shoulders  in  order 
to  maintain  the  equilibrium. 

Spondylolisthesis  is  the  term  applied  to  a  curious 
and  somewhat  uncommon  deformity,  in  which  the 
lumbar  vertebrae  slip  forwards  and  downwards  from 
the  top  of  the  sacrum.  It  arises  from  fracture  of  the 
articular    processes  of    the  lumbo-sacral   synchon- 

FiG.102. Lor-  drosis,    or     from     imperfect    development    of    the 

dosis.  (After  laminae  or  pedicles  of  the  lowest  lumbar  vertebra, 
Erichsen.)  as  a  resuit  of  which  the  pressure  of  loads  carried 
on  the  shoulders  or  the  weight  of  a  pregnant 
uterus  brings  about  the  displacement.  In  the  latter  instance  the 
enforced  lordosis  aggravates  this  tendency.  The  effects  produced 
are  shortening  of  the  stature,  together  with  the  formation  of  a 
marked  hollow  above  the  sacrum,  whilst  the  lumbar  vertebrae  are 
unduly  prominent  anteriorly.  The  condition  is  accompanied  by 
neuralgic  pain  and  weakness.  The  only  treatment  is  prolonged 
rest  in  the  recumbent  posture,  and  possibly  the  application  of  a 
well-fitting  leather  jacket,  closely  moulded  to  the  pelvis,  and 
supplied  with  crutches,  so  as  to  carry  part  of  the  weight  down- 
wards from  the  axillae  to  the  pelvic  support  without  utilizing  the 
spine. 


Deformities  of  the  Upper  Extremity. 

Congenital  Elevation  of  the  Scapula  (Sprengel's  Shoulder)  is  a 
condition  to  which  some  attention  has  been  recently  attracted. 
The  scapula  may  be  normal  in  size  or  a  little  smaller  than 
usual,  but  is  situated  above  its  proper  position,  thereby  causing 


DEFORMITIES  389 


some  deformity.  The  muscles  attached  to  its  upper  border  are 
shortened,  but  otherwise  normal,  though  in  a  few  instances  an 
osseous  band  has  replaced  them,  passing  between  the  upper  angle 
of  the  bone  and  the  seventh  cervical  vertebra.  The  lower  third 
of  the  trapezius  is  often  defective,  as  also  the  serratus  magnus. 
The  amount  of  disability,  which  is  usually  slight,  depends  on  the 
condition  of  these  muscles,  but  the  affected  arm  is  sometimes 
smaller  than  its  fellow.  A  slight  degree  of  scoliosis  develop? 
as  a  compensatory  phenomenon.  The  condition  is  supposed  to 
result  from  abnormal  intra-uterine  pressure  in  the  same  way  as 
congenital  torticollis  and  talipes.  The  only  treatment  consists  in 
dealing  with  the  affected  muscles  by  operation,  if  necessary. 
This  deformity  is  distinguished  from  the  '  growing-out  shoulder  ' 
of  ordinary  scoliosis  by  the  muscular  defects,  by  the  slight- 
ness  of  the  scoliotic  curve,  and  by  the  congenital  origin  of  the 
lesion. 

Various  types  of  Club-hand  occur,  in  which  the  hand  is  deflected 
to  one  or  the  other  side,  or  is  hyper-extended  or  flexed.  Perhaps 
the  most  frequent  cause  is  a  congenital  absence  of  the  radius,  under 
which  circumstances  the  hand  is  radially  abducted  to  a  marked 
degree,  the  ulna  is  shortened  and  curved,  and  its  lower  epiphysis 
much  altered  in  shape  and  expanded,  so  as  to  articulate  with  the 
carpal  bones.  Where  the  bones  are  normal,  the  hand  is  usually 
flexed  and  adducted  towards  the  ulnar  side.  In  any  of  these 
deformities  skiagraphy  should  be  employed,  so  as  to  ascertain  the 
exact  relation  of  the  bones  to  each  other. 

Congenital  Deformities  of  the  Finger  are  much  more  common, 
and  the  account  here  given'of  such  defects  of  the  upper  extremity 
applies  with  equal  force  to  those  which  occur  in  the  lower.  The 
following  varieties  may  be  alluded  to  : 

Polydactylism  consists  in  the  presence  of  supernumerary  fingers 
and  toes,  and  is  often  seen.  There  may  be  from  one  to  seven 
additional  digits,  and  the  condition  is  usually  symmetrical.  One 
case  is  on  record  with  twelve  and  thirteen  fingers  on  the  hands, 
and  twelve  toes  on  each  foot.  The  accessory  digits  are  often 
stunted,  and  smaller  in  size  than  the  normal,  but  may  be  of 
average  dimensions.  Usually  they  are  separated  from  the  true 
digits,  but  now  and  then  may  be  blended  with  them.  The  correct 
number  of  metacarpal  and  metatarsal  bones  may  be  present,  or 
they  also  may  be  multiplied.  Tn  one  of  our  cases  there  were  six 
digits  and  six  metatarsal  bones ;  but  the  last  two  digits  were  sup- 
ported by  an  accessory  metatarsal  apparently  springing  from  the 
outer  side  of  the  fourth.  The  condition  is  frequently  inherited. 
The  treatment  consists  in  removing  the  supernumerary  digits,  if 
useless,  obtrusive,  or  troublesome.  Sometimes  the  patients  are 
proud  of  their  abnormality,  and  refuse  to  part  with  it.  A  patient 
with  two  weak  thumbs  may  sometimes  be  benefited  by  uniting 
them  laterally  into  a  single  broad  one. 


39o 


A   MANUAL  OF  SURGERY 


Ectrodactylism,  or  the  absence  of  one  or  more  of  the  digits,  is 
occasionally  seen,  as  also  partial  arrests  of  development  of  fingers 
or  toes,  or  intra-uterine  amputations  at  a  higher  level. 

Macrodactyly  (Fig.  103)  consists  in  a  congenital  overgrowth  of 
one  or  more  fingers  or  toes.  The  structures  are  perfectly  normal 
in  character,  and  merely  gigantic  in  size  for  the  age  of  the 
individual.  Amputation  may  be  needed  in  these  cases,  as  the 
deformed  parts  grow  out    of  all  proportion   to  the  neighbouring 


Fig.  103. — Macrodactyly  and  Syndactyly. 

In  this  case  a  child,  aged  two  and  a  half  years,  had  the  ring  and  middle  fingers 
united  laterally  into  a  large  mass  which  projected  far  beyond  the  others. 
The  middle  finger  was  normal  in  size,  the  ring  finger  was  hyper- 
trophic. A  fruitless  attempt  was  made  to  save  the  middle  finger,  but 
both  had  finally  to  be  amputated. 

tissues.  Thus,  an  infant  with  enormous  overgrowth  of  the  second 
toe  of  the  right  foot  was  successfully  treated  by  excision  of  the 
digit,  together  with  a  V-shaped  portion  of  the  foot,  which  was  by 
this  means  reduced  to  normal  shape  and  size. 

Syndactylism,  or  webbed  fingers,  is  a  condition  in  which  two  or 
more  fingers  are  joined  together  laterally,  either  by  a  thin  web 


DEFORMITIES 


39' 


consisting  mainly  of  skin,  or  by  a  thick  fleshy  bond  of  union.  In 
the  foot  no  treatment  is  required,  but  in  the  hand  the  fingers  must 
be  separated.  If  there  is  merely  a  thin  web,  this  may  be  divided 
by  scissors ;  but  to  prevent  its  re-formation  from  below  upwards, 
as  healing  proceeds,  a  flap  of  skin  must  be  transplanted  into 
the  angle  between  the  fingers,  or  an  opening  in  the  base  of  the 
web  may  be  made  and  maintained,  and  the  edges  allowed  to 
cicatrize  before  the  web  itself  is  divided.  Where  the  union,  how- 
ever, is  thick  and  fleshy,  a  more  extensive  operation  is  needed. 
Two  flaps  of  skin  as  long  as  the  web,  and  half  the  width  of  a 
finger,  are  respectively  raised  from  the  dorsal  aspect  of  one  finger 
and  from  the  palmar  aspect  of  the  other,  in  such  a  manner  that, 
after  the  web  has  been  divided,  the  denuded  surfaces  can  be 
covered  by  wrapping  the  flaps  round  the  lateral  aspects  of  the 
fingers  and  suturing  them  in  position.  An  additional  flap  of  skin 
must  also  be  fixed  in  the  angle  between  the  separated  digits,  unless 
the  preliminary  measure  just  described  has  been  undertaken. 

Congenital  Contraction  of  the  Fingers  is  not  a  very  rare  de- 
formity ;  it  is  frequently  inherited,  and  usually  limited  to  the  little 
finger ;  it  may  be  associated  with  congenital  hammer-toe.  It  is 
due  to  contraction  of  the  central  prolongation  of  the  palmar  fascia 
in  the  finger,  whereas  in  Dupuytren's  contraction  it  is  the  palmar 
fascia  itself  and  its  lateral  prolongations  into  the  fingers  that  are 
involved.  Moreover,  the  character  of  the  deformity  differs  in  that 
in  the  congenital  form  the  first  phalanx  is  hyper-extended,  and  the 
second  and  third  flexed,  whereas  in  the  acquired  form  the  first  and 
second  phalanges  are  flexed  and  the  third  is  hyper-extended. 
Treatment. — It  often  suffices  to  use  massage  and  apply  a  splint, 
but  in  bad  cases  division  of  the  fascial  bands  may  be  needed. 

Acquired  Deformities  of  the  Hand. — After  burns  the  hand  may 
be  contracted  into  a  useless  mass  in  which  the  fingers  are  drawn 
into  the  palm  and  united  by  cicatricial  tissue  to  the  palmar 
structures,  so  that  all  treatment  is  hopeless. 

Spring-,  Jerk-,  or  Snap-Finger  is  a  curious  condition  in  which, 
when  the  patient  attempts  to  open  his  hand,  one  finger  remains 
flexed,  and  on  extending  it  with  the  other  hand  it  flies  open  with 
a  jerk  or  snap.  Some  slight  tenderness  and  pain  is  usually  felt 
near  the  metacarpo-phalangeal  articulation,  and  the  cause  of  the 
trouble  is  some  obstruction  to  the  free  working  of  the  long  tendons 
under  the  transverse  ligament  at  the  root  of  the  fingers.  In  a  few 
cases  a  ganglion  has  been  present  here,  but  in  most  instances  it 
is  due  to  an  increase  in  size  of  the  sesamoid  bone  which  the 
X-rays  have  taught  us  constantly  occurs  in  this  situation.  Treat- 
ment consists  in  an  aseptic  incision  to  remove  the  cause  of  the 
obstruction. 

A  Mallet  Finger  is  one  in  which  the  terminal  phalanx  is  main- 
tained in  a  state  a  flexion  owing  to  some  damage  to  the  extensor 
aponeurosis.  It  usually  follows  injuries,  which  lead  either  to  a 
separation  of  the  tendon  from  the  bone,  or  to  a  thinning  of  its 


392  A   MANUAL  OF  SURGERY 


texture,  whereby  the  flexor  tendon  is  able  to  act  with  undue 
power.  The  treatment  consists  in  the  application  of  an  anterior 
linger-splint  in  the  early  stages,  but  later  on,  should  the  deformity 
be  persistent,  an  incision  is  made  on  the  posterior  aspect  of  the 
joint,  and  the  weak  tendon  isolated  and  stitched  down  in  such  a 
way  as  to  give  it  a  better  attachment  to  the  bone. 

Contraction  of  the  Palmar  Fascia  (Dupuytren's  Contraction). — 
This  condition  is  usually  met  with  in  middle-aged  individuals  of  a 
gouty  temperament,  more  often  in  men  than  women,  and  not  un- 
frequently  on  both  sides  of  the  body.  It  may  or  may  not  be 
associated  with  direct  irritation  of  the  palm,  as  by  leaning  much 
on  a  round-headed  cane,  or  from  the  constant  use  of  some  instru- 
ment, such  as  an  awl,  whilst  heredity  is  an  important  causative 
factor.  Pathologically,  it  is  due  to  a  chronic  overgrowth  and 
contraction  of  the  fascia,  inflammatory  in  nature,  and  cirrhotic  or 


Fig.  104.  — Dupuytren's  Contraction.     (From  a  Photograph.) 

sclerosing  in  type.  It  commences  as  an  indurated  subcutaneous 
nodule  in  the  palm  of  the  hand,  about  the  situation  of  the  most 
marked  transverse  crease,  and  affects  most  commonly  the  ring  and 
little  fingers  first,  the  other  fingers  and  thumb  being  less  often  in- 
volved. The  induration  spreads  slowly  both  up  and  down  the 
fascial  bands  into  the  fingers,  which,  as  it  increases,  are  gradually 
drawn  into  the  palm  and  fixed,  so  that  extension  becomes  impos- 
sible (Fig.  104).  The  flexion  is  limited  to  the  first  and  second 
phalanges,  the  third  remaining  extended,  and,  indeed,  sometimes 
assuming  a  position  of  hyper-extension,  owing  to  the  injudicious 
application  of  a  splint.  The  skin  over  the  indurated  masses  is 
sooner  or  later  incorporated  with  them. 

The  Diagnosis  of  Dupuytren's  contraction  is  exceedingly  easy, 
the  only  condition  for  which  it  is  likely  to  be  mistaken  being  the 
congenital  contraction  already  noted  and  flexion  of  the  finger  due 


DEFORMITIES 


393 


to  contraction  of  the  long  tendons.  In  the  latter  case  there  is,  as 
a  rule,  no  palmar  induration,  and  on  attempting  to  straighten  the 
finger  the  tendons  may  be  felt  to  become  tense  above  the  wrist  ; 
the  terminal  phalanx  is  also  flexed  in  many  instances. 

The  only  satisfactory  Treatment  is  by  operation,  and  the  follow- 
ing methods  are  those  which  are  most  successful  :  (a)  Adams'  sub- 
cutaneous section  of  the  fascia  and  its  prolongations  consists  in 
dividing  the  indurated  bands  by  a  tenotome  in  several  places, 
where  they  can  be  felt  tense.  One  puncture  and  division  must  be 
made  in  the  centre  of  the  palm  ;  a  second  divides  the  same  band 
as  near  the  finger  as  possible,  whilst  the  third  and  fourth  deal  with 
the  lateral  prolongations  at  the  sides  of  the  finger ;  if  other 
bands  still  exist,  they  are  treated  similarly,  the  tenotome,  if 
possible,  in  all  cases  being  inserted  between  the  skin  and  the 
fascia.  The  improvement  thus 
produced  must  be  maintained 
and  increased  by  the  subsequent 
use  of  suitable  apparatus  and 
passive  movements,  but  the 
final  results  are  not  very  satis- 
factory, (b)  Kocher's  method 
consists  in  the  total  extirpa- 
tion of  the  thickened  bands  and 
their  prolongations  through 
longitudinal  incisions.  The 
fingers  are  at  once  straightened, 
and  subsequent  contraction  is 
prevented  by  mechanical  appli- 
ances. We  have  had  many 
excellent  and  lasting  cures  by 
the  latter  operation. 

Deformities  of  the  Lower 
Extremity. 

Coxa  Vara,  or  incurvation  cf 
the  neck  of  the  femur  (Fig.  105), 
is  a  condition  to  which  attention 
has  been  called  only  of  recent 
years.  The  neck  of  the  bone, 
instead    of    passing    obliquely 

upwards,  is  horizontal,  or  in  bad  cases  directed  downwards  and 
usually  backwards,  whilst  shortening  from  interstitial  absorption 
also  occurs,  and  the  head  becomes  mushroom-shaped  (Plate  IX.). 
At  first  the  osseous  tissue  is  softened,  but  after  a  while  sclerosis 
supervenes.  It  is  met  v.'ith  in  young  children  as  a  result  of  rickets, 
or  perhaps  more  frequently  in  adolescents,  when  it  is  sometimes 
supposed  to  be  a  late  manifestation  of  the  same  disease.  Certainly 
it  is  seen  most  frequently  in  those  who  have  to  do  much  walking 
or  carrying  of  heavy  weights.      In  some  cases  it  results  from  a 


Fig.  105. — Coxa  Vara. 

The  dotted   line   represents   the 
normal  neck  of  the  femur. 


394  A  MANUAL  OF  SURGERY 


gradual  slipping  down  of  the  epiphysis,  which  constitutes  the 
head  of  the  bone,  or  to  a  fracture  of  the  neck  in  a  child,  followed 
by  yielding  of  the  callus. 

The  Symptoms  commence  with  pain  in  the  region  of  the  hip, 
followed  by  a  distinct  limp.  As  the  neck  of  the  bone  becomes 
absorbed  or  curved,  the  trochanter  rises  above  Nelaton's  line, 
and  real  shortening  of  the  limb  occurs,  even  up  to  ih  inches. 
The  limb  is  also  everted  and  the  trochanter  increasingly  pro- 
minent, especially  on  flexing  the  thighs.  The  movements  of  the 
joint  are  limited,  particularly  in  the  direction  of  internal  rotation 
and  abduction,  the  latter  being  practically  impossible  in  the 
more  severe  cases,  owing  to  the  base  of  the  trochanter  hitching 
against  the  lip  of  the  acetabulum.  On  flexing  the  limb,  the 
thigh  sometimes  lies  across  the  sound  one,  whilst  in  the  later 
stages  the  adduction  may  be  so  marked  that  a  scissor-legged 
condition  occurs  if  both  sides  are  affected.  As  distinguishing 
features  may  be  mentioned  :  the  absence  of  local  swelling  or 
tenderness  on  pressure,  as  also  of  the  up-and-down  movement  on 
traction,  so  well  marked  in  congenital  dislocation,  whilst  suppura- 
tion never  follows,  and  thickening  of  the  trochanter  is  not  observed. 

Treatment. — In  the  early  stages  rest  is  the  essential,  and  thereby 
any  increase  in  the  deformity  already  existing  is  prevented  ;  local 
massage  and  manipulation  are  also  advisable,  whilst  in  children 
prolonged  extension  may  do  good.  In  the  later  stages,  subtro- 
chanteric osteotomy,  in  order  to  alter  the  axis  of  the  bone,  is  per- 
haps the  best  measure  to  undertake,  although  a  cuneiform  osteo- 
tomy of  the  neck  is  recommended  by  some.  The  subsequent 
shortening  may  be  dealt  with  by  means  of  a  thick  sole  to  the 
under  surface  of  the  boot. 

Genu  Valgum,  or  knock-knee,  is  a  deformity  in  which,  if  the 
knees  are  allowed  to  touch  with  the  patellae  looking  forwards, 
the  malleoli  are  separated  one  from  the  other — i.e.,  it  is  a  fixed 
condition  of  abduction  of  the  legs  from  the  middle  line,  with 
some  external  rotation  (Fig.  106).  One  or  both  limbs  may  be 
affected,  but  if  due  to  general  causes  the  double  form  is  more 
common.  Occasionally  genu  valgum  occurs  in  one  leg,  whilst 
the  other  is  in  a  condition  of  genu  varum. 

There  are  two  main  varieties  of  the  disease,  viz.:  (i)  The 
rachitic  genu  valgum  of  young  children,  and  (2)  the  static  form 
occurring  in  adolescents. 

The  genu  valgum  of  young  children  is  practically  always  due  to 
rickets,  in  which  the  softened  condition  of  the  bony  tissue  on  either 
side  of  the  epiphyses  results  in  an  interference  with  the  normal 
development.  It  is  still  an  open  question  as  to  whether  this 
deformity  is  primarily  due  to  increased  growth  on  the  inner  side, 
or  to  arrest  of  development  on  the  outer  ;  the  truth  probably  lies 
between  the  two.  It  is  also  a  question  as  to  whether  the  femur 
or  tibia  is  primarily  at  fault  ;  probably  the  location  of  the  mischief 


PLATE  IX. 


DEFORMITIES 


395 


varies  in  different  cases.  Some  are  certainly  due  not  to  epiphyseal 
mischief  at  all,  but  to  a  rachitic  curvature  of  the  diaphysis  of  the 
femur,  especially  when  the  child  has  been  allowed  to  walk  or  run 
about  too  early. 

The  genu  valgum  of  adolescents,  or  static  genu  valgum,  occurs 
most  commonly  in  young  people  under  twenty,  of  relaxed  consti- 
tution, and  particularly  in  those  who,  in  addition,  have  to  carry 
heavy  weights.  Thus,  anaemic  young  women  who  act  as  nurse- 
maids, and  young  bricklayers,  smiths,  and  porters,  are  very  liable 
to  it.  There  are  many  different  opinions  as  to  the  way  in  which 
it  is  produced,  but  the  most  likely  explanation  is  purely  mechanical. 
When  a  person  stands  in  the  erect  posture,  the  perpendicular  line 
which  represents  the  direction 
in  which  the  weight  is  trans- 
mitted downwards  from  the 
head  of  the  femur  passes 
through  the  outer  rather  than 
the  inner  condyle,  whilst  the 
latter  structure  is  lengthened 
in  order  to  maintain  the  hori- 
zontal position  of  the  articular 
surfaces  of  the  knee-joint.  A 
certain  amount  of  strain  is 
thus  normally  cast  upon  the 
internal  lateral  ligament  even 
in  a  healthy  person,  and  this 
is  increased  as  the  natural 
position  of  rest — i.e.,  with  the 
f^et  separated  and  slightly 
abducted  —  is  adopted.  A 
long  continuance  of  this  pos- 
ture tires  those  muscles  on 
the  inner  side  of  the  limb 
which  tend  to  counterbalance 
this  strain,  especially  if  a 
certain  amount  of  additional 

weight  has  to  be  carried,  and  particularly  in  those  whose  bones 
have  rapidly  increased  in  length  and  weight  without  any  coin- 
cident increase  in  power  of  muscles  or  ligaments.  Hence 
the  internal  lateral  ligament  becomes  more  and  more  stretched, 
and  not  unfrequently  a  certain  amount  of  lateral  mobility  of  the 
knee  is  noticed  in  the  early  stages.  Subsequently  the  outer  con- 
dyle becomes  atrophied  from  more  weight  being  transmitted 
through  it,  and  the  inner  condyle  becomes  lengthened  from  over- 
growth. It  is  also  important  to  note  that  flat-foot  and  lateral 
curvature  of  the  spine  often  accompany  this  form  of  genu  valgum, 
the  former  being  also  usually  due  to  ligamentous  relaxation,  whilst 
the  latter  may  be  merely  associated  with  it,  or  be  compensatory 
if  the  deformity  in  the  knee  is  unilateral. 


Fig.  io6.- 


-Genu  Valgum. 

MANNS.) 


(Till- 


396  A   MANUAL  OF  SURGERY 

Occasionally  genu  valgum  is  due  to  traumatic  causes,  such  as 
fracture  of  the  tibia  or  femur  close  to  the  joint,  or  lateral  dis- 
location of  the  knee ;  whilst,  again,  it  may  be  caused  by  atrophy 
consequent  on  interference  with  the  epiphysis  from  local  injury 
or  diseases  other  than  rickets.  It  is  sometimes  observed,  as  a 
result  of  riding,  in  those  with  long  legs,  as  in  cavalry  soldiers ; 
short-legged  individuals,  such  as  jockeys,  are  more  liable  to 
develop  a  condition  of  genu  varum. 

The  Physical  Condition  of  the  parts  about  the  knee  may  be 
summarized  as  follows : 

(a)  The  inner  condyle  of  the  femur  forms  a  marked  and  obvious 
subcutaneous  projection  ;  the  increase  in  size  is  mainly  in  the 
vertical  and  transverse  directions,  and  but  very  little  antero- 
posteriorly,  so  that,  on  flexion  of  the  joint,  the  deformity  to  a 
large  extent  disappears. 

(b)  In  rachitic  cases  a  localized  bony  outgrowth  can  usually  be 
detected  on  the  inner  surface  of  the  tibia  about  2  or  3  inches 
from  the  joint,  and  probably  due  to  a  localized  periostitis  at  the 
point  of  attachment  of  the  internal  lateral  ligament. 

(r)  Impaired  growth  and  atrophy  is  observed  in  the  outer 
femoral  condyle  and  tibial  tuberosity,  conditions  supposed  to  be 
due  to  the  weight  of  the  body  being  transmitted  more  directly 
through  these  structures. 

(d)  Relaxation  of  the  ligamentous  and  muscular  tissues  takes 
place  on  the  inner  side  of  the  joint.  This,  however,  is  not  con- 
stant, especially  in  the  later  stages  or  in  cases  which  are  stationary. 

(e)  The  tendons  and  ligaments  on  the  outer  aspect  of  the  joint 
are  contracted  and  shortened,  especially  the  external  lateral  liga- 
ment, the  ilio-tibial  band,  and  the  tendon  of  the  biceps. 

(/)  The  patella  tends  to  be  thrown  outwards  from  the  angular 
deformity  existing  at  the  knee-joint.  Occasionally  the  bone  is 
actually  dislocated,  and  when  this  has  once  happened  the  dis- 
placement is  very  likely  to  recur  from  time  to  time. 

The  following  secondary  conditions  may  be  met  with  resulting 
from  genu  valgum,  viz. :  The  feet  are  displaced  outwards,  or 
occasionally  inwards,  as  best  suits  the  convenience  of  the  patient 
in  obtaining  as  good  a  footing  as  possible ;  the  bones  of  the  legs 
and  of  the  thighs  are  often  bent ;  whilst,  if  unilateral,  the  pelvis 
is  tilted  downwards  on  the  affected  side,  and  the  spine  laterally 
curved  on  account  of  the  unnatural  shortness  of  the  limb. 

In  well-marked  cases  the  gait  of  the  patient  is  very  charac- 
teristic, since  the  knees  tend  to  get  in  the  way  of  each  other ; 
hence  the  term  '  knock-knee.'  The  legs  are  kept  partially  flexed, 
and  as  the  condyles  touch  or  overlap,  they  have  to  be  separated 
at  each  step  to  allow  of  progression,  and  ihus  a  curious  rolling 
sort  of  walk  results.  Occasionally  bursae  form  over  the  points 
where  the  friction  is  most  marked. 

Treatment. — In  rachitic  infants,  the  general  condition  must  be 


DEFORMITIES  397 


dealt  with  in  accordance  with  the  rules  given  elsewhere  (p.  527).  A 
suitable  diet  should  be  ordered,  cleanliness  attended  to,  and  plenty 
of  fresh  air  allowed.  Parrish's  food  is  perhaps  the  best  drug  to 
administer,  whilst  cod-liver  oil  is  rarely  needed,  since  it  tends  to 
increase  the  body-weight,  and  so  may  do  harm  rather  than  good. 
Absolute  rest  in  bed  is  enforced ;  the  limbs  are  well  rubbed  daily, 
and  such  manipulation  and  pressure  employed  as  will  tend  to 
remedy  the  deformity  and  straighten,  if  possible,  the  limb.  No 
pain  should  be  caused,  and  by  perseverance  slow  but  appreciable 
progress  may  be  made  until  the  limbs  are  straight.  In  older 
children,  especially  when  there  is  some  difficulty  in  keeping  them 
off  their  feet,  it  is  better  to  apply  splints  on  the  outer  side  of  the 
limbs,  reaching  from  the  pelvis  down  to  the  outer  malleoli,  or,  if 
need  be,  beyond  them.  These  are  retained  in  position  by  water- 
glass  bandages,  put  on  firmly  enough  to  draw  the  knees  out- 
wards. Such  an  arrangement  is  often  sufficient  in  early  cases 
to  bring  about  a  cure  in  the  course  of  a  few  months.  Some 
authorities  have  recommended  forcible  correction  of  the  deformity, 
and  subsequent  fixation  in  plaster  of  Paris,  but  the  condition  of 
the  epiphyses,  and  the  ease  with  which  they  are  detached,  are 
good  reasons  against  adopting  any  such  method. 

In  the  static  cases  the  administration  of  tonics,  such  as  iron  and 
arsenic,  combined  with  rest,  massage,  and  possibly  a  change  of 
air,  will  frequently  suffice  to  determine  a  cure  in  the  early  stages. 

When  the  deformity  is  somewhat  more  advanced,  more  efficient 
apparatus  is  needed  ;  that  usually  employed  consists  of  an  outside 
iron  stem,  jointed  at  the  knee,  fixed  below  into  a  slot  in  the  heel 
of  a  well-made  boot,  and  attached  above  to  a  pelvic  band.  From 
it  several  well- padded  straps  pass  round  the  limb,  and  at  the 
knee  itself  a  much  broader  one  covers  the  projecting  inner 
condyle ;  by  tightening  these,  the  limb  is  drawn  out  towards 
the  rod.  The  apparatus  is  somewhat  heavy,  but  if  carefully 
applied  for  some  months  may  effect  a  cure.  It  is  possible  that 
division  of  the  tense  structures  on  the  outer  side  of  the  joint  may 
considerably  assist  the  process. 

When,  however,  the  osseous  deformity  is  marked,  and  the  patient 
of  such  an  age  as  to  preclude  the  hope  of  a  cure  by  mechanical 
means,  osteotomy  must  be  resorted  to.  Amongst  the  many  plans 
which  have  been  suggested,  only  two  need  be  mentioned  here, 
viz.,  those  devised  by  Ogston  and  Macewen.  Ogston's  operation 
consists  in  sawing  off  the  enlarged  inner  condyle  through  an 
incision  made  by  inserting  a  narrow  finger-knife  obliquely  above 
the  condyle,  and  pushing  it  downwards  in  front  of  the  bone  to  the 
level  of  the  articulation.  The  objections  to  the  plan  are  the 
necessary  implication  of  the  joint  and  of  the  epiphyseal  cartilage, 
so  that  ankylosis  may  occur  on  the  one  hand,  or  such  interference 
with  the  growth  of  the  inner  condyle,  on  the  other,  as  leads  later 
on  to  genu  varum.     The  immediate  result   is  very  satisfactory, 


398  A  MANUAL  OF  SURGERY 


and  it  may  be  used  with  success  in  adults  where  no  more  growth 
is  expected.  Macewcns  operation  is,  however,  that  most  generally 
applicable,  and  has  practically  superseded  all  others.  It  consists 
in  the  division  of  the  femur  transversely  about  a  finger's  breadth 
above  the  upper  border  of  the  external  condyle,  so  as  to  be  well 
away  from  the  epiphyseal  cartilage.  Macewen  himself  uses  an 
osteotome*  for  the  purpose,  introducing  it  through  an  incision 
made  £  inch  in  front  of  the  tendon  of  the  adductor  magnus,  and 
turning  it  so  as  to  lie  at  right  angles  to  the  long  axis  of  the  shaft ; 
he  divides  the  bone  for  three-quarters  of  its  diameter,  and  breaks 
the  remainder.  A  similar  method  may  be  employed  from  the 
outer  side,  the  force  used  in  breaking  the  inner  layer  of  compact 
bone  comminuting  and  compressing  that  portion,  and  so  diminish- 
ing the  deformity.  Many  surgeons,  however,  prefer  to  divide  the 
bone  with  a  saw,  previously  making  a  track  for  it  along  the  front 
of  the  femur,  and  we  certainly  consider  that  such  an  operation  is 
simpler,  and  equally  efficacious.  The  limb,  having  been  straight- 
ened, is  either  put  up  at  once  in  plaster  of  Paris,  or,  perhaps,  at 
first  in  a  Gooch's  splint,  which  allows  the  wound  to  be  looked  at 
and  dressed,  and  subsequently  in  plaster.  Union  is  complete 
in  six  weeks,  but  an  immovable  apparatus  should  be  kept  on  for 
three  months. 

In  a  few  cases  due  to  rickets  it  may  be  necessary  to  divide  the 
tibia  just  below  the  tubercle  in  addition  to  dealing  with  the  femur. 
This  is  best  accomplished  as  a  first  step,  and  if  necessary  the 
fibula  may  also  be  divided.  When  these  wounds  have  con- 
solidated, the  femur  is  dealt  with,  if  necessary. 

Genu  Varum  (one  form  of  bow-leg)  is  a  less  common  condition, 
the  exact  opposite  of  genu  valgum,  and  what  has  been  said  above 
of  the  one  is  true  of  the  other,  if  the  word  '  internal '  be  substituted 
for  '  external '  and  vice  versa.  Treatment  is  only  required  in  bad 
cases. 

Genu  Recurvatum,  or  Back-knee,  is  a  deformity  occasionally  met 
with  in  which  the  joint  is  hyper-extended,  the  limb  describing  a 
curve  with  the  concavity  forwards  ;  it  is  necessarily  associated 
with  relaxation  or  stretching  of  the  crucial  ligaments,  and  is  usually 
due  to  a  congenital  displacement,  possibly  the  result  of  the  limbs 
not  being  flexed  in  ntero,  but  extended  with  the  feet  under  the 
chin.  It  is  sometimes  the  result  of  paralysis  of  the  flexor  muscles 
of  the  knee  and  of  the  popliteus,  or  may  arise  from  irregular 
growth  along  the  epiphyseal  line,  possibly  as  a  sequela  of  tuber- 
culous or  other  disease  of  limited  extent  in  that  region.  It  has  also 
been  known  to  occur  as  an  acquired  accomplishment  m  fakirs  and 

*  An  osteotome  differs  from  a  chisel  in  the  fact  that  the  former  is  bevelled  on 
both  sides,  whilst  the  latter  is  merely  bevelled  on  one  side. 


DEFORMITIES  399 


contortionists.     If  treatment  is  necessary,  it  must  be  suited  to  the 
special  requirements  of  the  individual  case. 

Contractions  of  the  Knee  may  arise  from  many  different  causes, 
which  may  be  either  intra-  or  extra-articular  in  character.  The 
extra-articular  causes  of  this  affection  may  be  situated  (1)  in  the 
skin  and  subcutaneous  tissue,  as  a  result  of  the  contraction  of 
cicatrices  of  burns  or  ulcers  ;  or  (2)  in  the  flexor  muscles,  which 
may  become  contracted  in  consequencce  of  diffuse  suppuration 
within  their  sheaths,  or  of  infantile  paralysis  of  the  extensors,  or 
as  a  secondary  result  of  inflammatory  troubles  in  the  knee-joint. 
(3)  The  contraction  is  in  some  cases  hysterical  in  origin,  the  joint 
being  fixed  by  muscular  action,  but  remaining  healthy,  although 
much  local  pain  and  superficial  tenderness  are  complained  of. 
The  diagnosis  of  such  a  condition  is  readily  made  by  inducing 
anaesthesia,  or  taking  the  patient  unawares,  when  the  limb  is 
found  freely  moveable  and  can  easily  be  straightened.  The 
treatment  of  the  preceding  conditions  is  conducted  on  general 
principles. 

The  articular  causes  of  contracted  knee  are  as  follows:  (1)  Where 
the  capsule  and  ligaments  are  affected  as  well  as  the  muscles,  the 
causative  inflammation  having  been  usually  of  a  rheumatic  or 
gonorrhceal  nature.  The  limb  is  fixed,  but  there  is  no  actual 
displacement  of  the  head  of  the  tibia.  (2)  Fibrous  adhesions  of 
greater  or  less  density  may  pass  between  the  articular  surfaces, 
as  a  result  either  of  acute  synovitis,  or  of  tuberculous  or  acute 
arthritis.  In  the  former  case  some  mobility  may  be  present,  but 
in  the  latter  the  movements  may  be  very  defective.  (3)  Osseous 
ankylosis  may  exist  as  an  outcome  of  tuberculous  or  acute 
arthritis,  the  position  of  the  limb  depending  on  the  previous 
treatment  of  the  case.  Thus  the  limb  may  be  straight  and  in 
good  position,  but  occasionally  the  tibia  is  flexed  on  the  femur, 
whilst  its  upper  articular  surface  is  displaced  horizontally  back- 
wards, and  the  lower  limb  rotated  outwards,  constituting  what  is 
known  as  the  triple  displacement.  If  the  limb  has  been  allowed  to 
lie  on  its  outer  side  whilst  disorganization  was  proceeding,  there 
may  be  an  additional  lateral  displacement  of  the  head  of  the 
tibia  outwards.  (4)  After  partial  excision  in  early  life,  the  knee 
may  become  flexed  or  hyper-extended  years  later,  as  a  result  of 
irregular  growth  at  the  epiphyseal  line.  Flexion  is  much  more 
common  than  extension. 

The  Treatment  of  these  conditions  necessarily  depends  on  their 
nature.  Where  adhesions  exist  within  the  joint,  or  the  ligaments 
alone  are  contracted,  it  may  be  possible  to  straighten  the  limb 
under  an  anaesthetic  by  forcible  manipulation.  Where  the  con- 
traction is  associated  with  osseous  ankylosis,  a  suitable  wedge- 
shaped  piece  of  bone  {cuneiform  osteotomy)  should  be  removed.  In 
the  triple  displacement  ordinary  excision  may  be  undertaken,  but 


400  A  MANUAL  OF  SURGERY 

it  is  often  a  difficult  matter  to  remedy  the  backward  displacement 
of  the  tibia.  The  bones  should  subsequently  be  kept  in  position 
by  silver-wire  sutures,  or  other  means. 

Rachitic  Tibia  and  Fibula. — It  will  be  hereafter  pointed  out  that 
the  tibia  and  fibula  are  liable  to  a  considerable  amount  of  dis- 
tortion in  the  course  of  an  attack  of  rickets  if  the  child  is  allowed 
to  run  about.  As  a  rule,  the  antero-posterior  curve  is  increased, 
and  some  amount  of  ab-  or  ad-duction  may  also  be  present 
(Fig.  182).  The  bones,  too,  are  usually  flattened  from  side  to 
side,  presenting  a  sharp  edge,  and  with  a  buttress-like  support 
reaching  along  the  concavity  ;  they  become  exceedingly  dense 
and  sclerosed.  Operations  for  remedying  the  defect  should 
never  be  undertaken,  however,  until  all  active  signs  of  rickets 
have  disappeared.  Osteotomy  may  then  be  performed,  and 
the  character  of  the  operation  will  necessarily  vary  with  the 
amount  of  deformity.  The  general  rule  for  the  guidance  of  the 
surgeon  is  either  to  divide  the  bones  at  their  most  prominent 
part,  or,  if  it  is  considered  necessary,  to  remove  a  wedge-shaped 
portion  from  the  tibia  (cuneiform  osteotomy)  ;  the  sections  should 
always  be  made  at  right  angles  to  the  upper  and  lower  segments 
of  the  bone  respectively.  The  fibula  never  needs  more  than 
simple  division,  and  this  is  accomplished  through  a  separate 
incision. 

The  tibia  and  fibula  also  become  distorted  and  curved  antero- 
posteriorly  as  the  result  of  inherited  syphilis.  The  deformity  in 
this  case  is  purely  antero-posterior,  without  lateral  deviation, 
whilst  the  subcutaneous  margin  of  the  tibia  is  rounded,  and  not 
sharp  as  in  rickets.  Moreover,  the  curve  is  mainly  placed  in  the 
centre  of  the  shaft,  whilst  in  rickets  the  chief  deformity  occurs 
either  near  the  knee  or  a  little  above  the  ankle.  There  ought, 
therefore,  to  be  but  little  difficulty  in  distinguishing  these  two 
conditions,  and  a  careful  inquiry  as  to  the  previous  history  of 
the  case  should  materially  assist  the  surgeon  in  forming  a  correct 
diagnosis. 

Talipes. 

By  talipes,  or  club-foot,  is  meant  a  deformity  of  the  foot  due 
to  muscular,  ligamentous,  or  osseous  causes,  the  displacement 
occurring  mainly  at  the  ankle  and  mid-tarsal  joints. 

Causes. — Talipes  may  generally  be  said  to  result  from  some 
derangement  in  the  equilibrium  normally  maintained  between 
opposing  groups  of  muscles,  in  consequence  of  which  the  more 
powerful  group  draws  the  foot  into  an  abnormal  position.  Con- 
sidered more  in  detail,  it  is  well  to  study  the  aetiology  of  the 
acquired  and  congenital  forms  separately. 

Congenital  malformation  or  malposition  is  responsible  for  a 
certain  percentage  of  the  cases.     Such  may  result  from  imperfect 


DEFORMITIES  401 


development  of  the  bones  of  the  foot  or  leg,  or  from  intra-uterine 
paralysis  of  central  origin.  Other  cases  seem  to  be  due  to  a 
deficient  amount  of  liquor  amnii,  as  a  result  of  which  the  feet 
are  abnormally  compressed,  and  held  in  one  position.  It  must 
be  remembered  in  this  connection  that  in  the  foetus  the  legs  are 
naturally  in  a  state  of  flexion,  and  the  feet  usually  in  the 
position  corresponding  to  that  of  talipes  varus ;  it  is  easy  then  to 
understand  that  in  an  unusually  small  uterus  this  tendency  may 
be  exaggerated.  Spina  bifida  in  the  lumbar  region  is  occasionally 
associated  with  congenital  talipes,  which  is  then  probably  due  to 
impairment  of  nervous  control.  The  congenital  variety  is  often 
hereditary,  and  may  occur  in  several  members  of  the  same  family, 
or  be  transmitted  through  many  generations. 

The  acquired  varieties  are  somewhat  easier  to  understand  than 
the  congenital,  since  they  arise  from  definite  pathological  lesions, 
such  as :  (a)  Paralysis  of  central  origin,  one  of  the  commonest 
causes  of  talipes ;  in  young  children  it  is  usually  due  to  infantile 
palsy  (anterior  polio-myelitis),  whilst  a  similar  affection  is 
occasionally  seen  in  adults,  (b)  Contraction  of  muscles,  the 
result  of  diffuse  suppuration,  arising  from  burns  or  disease  of 
neighbouring  bones  ;  thus,  necrosis,  or  caries,  of  the  tibia  may 
lead  to  the  formation  of  an  abscess  in  the  sheaths  of  the  tibialis 
anticus  or  posticus,  and  contraction  of  one  or  both  of  these 
muscles  may  cause  talipes  varus,  (c)  Essential  shrinking,  re- 
sulting from  a  transformation  of  the  muscle  substance  into  fibro- 
cicatricial  tissue,  is  occasionally  met  with  in  elderly  people  ;  it  is 
due  to  a  chronic  inflammation  (myositis  fibrosa),  the  nature  of 
which  is  but  little  understood,  (d)  Affections  of  the  main 
peripheral  nerve  trunks  of  the  leg  also  result  in  talipes.  If  the 
internal  popliteal  nerve  is  involved,  talipes  calcaneo-valgus  will 
ensue,  whilst  a  lesion  of  the  external  popliteal  nerve  produces  talipes 
equino-varus,  but  never  to  any  marked  degree,  (e)  Deep  spinal 
mischief  of  a  sclerosing  type  occasionally  leads  to  spasm  of  some 
group  of  muscles  and  talipes  of  a  spastic  type.  (/)  Shortening  of 
the  leg  from  hip  or  knee  mischief  often  causes  a  compensatory 
talipes  equinus,  whilst  injuries  or  diseases  of  one  of  the  epiphyses 
of  the  leg-bones  may  stop  its  growth,  and  then  the  continued 
development  of  the  other  bone  forces  the  foot  to  one  side  or  the 
other,  (g)  It  is  a  question  whether  the  condition  known  as  flat- 
foot,  arising  from  prolonged  standing,  is  to  be  classed  as  a  form  of 
talipes ;  some  surgeons  draw  but  little  difference  between  it  and 
talipes  valgus,  (h)  Finally,  prolonged  maintenance  of  the  foot  in 
a  bad  position  may  lead  to  permanent  deformity,  as  in  the  variety 
known  as  talipes  decubitus.  The  barbarous  custom  still  practised 
by  the  Chinese  of  forcibly  compressing  the  feet  of  female  children 
brings  about  a  similar  result. 

Varieties. — In  considering  the  different  forms  of  club-foot,  it 
must  be  remembered  that  the  ankle  is  a  hinge  joint  only  allowing 

26 


402 


A   MANUAL  OF  SURGERY 


of  flexion  and  extension,  although  when  fully  plantar-flexed  a  little 
lateral  mobility  is  also  possible.  The  movements  of  abduction 
and  adduction  of  the  loot  take  place  chiefly  below  the  astragalus 
and  at  the  mid-tarsal  articulation.  Four  primary  varieties  of 
talipes  are  hence  described,  viz. :  T.  Equinus,  in  which  the  heel 
is  drawn  up,  the  patient  walking  on  the  toes  (plantar-flexion) ; 


A  B  C 

Fig.   107. — Various  Forms  of  Talipes  Equinus. 


T.  Calcaneus,  in  which  the  toes  are  raised  from  the  ground  (dorsi- 
flexion)  ;  T.  Varus,  in  which  the  anterior  half  of  the  foot  is 
adducted,  and  the  inner  side  of  the  foot  is  raised,  the  patient 
walking  on  the  outer ;  and  T.  Valgus,  due  to  abduction  and 
eversion  of  the  anterior  half  of  the  foot,  or  to  yielding  of  the 
longitudinal  arch  on  the  inner  side.  Not  unfrequently  mixed 
forms  occur,  due  to  the  association  of  two  of  the  above,  e.g., 
T.  equino-varus,  or  T.  equino-valgus  or  T.  calcaneo-valgus. 

As  to  the  relative  frequency  of  these  different  forms,  there  is  not 
the  slightest  question  that  T.  equino-varus  is  by  far  the  commonest. 
If,  however,  we  exclude  congenital  cases  and  flat-foot,  T.  equinus 
is  in  all  probability  the  variety  most  frequently  observed. 

Talipes  Equinus  (Fig.  107,  A,  B,  and  C)  is  almost  always  acquired ; 
it  has  been  known  to  occur  congenitally,  but  this  is  exceedingly 
rare.  It  is  usually  due  to  paralysis  of  the  extensor  muscles, 
either  from  infantile  palsy  or  injury  to  the  anterior  tibial  nerve  ; 
secondary  contraction  of  the  calf  muscles  follows,  the  tendo 
Achillis  being  specially  tense  and  rigid.  It  also  occurs  as  a  com- 
pensatory manifestation  where  the  limb  has  been  shortened,  as 
after  hip  disease,  and  a  variety  known  as  T.  decubitus  results 
from  the  bed-clothes  pressing"  for  some  length  of  time  on  the 
dorsum  of  the  foot  of  a  bed-ridden  patient. 


DEFORMITIES 


403 


In  the  slightest  cases  all  that  is  noticed  is  that  the  foot  cannot 
be  dorsi-flexed  beyond  a  right  angle  (right-angled  contraction  of 
the  ankle).  When  the  condition  is  more  marked,  the  heel  is 
actually  drawn  up,  and  the  patient  walks  on  the  heads  of  the 
metatarsal  bones  and  on  the  toes,  which  are  usually  hyper- 
extended.  Occasionally,  however,  in  neglected  cases  due  to 
paralysis,  the  toes,  instead  of  being  extended,  become  flexed,  the 


Fig.   108. 


-Congenital  Talipes 
Varus. 


Fig. 


mm 

109. — Paralytic  Form  of 
Talipes  Equino-varus. 


patient  walking  on  their  upper  surface  (Fig.  107,  C)  ;  if  such  a 
condition  is  allowed  to  persist,  the  whole  dorsum  of  the  foot  may 
in  time  be  turned  downwards.  The  astragalus  is  somewhat  dis- 
placed from  under  the  malleolar  arch,  only  the  posterior  part  of 
the  articular  surface  being  in  contact  with  the  tibia.  In  cases 
due  to  paralysis  the  deformity  is  always  associated  with 
dropping  of  the  anterior  segment  of  the  foot  at  the  mid-tarsal 
joint,  so  that  the  head  of  the  astragalus  and  scaphoid  constitute 
a  marked  prominence  beneath  the  skin.  In  all  cases  the  sole  of 
the  foot  is  shortened  by  contraction  of  the  plantar  fascia,  and  of 
the  short  plantar  muscles,  a  condition  we  shall  shortly  refer  to 
under  the  name  of  pes  cavus.  In  old-standing  cases  a  certain 
amount  of  varus  is  almost  always  present.  In  this,  as  in  all  forms 
of  talipes,  callosities,  and  perhaps  bursae  beneath  them,  form  over 
points  of  pressure,  viz.,  under  the  heads  of  all  the  metatarsal 
bones. 

Talipes  Varus,  or,  as  it  is  most  frequently  termed,  Equino-varus, 
is  the  commonest  variety  of  congenital  club-foot,  but  is  not  a 
very  unusual  result  of  infantile  palsy  of  the  extensor  and  peroneal 
muscles,  with  secondary  shortening  of  the  tibialis  anticus  and 
posticus,  the  flexor  longus  digitorum,  and  of  the  tendo  Achillis. 
Other  cases  are  due  to  a  primary  spastic  contraction  of  these 
muscles. 


4°4 


A  MANUAL  OF  SURGERY 


The  heel  is  drawn  up,  and  the  anterior  half  of  the  foot  adducted 
and  drawn  inwards  (Fig.  108).  The  inner  border  of  the  foot  is 
concave,  and  a  well-marked  transverse  crease  crosses  the  sole  on 
a  level  with  the  mid-tarsal  joint  ;  the  outer  border  is  convex,  and 
in  adults  who  have  walked  a  thick  bursal  formation  is  usually 
present  over  the  cuboid.  In  neglected  cases  the  patient  may  even 
stand  on  the  dorsal  aspect  of  the  latter  bone  (Fig.  no,  A).     The 


A  B 

Fig.  iio. — Neglected  Case  of  Talipes  Varus. 


sole  of  the  foot  is  arched  from  secondary  contraction  of  the 
plantar  fascia  and  short  muscles  of  the  sole,  especially  the  abductor 
hallucis,  and  a  longitudinal  crease  may  run  down  the  centre  of 
the  sole,  owing  to  doubling  over  of  the  outer  metatarsal  bones 
(Fig.  no,  B). 

The  most  marked  Anatomical  Changes  are  found  in  the  astra- 
galus. In  infants  the  head  and  neck  are  normally  set  at  an  angle 
to  the  body  of  the  bone,  being  directed  slightly  inwards ;  as 
growth  proceeds,  this  diminishes  from  about  350  to  10°,  so  that 
in  the  adult  there  is  but  little  obliquity  of  the  neck.  In  Talipes 
varus  this  angle  is  increased,  often  amounting  to  500  or  more,  the 
neck  at  the  same  time  being  longer  than  usual,  a  condition  simu- 
lating that  found  in  some  of  the  higher  apes.  The  bone  also 
projects  forwards  from  under  the  tibio-fibular  arch,  the  posterior 
portion  of  the  upper  articular  facet  alone  remaining  in  contact 
with  it.  The  scaphoid  is  displaced  to  the  inner  side  of  the  head 
of  the  astragalus,  so  that  only  the  inner  portion  of  the  latter 
structure  articulates  with  it ;  the  tuberosity  is  usually  in  close 
proximity  to,  or  may  even  touch,  the  inner  malleolus.  The  os 
calcis  and  other  tarsal  bones  are  also  modified  to  some  extent  in 
position  and  shape  to  correspond  with  these  changes.  The  dorsal 
tendons  are  displaced  slightly  inwards,  usually  occupying  the 
centre  of  the  concavity  between  the  foot  and  the  leg.  The  liga- 
ments on  the  inner  side  of  the  foot  are  contracted,  especially  the 
anterior  portion  of  the  deltoid,  the  inferior  calcaneo-scaphoid,  and 
to  a  less  extent  the  long  and  short  plantar  ligaments. 


DEFORMITIES 


405 


The  following  table  (slightly  modified  from  Mr.  Tubby's  ex- 
cellent work  on  Deformities")  will  suffice  to  indicate  the  chief 
diagnostic  points  between  congenital  and  paralytic  T.  equino- 
varus : 

Congenital.  Paralytic. 

History Affection  has  existed     Affection  not  developed  till 

from  birth.  the  second  or  third  year, 

and  ushered  in  by  convul- 
sions, fever,  etc. 

Feet  affected    Usually  bilateral.  More  often  unilateral. 

Circulation Good.  Feeble;  limb  is  cold,  blue, 

and  clammy. 

Muscles     But  little  wasting.  Extreme  wasting. 

Electrical  Reactions     Not  much  impaired.       Almost    entirely    absent    in 

paralyzed  muscles. 

Growth  of  Bones.  .. .     Much  as  usual.  Considerably  diminished. 

Furrows  in  Sole  ....     Present.  Absent. 

Talipes  Calcaneus  (Fig.  11 1)  is  an  unusual  variety  of  the 
deformity,  and  may  be  either  congenital  or  acquired.  In  the 
congenital  form  the  toes  are  drawn  up- 
wards so  that  the  heel  alone  comes  into 
contact  with  the  ground,  the  sole  point- 
ing forwards.  The  extensor  tendons  are 
contracted,  but  the  toes  may  be  flexed 
owing  to  the  tension  of  the  flexor  longus 
digitorum.  It  is  sometimes  associated 
with  deviation  of  the  foot  inwards  or 
outwards,  constituting  a  condition  of 
T.  calcaneo  -  varus  or  -  valgus.  The  ^ 
inquired  variety  is  generally  due  to  vi%aBS! 
infantile  palsy  of  the  call    musi  les,   but  ^fj^lr  ■• 

occasionally  results  from  over-stretching 
of    the    tendo   Achillis    after   tenotomy. 
The   longitudinal   arch   of    the    foot   is 
increased,  partly  from  the  development        Talipes  Calcaneus. 
of  a  large  pad  of  fat  over  the  calcaneal 

tuberosities,  but  mainly  from  the  toes  not  being  drawn  up  towards 
the  leg  as  in  the  preceding  variety.  The  anterior  half  of  the 
foot  appears  to  drop  forwards  from  the  mid-tarsal  joint  owing  to 
secondary  contraction  of  the  plantar  fascia  and  short  muscles  of 
the  sole. 

Talipes  Valgus  is  a  condition  seldom  met  with  as  a  congenital 
deformity,  except  in  association  with  T.  equinus.  In  it  the  outer 
side  of  the  foot  is  abducted  and  everted,  owing  to  contraction  of 
the  peronei  muscles.  The  sole  becomes  flattened,  and  the  inner 
border  of  the  foot  comes  in  contact  with  the  ground  (Fig.  112). 
Considerable  pain  is  usually  experienced  after  walking  a  short 
distance.     The  scaphoid  is  displaced  outwards,  so  that  the  inner 

*  Macmillan,  1896,  p.  398. 


406 


A  MANUAL  OF  SURGERY 


portion  of  the  head  of  the  astragalus  projects  into  the  sole  of  the 
foot,  the  cartilage  being  uncovered.  This  deformity  is  occasionally 
due  to  absence  of  the  fibula.  The  acquired  variety,  which  is  not 
uncommon  (Fig.  113),  is  produced  as  a  result  of  paralysis  of  the 
tibial  muscles,  or  from  spastic  contraction  of  the  peronei,  the 
condition  in  these  cases  closely  simulating  the  deformity  known 
as  fiat-foot. 

The  Diagnosis  of  the  different  varieties  of  talipes  is,  as  a  rule, 


a  t 

Fig.  112. — Talipes  Valgus  (Congenital), 
with  a  Little  Tendency  to  Calcaneus. 


Fig.  113. — Acquired  Talipes 
Valgus. 


easily  made,  although  the  cause  of  the  deformity  is  not  always 
so  readily  ascertained.  In  paralytic  cases  the  limb  is  always 
atrophied,  bluish  in  colour,  and  feels  cold  and  clammy.  Trophic 
lesions  are  not  uncommon  in  the  shape  of  recurrent  ulceration, 
and  even  ulcers  of  the  perforating  type  may  develop,  especially  in 
cases  due  to  nerve  lesions,  whether  central  or  peripheral.  The 
trouble  is  often  unilateral,  and  the  muscles  are  wasted  and 
flabby.  In  congenital  cases  the  condition  is  usually  symmetrical, 
and  of  course  present  from  birth  ;  considerable  resistance  is  felt 
on  any  attempt  being  made  to  correct  the  deformity,  and  the 
limbs  are  well  nourished,  at  any  rate  at  first.  In  spastic  cases 
(most  frequently  T.  equinus)  spasm  or  contraction  of  other  parts 
is  usually  present,  which  renders  the  diagnosis  obvious ;  one  or 
both  limbs  may  be  affected ;  the  muscles,  at  first  firmly  con- 
tracted, may  finally  atrophy. 

The  Treatment  of  talipes  is  always  somewhat  tedious,  demand- 
ing care  and  patience  on  the  part  of  all  concerned.  In  the  con- 
genital variety  no  time  should  be  lost  in  correcting  the  deformity, 
and,  in  fact,  treatment  should  commence  as  soon  after  birth  as 
possible.  The  nurse  must  be  instructed  to  manipulate  the  foot 
into  a  good  position,  holding  it  there  for  some  time  daily.  At 
the  same  time  the  muscles  on  the  offending  side  of  the  limb 
should  be  rubbed  and  stimulated.  In  the  early  stages  of  the 
paralytic  variety  friction  and  faradization  of  the  paralyzed  muscles 
must  be  regularly  undertaken.     At  a  somewhat  later  date  treat- 


DEFORMITIES 


407 


ment  by  the  application  of  suitable  mechanical  apparatus  may 
suffice  to  restore  the  foot  to  its  normal  position.  If  this  is  un- 
successful, division  of  the  contracted  tendons,  ligaments,  and 
fasciae  will  be  necessary,  whilst  in  severe  and  neglected  cases 
more  extensive  operations  in  the  shape  of  tarsectomy  or  tarsotomy 
may  have  to  be  performed. 

Talipes  equinus,  if  secondary  to  hip  disease,  should  not,  as  a  rule, 
be  interfered  with.     In  other  early  cases,  it  may  be  remedied  by 


Fig.  114. — Sayre's  Apparatus  for  Talipes  Equinus. 
The  upper  figure  shews  how  the  strapping  is  fixed  to  the  plantar  splint. 

what  is  known  as  Sayre's  apparatus  (Fig.  114).  This  consists  in 
the  application  of  a  plantar  splint  which  projects  slightly  beyond 
the  toes,  and  from  the  anterior  end  of  which  a  piece  of  adhesive 
strapping  is  carried  to  just  below  the  knee,  to  which  it  is  applied 
and  fixed  by  a  firm  bandage.  Each  day  the  bandage  is  carried 
a  little  lower  down  the  limb,  and  as  the  traction  of  the  strapping 
is  thereby  increased,  the  foot  is  gradually  extended.  In  the  more 
serious  varieties  tenotomy  of  the  tendo  Achillis  may  be  required, 
accompanied,  if  necessary,  by  division  of  the  plantar  fascia,  whilst 
in  neglected  cases,  or  where  tenotomy  has  failed,  excision  of  the 
astragalus  gives  most  excellent  results,  the  patient  being  able  to 
walk  subsequently  with  a  plantigrade  foot. 

Talipes  equino-vavus  may  be  treated  in  the  early  stages  by  apply- 
ing to  the  foot  a  carefully-fitted  malleable  splint  (Fig.  115),  the 
shape  of  which  is  gradually  altered  so  as  to  bring  it  in  time  to  a 
normal  position,  or  by  a  series  of  casings  of  plaster  of  Paris,  a 
little  improvement  being  obtained  at  each  change.  By  care  and 
patience  many  a  cure  will  thus  be  obtained.  In  some  cases  the 
tendo  Achillis  may  be  divided  and  the  equinus  element  cured, 
thereby  rendering  the  varus  condition  more  amenable  to  pressure. 
Should  this  fail,  tenotomy  of  the  tibial  tendons  may  be  under- 
taken, and  the  limb  is  at  once  restored  to  a  good  position,  and  put 
up  in  plaster  of  Paris.  In  the  more  marked  cases  division  of  the 
tense  ligaments  on  the  inner  side  of  the  foot  (syndesmotomy)  may 


4o8  A  MANUAL  OF  SURGERY 

be  necessary,  particularly  the  anterior  portion  of  the  internal 
lateral  ligament  of  the  ankle-joint.  The  abductor  hallucis  muscle 
may  also  require  section. 

In  neglected  cases  where  the  patient  walks  on  the  outer  aspect 
of  the  foot,  two  chief  forms  of  operative  treatment  have  been 
advocated,  viz.,  tarsectomy,  and  Phelps'  operation,  i.  In  tarsectomy, 
a   wedge  shaped    portion   of    bone   is   removed   from   the   outer 


Fig    115. — Malleable  Splint  for  Treatment  of  Congenital  Talipes 
Equino-varus. 

It  consists  of  two  plates  of  metal,  shaped  to  fit  the  sole  of  the  foot  and  the 
lower  part  of  the  leg  respectively ;  these  are  united  by  a  malleable  curved 
bar  of  copper.  The  foot-piece  is  first  fixed,  and  then  the  foot  brought 
into  as  good  a  position  as  possible,  and  the  leg-piece  bandaged  on.  Each 
week  the  foot-piece  is  bent  a  little  more  towards  the  normal  position. 

aspect  of  the  foot.  This  is  accomplished  through  an  incision 
round  the  outer  border  on  a  level  with  the  cuboid.  The  thick 
subcutaneous  structures,  including  the  bursa,  are  removed,  and 
the  tendons  stripped  up  from  the  bones  both  on  the  dorsal  and 
plantar  aspects  by  the  aid  of  a  raspatory,  and  held  aside  by 
retractors.  The  extensor  tendons  are  already  displaced  some- 
what inwards,  and  hence  are  not  injured  by  this  proceeding.  The 
tarsus  is  now  divided  by  a  chisel  in  two  places  in  such  a  way 
that  a  wedge  of  bone  can  be  removed,  the  base  being  on  the 
outer  aspect,  and  the  apex  on  the  inner.  The  position  of  the 
joints  need  not  be  taken  into  consideration,  and  as  far  as  possible 
the  sections  are  made  at  right  angles  to  the  anterior  and  posterior 
segments  of  the  foot  respectively.  The  wound  is  closed,  and  the 
foot  placed  in  a  good  position,  in  which  it  is  maintained  by  plaster 
of  Paris.  The  after-treatment  is  likely  to  be  prolonged,  but 
otherwise  the  results  are  excellent,  the  foot,  although  a  little 
shortened,  being  firm  and  plantigrade.  2.  Phelps'  opevation  con- 
sists in  dividing  all  the  structures  on  the  inner  aspect  of  the  foot 
through  a  vertical  incision,  starting  above  just  in  front  of  the 
internal  malleolus.  Joints  are,  if  need  be,  opened,  tendons  and 
ligaments  divided,  and  the  foot  put  up  in  a  good  position  with 
the  wound  gaping.     Healing  may  be  accelerated  by  skin  grafting. 


DEFORMITIES 


409 


The  results  are  at  first  quite  as  good  as  those  attained  by  tarsec- 
tomy,  and  the  operation  has  the  advantage  of  not  shortening  the 
foot ;  but  there  is  a  decided  tendency  for  the  deformity  to  recur 
as  cicatrization  advances. 

In  talipes  calcaneus  all  that  may  be  needed  is  division  of  the 
extensor  tendons ;  but  in  the  paralytic  variety  some  form  of 
apparatus  must  always  be  worn.  Where  the  tendo  Achillis  is 
thin  and  attenuated,  a  portion  of  it  may  be  excised,  and  the  ends 
united  by  suture ;  or  the  healthy  peroneus  longus  tendon  may  be 
grafted  into  the  tendo  Achillis  ;  or  the  tubercle  of  the  os  calcis 
into  which  the  latter  is  inserted  may  be  sawn  off  and  reattached 
by  a  nail  or  peg  to  the  bone  at  a  lower  level  (Walsham)  ;  but  the 
prognosis  in  all  forms  due  to  paralysis  is  somewhat  unsatisfactory. 

Talipes  valgus,  if  unrelieved  by  the  application  of  suitable  boots, 
may  need  division  of  the  peroneal  tendons,  or  in  severer  cases 
wrenching  the  foot  into  position,  and  fixation  in  plaster  of  Paris. 
Removal  of  a  wedge-shaped  portion  of  bone  from  the  inner  aspect 
of  the  foot  may  be  undertaken,  but  is  not  very  successful. 

Flat-foot  (syn. :  Splay-foot  or  Spurious  Valgus)  is  a  condition 
frequently  seen  in  young  adults  whose  occupation  exposes  them 
to  long  standing,  over-fatigue,  or  the  carrying  of  heavy  weights; 
hence  it  is  commonly  met  with  in  nurse-girls  and  shop-boys  who 
have  only  recently  left  school,  any  general  deterioration  of  the 
health  also  assisting  in  the  production  of  the  deformity.  It  occurs 
as  a  natural  condition  in  many  of  the  negro  races,  and  is  more 
often  seen  in  long  than  in  short  feet. 

Mechanism. — As  already  stated,  there  is  some  difference  of 
opinion  amongst  surgeons  as  to  the  primary  causative  factor  in 
the  production  of  this  deformity.  The  most  generally  accepted 
idea  is  that  it  is  in  the  majority  of  cases  due  to  a  relaxation  of  the 
inferior  calcaneo-scaphoid  ligament,  which  extends  between  the 
adjacent  surfaces  of  the  os  calcis  and  scaphoid,  supporting  the 
under  surface  of  the  head  of  the  astragalus,  and  thus  keeping  up  the 
inner  portion  of  the  longitudinal  arch  of  the  foot.  This  in  its  turn 
is  braced  up  by  the  tendon  of  the  tibialis  posticus  and  an  expan- 
sion backwards  therefrom  to  the  os  calcis,  as  also  by  the  plantar 
fascia  and  ligaments,  and  by  the  short  muscles  of  the  sole.  When 
the  weight  of  the  body  increases  rapidly,  and  out  of  all  proportion 
to  the  muscular  development,  chis  important  ligament  is  likely  to 
yield,  and  then  the  head  of  the  astragalus  is  displaced  downwards 
into  the  foot,  causing  obliteration  of  the  instep.  Possibly  paresis, 
if  not  paralysis,  of  the  tibialis  anticus  assists  in  this  process,  allow- 
ing the  peronei  tendons  to  abduct  the  front  of  the  foot  from  the 
mid-tarsal  joint,  and  in  the  later  stages  these  tendons  are  often 
found  tense  and  rigid.  By  the  majority  of  authorities,  this  con- 
traction of  the  peronei  is  considered  to  be  secondary  to  the  liga- 
mentous lesion,  and  quite  independent  of  any  weakening  of  the 


4io 


A  MANUAL  OF  SURGERY 


tibial  muscles.  Occasionally  the  deformity  is  due  to  a  gonor- 
rhoeal  inflammation  of  the  inferior  calcaneo-scaphoid  ligament, 
which  becomes  relaxed  and  yields  under  the  weight  of  the  body. 
However  produced,  the  deformity  is  tolerably  characteristic 
(Fig.  116).  The  sole  of  the  foot  is  flat,  and  in  well-marked 
cases  comes  in  contact  with  the  ground  throughout  the  whole  of 
its  extent.  The  inner  border  is  convex  and  somewhat  lengthened, 
whilst  there  is  a  tendency  to  eversion  of  its  anterior  portion  : 
the  outer  border  may  be  slightly  raised  from  the  ground.  The 
head  of  the  astragalus  is  distinctly  felt  a  little  in  front  of  and 


Fig.  116. — Flax-foot. 


below  the  internal  malleolus,  whilst  the  sustentaculum  tali,  which  is 
normally  to  be  distinguished  about  three-quarters  of  an  inch  below 
the  malleolus,  is  buried  by  this  displacement.  The  tubercle  of 
the  scaphoid  is  less  evident  than  usual,  being  situated  below  and 
in  front  of  the  head  of  the  astragalus.  The  gait  becomes  some- 
what shuffling,  and  severe  pain  is  experienced,  not  only  in  the  sole, 
but  also  about  the  heads  of  the  metatarsal  bones  and  in  the  toes. 
Sometimes  it  is  extremely  marked  in  the  metatarso-phalangeal 
joint  of  the  great  toe,  which  may  be  enlarged  and  rigid,  owing  to 
an  associated  osteo-arthritis. 

Treatment. — In  the  earliest  stages,  when  the  deformity,  though 
threatening,  has  not  yet  actually  developed,  all  that  is  required 
in  many  cases  is  rest,  so  as  to  allow  the  overstrained  muscles  and 
ligaments  to  recover  themselves  ;  at  the  same  time  the  parts 
should  be  well  rubbed  with  stimulating  embrocations,  and  tonics 
administered  to  improve  the  general  tone  of  the  systen.  In  the 
next  stage,  where  the  deformity,  though  present  on  standing,  can 
be  made  to  disappear  by  manipulation,  or  on  making  the  patient 
stand  on  tiptoe,  some  slight  support  is  advisable,  and  probably 
an  indiarubber  or  cork  instep  pad  worn  inside  the  sock  or  stock- 
ing will  be  all  that  is  necessary.     In  addition  to  this,  square-toed 


DEFORMITIES 


411 


boots  must  be  used,  so  as  to  prevent  any  tendency  to  an  increase 
in  the  valgoid  position  of  the  anterior  segment  of  the  foot.  It  is 
also  wise  to  make  the  patient  walk  with  the  toes  turned  inwards, 
and  in  some  cases  assistance  may  be  obtained  by  ordering  him 
to  sit  cross-kneed,  in  the  tailor  position,  so  as  to  exercise  a  certain 
amount  of  constant  pressure  inwards  upon  the  front  of  the  feet. 
Regular  exercises  ought  to  be  instituted,  such  as  raising  the  body 
on  tiptoe  with  the  feet  inverted  ;  such  can  only  be  undertaken  for 
a  short  time  at  first,  but  as  the  muscles  regain  their  tone  a  longer 
period  can  be  tolerated.  Elastic  tension  applied  to  the  sunken 
arch  is  also  useful  in  many  of  these  cases  ;  Golding-Bird's  sling 
can  be  employed  for  this  purpose.  It  consists  of  a  loop  of  soft 
webbing  passed  round  the  ankle  and  then  under  the  instep,  its 


Fig.  117. — Mr.  Golding-Bird's  Sling 
of  Soft  Webbing  for  supporting 
the  Arch  of  the  Foot. 


Fig.   118. — The  Sling  applied. 


free  end  being  drawn  up  on  the  inner  side  and  attached  to  an 
elastic  accumulator  which  is  connected  with  a  steel  garter-piece 
(Figs.  1 17  and  118).  In  still  worse  cases  a  metal  spring  or  instep 
pad  may  be  required  ;  but  frequently  the  tenderness  of  the  sole  is 
so  great  that  it  cannot  be  borne. 

When  the  affection  has  reached  a  later  stage,  and  the  deformity 
cannot  be  remedied  by  ordinary  manipulation,  forcible  rectification 
under  an  anaesthetic  may  be  employed.  The  foot  is  firmly  grasped 
in  the  two  hands  or  in  a  Thomas's  wrench  (Fig.  119),  and  the 
anterior  portion  is  forced  inwards  and  backwards  in  such  a  way 
as  to  draw  the  scaphoid  round  the  head  of  the  astragalus  as  a 
fulcrum,  and  thus  restore  the  arch.  Probably  a  number  of 
adhesions  in  the  astragalo- scaphoid  and  other  joints  will  be  felt  to 
give  way  during  this  manipulation.  Tenotomy  of  the  peronei  is 
sometimes  required  before  rectification  of  the  position  is  possible. 


412  A  MANUAL  OF  SURGERY 


The  foot  is  then  put  up  in  plaster  of  Paris  and  kept  at  rest  for 
some  weeks.     Satisfactory  results  have  followed. 

In  advanced  cases  that  have  been  entirely  neglected,  operative 
proceedings  are  necessary,  and  probably  the  best  of  the  many 
that  have  been  suggested  consists  in  removal  of  a  wedge-shaped 
portion  of  bone  from  the  inner  side.  Ogston  advises  that  this 
should  be  taken  from  the  neck  of  the  astragalus,  but  others  have 
advised  either  removal  of  the  scaphoid  or  of  a  wedge-shaped 
section  of  the  foot  without  respect  to  joints  (Stokes). 

Pes  Cavus  (Hollow  or  Claw  Foot)  is  a  condition  characterized  by 
increased  concavity  of  the  plantar  arch,  so  that  when  the  indi- 
vidual stands  there  is  a  greater  interspace  than  usual,  if  not  an 
absolute  break,  between  the  impressions  produced  by  the  anterior 
and  posterior  segments  of  the  foot  (Fig.  107,  B).  It  is  almost 
always  an  acquired  deformity,  although  a  few  cases  of  congenital 
cavus  have  been  reported.     Corresponding  to  the  increased  con- 


Fig.   119. — Thomas's  Wrench.     (Down  Bros.) 

The  two  cross-bars  are  protected  by  thick  indiarubber,  and  can  be  approxi- 
mated or  separated  by  rotation  of  the  handle.  The  anterior  portion  of 
the  foot  is  firmly  grasped  between  them,  one  being  placed  on  the  dorsal 
and  one  on  the  plantar  aspect,  and  forcible  wrenching  movements  can 
then  be  carried  out. 

cavity  in  the  sole,  there  is  a  marked  convexity  on  the  dorsal 
aspect  of  the  foot,  whilst  the  toes  are  generally  in  the  condition 
to  be  immediately  described  as  hammer-toe  ;  the  heads  of  the 
metatarsal  bones  are  unduly  prominent  below,  and  callosities 
often  form  beneath  them.  Considerable  pain  and  inconvenience 
are  occasioned  by  these  associated  deformities. 

Causation. — Duchenne  originally  maintained  that  it  arose  from 
paralysis  of  the  interossei  and  lumbricales  in  a  manner  similar  to 
that  which  leads  to  the  main-en-griffe  after  paralysis  of  the  ulnar 
nerve,  and  it  is  quite  possible  that  this  accounts  for  a  certain  small 
proportion  of  the  cases.  Others  rightly  associate  it  with  a  slight 
degree  of  talipes  equinus  (right-angled  contraction),  and  Parkin 
of  Hull  has  worked  out  its  method  of  production  from  this  cause. 
The  weight  is  normally  carried  to  the  ground  mainly  through  the 
heel,  but  also  partly  through  the  toes  ;  in  these  cases  it  is,  how- 
ever, only  transmitted  through  the  toes  and  front  of  the  foot,  and 
since  the  anterior  extensor  muscles  are  supposed  to  be  weak  and 
paretic,  the  short  flexors  are  able  to  act  at  an  advantage,  and  by 


DEFORMITIES 


413 


contracting  draw  the  heel  downwards  so  as  to  reach  the  ground, 
and  thus  the  arch  is  increased. 

The  Treatment  in  the  early  stages  consists  in  friction  applied 
to  the  weakened  muscles  of  the  leg,  together,  possibly,  with  the 
application  of  a  splint  to  the  sole.  In  more  marked  cases  division 
of  the  tendo  Achilles  is  needed,  together  with  subcutaneous  section 
of  the  tense  plantar  fascia.  The  deformity  of  the  toes  usually 
disappears  when  the  equinus  is  corrected,  but  may  require  further 
attention. 

Hallux  Rigidus  (syn  :  H.  nexus)  is  a  painful  condition  of  the 
great  toe,  due  to  an  affection  of  its  metatarso-phalangeal  articula- 
tion. It  usually  occurs  in  young  males  with  flat-feet.  The  foot 
is  abnormally  long ;  its  circulation  is  defective  :  the  toe  itself 
may  be  in  good  position,  but  not  unfrequently  the  first  phalanx  is 
flexed,  and  the  distal  one  hyper-extended.  The  joint  is  practically 
in  a  condition  of  chronic  traumatic  arthritis,  with  fibrillation  of  the 
cartilage  and  lipping  of  its  margins.    It  is  probably  due  to  abnormal 


Fig.   120. — Hallux  Valgus. 

pressure   being    brought   to   bear   upon   it   owing   to  the  valgoid 
position  of  the  foot,  and  possibly  to  wearing  too  short  a  boot. 

Treatment. — In  the  early  stages  correct  the  flat-foot  and  give 
attention  to  the  boots.  Failing  this,  careful  strapping  with  Scott's 
dressing  may  give  relief,  but  in  bad  cases  excision  of  the  head  of 
the  metatarsal  may  be  required. 

Hallux  Valgus. — This  condition  consists  in  a  displacement  out- 
wards of  the  great  toe  from  the  median  line  of  the  body,  as  a  result 
of  which  the  other  toes  are  huddled  together,  and  in  extreme 
cases  the  hallux  is  placed  over  or  under  them  (Fig.  120).  It  is 
present  in  the  majority  of  people  in  some  measure,  owing  to  the 
usual  shape  in  which  boots  are  made  ;  but  in  its  severer  forms  it 
generally  occurs  in  elderly  people,  and  is  often  associated  with 
osteo-arthritis  of  the  metatarso-phalangeal  joint  of  the  hallux, 
the  greater  power  of  the  adductor  group  of  muscles  explaining 
the  deformity.  The  cartilaginous  surface  of  the  head  of  the  first 
metatarsal  bone  becomes  exposed  beneath  the  skin,  and  by  the 
constant  irritation  of  the  boot  it  becomes  inflamed,  its  structure 


4i4  A   MANUAL  OF  SURGERY 


and  shape  altered,  and  the  joint  more  or  less  disorganized.  Two 
other  conditions  are  also  met  with  arising  from  this  deformity, 
viz.,  bunion  and  hammer-toe. 

A  bunion  consists  in  the  formation  of  a  bursa  over  the  head  of 
the  first  metatarsal  bone,  which  becomes  inflamed  from  cold  or 
injury,  and  may  even  suppurate,  the  abscess  usually  communi- 
cating with  the  joint,  and  leading  to  its  disorganization.  A 
marked  bony  outgrowth  is  usually  found  under  the  bursa, 
springing  from  the  inner  side  of  the  head  of  the  bone,  and  due 
to  a  localized  chronic  periostitis. 

The  Treatment  of  hallux  valgus  in  its  earliest  stages  consists 
in  the  use  of  correctly-shaped  boots,  with  the  inner  border  straight 
from  toe  to  heel.  In  worse  cases  an  apparatus  may  be  worn, 
consisting  of  a  band  around  the  dorsum  of  the  foot,  to  which  is 
attached  a  support  running  along  its  inner  border,  towards  which 
the  great  toe  can  be  drawn  by  elastic  tension.  In  the  most 
severe  types  excision  of  the  projecting  head  of  the  metatarsal  bone 
gives  admirable  results.  The  operation  is  best  conducted  by 
turning  up  a  flap  of  skin  and  subcutaneous  tissues  over  the  inner 
aspect  of  the  head  of  the  metatarsal  with  its  convexity  backwards. 
The  bone  is  then  divided  by  a  chisel  and  the  head  removed, 
allowing  the  toe  to  be  easily  replaced  in  a  normal  position.  The 
skin  is  then  laid  down  in  place,  and  if  need  be  shortened  to  meet 
the  requirements  of  the  case.  Very  rarely  ought  the  second  toe 
to  be  removed  for  this  condition,  as  the  lateral  support  of  the 
great  toe  is  thus  weakened,  and  the  deformity  is  probably  aggra- 
vated. An  inflamed  bunion  is  treated  by  removing  all  local  pres- 
sure, and  applying  fomentations.  If  the  joint  is  involved  in 
suppurative  disease,  excision  of  the  head  of  the  bone,  or  amputa- 
tion of  the  toe,  may  be  required.  In  less  serious  cases  it  may 
suffice  merely  to  remove  the  thickened  bursa. 

Hammer-toe. — This  deformity  is  constituted  by  hyper-extension 
of  the  first  phalanx,  marked  flexion  to  an  acute  angle  of  the 
second,  and  either  flexion  or  extension  of  the  terminal  phalanx, 
so  that  the  first  interphalangeal  joint  projects  under  the  upper 
leather  of  the  boot,  whilst  the  patient  walks  on  the  extremity  of 
the  ungual  phalanx,  or  even  on  the  nail  (Fig.  121).  Corns  form 
upon  the  points  ot  pressure  (1,  2,  and  3),  especially  on  the  dorsal 
aspect,  and  a  subcutaneous  bursa  over  the  head  of  the  first 
phalanx  (4),  giving  rise  to  great  pain  and  inconvenience.  The 
second  toe  is  that  most  frequently  affected,  with  or  without  the 
others,  but  it  is  uncommon  for  the  hallux  to  be  thus  deformed. 

The  Causes  are  numerous.  It  is  occasionally  congenital,  but 
more  often  acquired,  and  then  (a)  it  may  be  secondary  to  hallux 
valgus  :  (b)  it  may  result  from  wearing  short  and  pointed  boots, 
or  very  high  heels ;  in  either  case  the  toes  are  crowded  together 


DEFORMITIES  415 

and  drawn  up  out  of  the  way  of  pressure  :  (c)  it  follows  contrac- 
tion of  the  plantar  fascia,  and  is  then  associated  with  pes 
cavus  and  talipes  equinus  :  (d)  paralysis  of  the  interossei  and  lum- 
bricales  may  also  lead  to  this  condition  in  the  same  way  that  the 
viain-en-griffe  follows  ulnar  paralysis. 

However   caused,  the  hyper-extension  of  the  first  phalanx  is 


2  I 

Fig.  121.- — Hammer-toe.     (After  Keen  and  White.) 

1,  Callosity  over  head  of  metatarsal  bone  in  sole  ;  2,  callosity  over  end  of  toe  ; 
3,  callosity  or  corn  over  head  of  first  phalanx  ;  4,  adventitious  bursa  over 
the  same  bony  point. 

associated  with  a  contracted  state  of  the  extensor  tendons,  which 
stand  out  very  evidently  beneath  the  skin.  The  flexion  of  the 
second  phalanx  on  the  first  is  carried  to  such  a  degree  that  the 
former  bone  is  semi-dislocated.  The  prolongations  of  the  plantar 
fascia  on  either  side  are  much  shortened,  and  the  lower  portions 
of  the  lateral  ligaments  of  these  articulations  are  also  contracted. 
Treatment  may  be  commenced  by  the  use  of  correctly-shaped 
boots,  but  the  case  has  usually  progressed  to  such  an  extent  when 
the  patient  is  first  seen  that  no  palliative  measures  are  of  any 
avail.  Operation  is  then  necessary,  and  this  may  in  the  first  place 
be  directed  to  the  contracted  tendo  Achilis  and  plantar  fascia,  if 
such  conditions  are  present,  or  to  division  of  the  lateral  ligaments 
of  the  first  inter-phalangeal  articulation.  Division  of  the  extensor 
tendons  may  also  be  tried,  but  probably  the  displacement  of  the 
base  of  the  second  phalanx  is  such  that  nothing  short  of  removal 
of  the  head  of  the  first  phalanx  holds  out  any  prospect  of  perma- 
nent relief.  An  incision  is  made  longitudinally  over  the  joint,  the 
extensor  tendon  being  split  down  the  middle  ;  the  head  of  the 
bone  is  then  cleared  by  the  raspatory,  and  nipped  off  by  cutting- 
pliers.  The  foot  is  put  up  on  a  splint,  and  care  taken  to  maintain 
the  toes  in  a  good  position  by  the  use  of  some  suitable  appliance 
(Fig.  122).  Sometimes  there  is  but  little  room  between  the 
great  and  third  toes,  so  that  even  if  one  corrected  the  deformity  of 
the  second  toe  there  is  no  space  for  it  to  lie  comfortably  ;  ampu- 
tation should  then  be  performed. 


4i6 


A   MANUAL  OF  SURGERY 


Fig.  122. — T-shaped  Splint  for 
Hammer-toe,  which  can  be  used 
in  Slight  Cases,  or  after 
Operation  in  Bad  Cases. 


Metatarsalgia,  or  Morton's  Disease,  is  characterized  by  severe 
pain  of  a  neuralgic  type  located  primarily  about  the  head  of  one 
or  more  of  the  metatarsal  bones, 
but  also  radiating  thence  up  and 
down  the  limb.  It  often  occurs 
in  gouty  or  rheumatic  subjects, 
and  may  be  attributed  to  some 
injury;  a  slight  degree  of  flat- 
foot  and  the  wearing  of  tight 
boots  certainly  predispose  to  it. 
Morton's  explanation  is  that,  as 
a  result  of  the  pressure  of  badly- 
fitting  boots,  the  metatarsal  bones 
and  phalanges  are  laterally  dis- 
placed, and  the  digital  nerves 
compressed  either  between  the 
third  and  fourth  or  between  the 
fourth  and  fifth.  That  this  displacement  does  occur  in  some  cases 
has  been  demonstrated  by  skiagraphy,  but  it  is  doubtful  whether 
the  nerves  are  in  reality  compressed  between  the  bones.  R.  Jones, 
of  Liverpool,  has  recently  adduced  weighty  reasons  for  believing 
that  the  pain  is  rather  to  be  explained  by  compression  of  the  nerves 
between  the  bones  and  the  ground.  The  foot  is  usually  found  to 
be  broader  than  usual,  and  marked  callosities  or  corns  are 
observed  on  the  under  surface  close  to  the  heads  of  the  bones, 
one  or  more  of  which  may  be  unduly  prominent.  In  a  few  cases 
small  bony  enlargements  have  projected  from  the  heads  of  the 
metatarsal  bones,  and  in  others  definite  fibrous  growths  have  been 
found  in  the  subcutaneous  tissues ;  in  other  cases  a  simple  peri- 
pheral neuritis  may  explain  the  manifestations.  The  pain  is 
generally  induced  by  walking,  and  comes  on  in  characteristic 
paroxysms.  Lateral  pressure  over  the  metatarsal  bones  some- 
times relieves  the  pain,  Occasionally  evidences  of  osteo-arthritis 
are  manifested  in  one  of  the  neighbouring  joints. 

Treatment  consists  in  resting  the  foot,  whilst  suitable  diet  and 
drugs  are  ordered  to  combat  any  gouty  or  rheumatic  tendency. 
At  the  end  of  a  few  weeks  the  patient  may  be  allowed  to  walk 
again  with  boots,  which  are  broad  anteriorly,  and  fitted  with  an 
instep  pad  if  necessary.  Morton's  recommendation — viz.,  excision 
of  the  head  of  the  metatarsal  bone — may  be  reserved  for  the  more 
aggravated  and  serious  forms. 


CHAPTER  XVII. 

INJURIES  OF  BONES— FRACTURES. 

Contusion  of  a  Bone  and  of  its  periosteum  is  usually  a  mattei 
of  no  great  moment,  although  the  part  becomes  painful,  and 
swollen.  Occasionally  a  subacute  periostitis  is  caused  in  people 
liable  to  rheumatism  or  gout,  or  in  the  subjects  of  syphilis; 
whilst  in  those  who  are  thoroughly  out  of  health,  and  with  low 
germicidal  power,  acute  infective  periostitis  or  osteomyelitis, 
resulting  in  necrosis,  mav  be  lighted  up.  The  Treatment  of  an 
uncomplicated  case  consists  merely  in  the  application  of  cooling 
lotions  or  a  bandage,  whilst  if  periosteal  thickening  results,  iodide 
of  potassium  may  be  given,  and  iodine  paint  applied  locally. 

Bending  of  Bone  may  or  may  not  be  associated  with  fracture. 
Bending  without  fracture  occurs  mainly  in  children,  and  in  adults 
is  only  the  result  of  some  local  disease.  More  commonly  a  partial 
or  green-stick  fracture  is  produced  (p.  388).  The  deformity  can 
generally  be  remedied  by  the  application  of  a  little  force. 

Fractures. 

A  fracture  may  be  defined  as  a  sudden  solution  of  continuity  in 
a  bone,  usually  resulting  from  external  violence. 

Predisposing  Causes  of  Fracture. — Age  has  a  considerable 
influence  in  the  determination  of  fractures,  and  for  two  reasons : 
firstly,  because  the  strength  and  elasticity  of  bones  vary  consider- 
ably at  different  periods  of  life  ;  and,  secondly,  because  the  liability 
to  injury  is  likewise  variable.  From  two  to  four  fractures  are 
not  uncommon,  owing  to  the  unsteady  gait  and  frequent  falls  to 
which  little  children  are  exposed ;  from  four  to  six  they  are  less 
common,  the  bones  often  bending  so  as  to  cause  green-stick  frac- 
tures, whilst  injuries  near  joints  induce  separation  of  epiphyses ; 
from  six  years  onwards  fractures  are  frequent  enough,  and 
increase  steadily  with  the  age,  old  people  being  peculiarly  liable 
to  this  form  of  accident,  owing  to  the  brittleness  of  their  bones. 

Sex. — As  might  be  expected,  fractures  are  more  common  in  the 
male  sex  during  boyhood  and  adult   life ;  but  up  to  the  age  of 

27 


4i8  A   MANUAL  OF  SURGERY 


four  or  five  they  are  equally  frequent  in  the  two  sexes,  whilst 
after  forty-five  they  are  more  common  in  women,  owing  to  their 
great  liability  to  intracapsular  fracture  of  the  cervix  femoris  and 
to  Colles's  fracture. 

Morbid  Conditions  of  the  Bones  predispose  to  fracture  in  a  marked 
manner,  very  slight  force  occasionally  sufficing  to  bring  it  about. 
Under  this  heading  may  be  included:  (i)  Atrophy  of  bone,  from 
whatever  cause  it  arises.  Thus,  it  may  be  of  the  senile  type,  as 
manifested  especially  in  the  cervix  femoris ;  or  it  may  be  due 
to  want  of  use,  as  in  a  paralyzed  limb  or  from  an  ankylosed 
joint.  Certain  nervous  affections,  such  as  general  paralysis  and 
other  forms  of  insanity,  and  even  tabes  dorsalis,  are  often  asso- 
ciated with  atrophic  conditions  of  the  bones,  which  lead  to 
fracture  without  any  apparent  cause.  (2)  Fragilitas  ossium  or 
osteo-psathyrosis  consists  in  an  inherited  tendency  to  spontaneous 
fracture.  It  results  in  a  multiplicity  of  fractures,  occurring  even 
in  children ;  thus,  a  girl,  aged  twelve  and  a  half  years,  had 
suffered  from  forty-one  fractures  since  the  second  year  of  life. 
No  explanation  of  this  condition  is  known ;  the  lesions  often 
unite  perfectly,  though  sometimes  with  a  good  deal  of  deformity. 
(3)  General  bone  diseases,  such  as  rickets  and  osteo-malacia,  also 
predispose  to  fracture ;  in  those  due  to  the  latter  affection  there  is 
usually  no  attempt  at  repair.  (4)  Local  bone  disease  may  also 
constitute  an  important  predisposing  factor  by  so  weakening  the 
bone  as  to  lead  to  its  fracture  from  a  very  slight  injury.  Thus, 
sarcoma  and  secondary  cancer  of  bone  are  often  first  recognised 
by  causing  a  spontaneous  fracture,  whilst  manipulation  of  a  limb 
which  is  the  seat  of  caries  or  necrosis  may  lead  to  a  similar 
result. 

The  Exciting  Causes  of  Fracture  are  threefold :  (1)  Direct  violence, 
the  fracture  occurring  at  the  spot  struck.  The  direction  of  such 
lesions  is  often  transverse,  and  they  are  not  unfrequently  com- 
minuted, or  complicated  with  injuries  to  the  adjacent  soft  parts. 

(2)  When  due  to  indirect  violence,  the  bone  gives  way  at  a  distance 
from  the  point  to  which  the  force  is  applied.  The  accident  is 
usually  produced  by  the  compression  or  bending  of  the  bone  with 
such  force  as  to  exceed  the  limits  of  its  natural  elasticity,  so  that 
it  yields  at  the  weakest  spot.  Thus,  when  a  person  jumps  from  a 
height,  the  leg  bones  are  compressed  between  the  weight  of  the 
body  and  the  resistance  of  the  ground,  and,  if  the  violence  is 
excessive,  a  fracture  occurs  at  some  point  of  mechanical  dis- 
advantage;  if  a  person  jumps  from  a  carriage  or  train  in  motion, 
the  same  conditions  obtain.  Fractures  produced  in  this  way  are 
often  oblique  or  spiral  in  direction,  and  as  the  displacement  may 
be  considerable,  there  is  great  risk  of  them  becoming  compound. 

(3)  Muscular  action  is  most  commonly  the  cause  of  fracture  of 
small  bones,  or  of  osseous  prominences  into  which  powerful 
muscles  are  inserted.     The  patella  and  olecranon  are  not  unfre- 


INJURIES  OF  BONES—FRACTURES  419 


quently  broken  in  this  way,  the  former  often  occurring  from 
sudden  and  vigorous  efforts  to  avert  a  fall.  Occasionally  one 
of  the  long  bones,  such  as  the  humerus  or  clavicle,  has  been 
broken  by  violent  muscular  exertion,  as  by  throwing  a  cricket- 
ball. 

Intra-uterine  Fractures  may  be  caused  by  blows  upon  the 
mother's  abdomen,  or  by  abnormal  or  violent  uterine  contractions, 
especially  if  the  liquor  amnii  is  deficient  in  amount ;  when 
multiple,  they  are  usually  due  to  fcetal  syphilis.  They  may 
present  any  type  of  deformity  at  birth,  and  may  be  partially  or 
completely  united.  They  must  be  clearly  distinguished  from 
malformations  resulting  from  imperfect  development. 

Congenital  Fractures  are  produced  during  birth  by  violence 
used  by  the  accoucheur,  or  from  excessive  uterine  contractions. 
They  are  most  common  in  the  thighs  if  due  to  traction,  or  in  the 
skull  if  due  to  the  pressure  of  forceps. 

Varieties  of  Fractures. — Many  terms  are  used  to  describe  the 
multiplicity  of  conditions  which  may  be  met  with  in  connection 
with  a  broken  bone.  The  following  are  the  more  important :  A 
Simple  Fracture  is  one  in  which  the  skin  is  unbroken,  or,  at  any 
rate,  where  the  external  air  has  no  admission  to  the  site  of  injury. 
A  Compound  Fracture  is  present  when  the  skin  or  mucous  mem- 
brane over  the  injured  spot  is  lacerated,  so  that  there  is  direct 
communication  between  the  fracture  and  the  external  air.  In  the 
base  of  the  skull,  however,  a  fracture  may  open  up  one  of  the 
deeper  air-sinuses,  and  thus  cause  it  to  become  compound  without 
any  apparent  external  lesion.  These  terms,  though  sanctioned 
by  the  approval  of  centuries,  are  neither  of  them  good,  sub- 
cutaneous and  open  being  preferable.  A  subcutaneous  fracture  is 
often  anything  but  a  simple  injury,  and  may  result  in  the  most 
disastrous  consequences,  whilst  an  open  fracture  may  be  a  matter 
of  comparatively  little  importance.  Indeed,  with  our  present 
appliances  and  methods  of  treatment  open  fractures  often  give 
better  results  than  those  that  are  called  simple. 

Fractures  are  complete  or  incomplete,  according  to  whether  or 
not  the  continuity  of  the  bone  is  entirely  interrupted.  Various 
forms  of  Incomplete  Fracture  are  described,  and  since  the  introduc- 
tion of  skiagraphy  their  presence  has  frequently  been  determined 
in  cases  which  would  otherwise  have  been  overlooked.  Thus, 
the  green-stick  fracture  is  one  which  only  occurs  in  young  children, 
and  most  often  in  those  thai  are  rickety ;  curved  bones,  such  as 
the  clavicle,  are  usually  affected,  and  the  fracture  merely  involves 
the  convexity  of  the  curve,  whilst  the  concave  half  is  bent,  just 
as  when  a  green  bough  or  twig  is  partially  broken.  Depressions 
of  the  skull  may  be  similarly  incomplete  when  the  outer  table  is 
driven  in  without  fracture  and  the  inner  table  alone  splintered. 
Fissured  fractures  also  are  often  only  partial. 

Complete  Fractures  may  be  transverse,  though  this  is  not  very 


420  A   MANUAL  OF  SURGERY 

common ;  oblique,  arising  usually  from  indirect  violence ;  spiral, 
when  the  fracture  is  due  to  a  force  acting  longitudinally,  but  at 
the  same  time  with  a  rotary  movement  superadded ;  it  occurs 
most  frequently  in  the  tibia  or  femur,  and  the  lower  fragment 
often  has  a  sharp  triangular  upper  end,  giving  it  somewhat  the 
appearance  of  the  mouthpiece  of  a  clarionet  (fracture  en  bee  de 
flute ;  see  Plate  X.).  A  longitudinal  fracture  is  one  due  to  Assuring 
or  splitting  of  the  bone  in  its  long  axis  ;  it  is  most  common  in 
military  surgery,  as  the  result  of  gunshot  injuries;  the  neighbour- 
ing joints  may  or  may  not  be  involved.  If  it  is  combined  with  a 
transverse  fissure,  it  is  often  termed  T-shaped.  Comminuted  is  a 
term  used  to  describe  the  condition  when  the  bone  is  broken  into 
more  than  two  pieces  ;  impacted,  when  one  fragment  is  driven  into 
the  other ;  multiple,  when  more  than  one  fracture  exists  ;  com- 
plicated, when  important  structures,  such  as  an  artery  or  joint,  are 
damaged  as  well  as  the  bone. 

The  Separation  of  an  Epiphysis  is  not  an  uncommon  occurrence 
in  people  under  twenty-two  years  of  age.  It  results  from  injury 
or  violence  directed  to  the  ends  of  the  bones,  but  occasionally  is 
more  or  less  spontaneous,  or  predisposed  to  by  disease  of  the 
epiphysis  or  of  the  adjacent  portion  of  the  diaphysis  {e.g.,  from 
inherited  syphilis,  or  acute  infective  or  tuberculous  epiphysitis). 
The  ends  of  the  femur,  humerus,  or  radius  are  those  most  often 
affected.  The  line  of  cleavage  usually  runs  through  the  soft 
spongy  bone  on  the  diaphyseal  side  of  the  cartilage,  so  that  there 
is  cartilage  with  spicules  of  bone  on  one  side,  and  spongy  bone  on 
the  other.  The  direction  taken  is  in  the  main  transverse,  but  most 
epiphyses  are  more  or  less  concave  or  cup-shaped,  the  ends  of  the 
diaphyses  being  convex.  In  very  young  children,  where  the 
epiphysis  is  entirely  or  mainly  cartilaginous,  the  lesion  is  almost 
always  a  pure  separation  of  the  epiphysis  from  the  shaft ;  but  at  a 
later  date  it  is  not  unusual  for  the  fracture  also  to  implicate  the 
adjacent  end  of  the  diaphysis  (Fig.  143).  A  very  marked  feature 
in  all  these  lesions  is  the  stripping  up  of  the  periosteum,  which, 
though  loosely  attached  to  the  shaft  and  easily  detached  from  it  in 
children,  is  firmly  adherent  to  the  cartilage,  and  hence  retains  its 
connection  with  it,  thus  frequently  limiting  displacement.  If, 
however,  the  force  is  sufficient,  the  periosteum  is  torn  through  on 
one  side  by  the  edge  of  the  bone,  and  the  periosteal  '  sleeve  ' 
which  thus  invests  it  may  to  some  extent  hinder  reduction.  The 
displacement  is  mainly  lateral,  and  may  somewhat  resemble  that  of 
a  dislocation.  Union  usually  occurs  by  means  of  bone,  and  arrest 
of  the  longitudinal  growth  may  follow,  though  not  so  frequently 
as  was  at  one  time  supposed,  and  probably  only  when  the  parts 
are  not  in  exact  apposition.  This  is  a  matter  of  special  import- 
ance where  one  of  the  bones  of  the  leg  or  forearm  is  affected,  since 
deformities  of  the  hand  or  foot  often  result  from  the  continued 
growth  of  the  uninjured  bone.  Suppuration  sometimes  occurs  as 
a  sequela  in  unhealthy  children,  or  when  the  accident  is  due  to 


PLATE  X. 


Oblique  Fracture  of   Tibia,  showing  the  Ends  of  the  Fragments'  shaped 

en  bee  de  flute. 

The  skiagram  was  taken  from  the  front  through  a  casing  of  plaster  of  Paris,  the 

irregular  outline  of  which  can  be  seen  on  the  inner  side  of  the  limb. 

To  face  p.  420.] 


INJURIES  OF  BONES— FRACTURES  421 


preceding  disease  of  the  epiphysis,  and  may  result  in  an  acute 
arthritis,  possibly  necessitating  amputation. 

Partial  detachment  of  an  epiphysis  (the  juxta-epiphyscal  strain  of 
Oilier)  often  occurs,  giving  rise  to  phenomena  similar  to  those  of 
a  sprain  ;  if  overlooked  and  neglected,  it  is  likely  to  prove  a  fertile 
source  of  tuberculous  disease,  or  may  interfere  with  the  growth  of 
the  limb.  The  essential  feature  is  a  more  or  less  tender  but 
very  distinct  swelling  of  the  bone  close  to  the  epiphysis,  but  the 
neighbouring  joint  remains  unaffected.  Treatment  consists  in 
immobilization  in  plaster  of  Paris. 

Signs  of  Fracture. — The  history  usually  given  by  the  patient  is 
that,  as  the  result  of  some  accident,  he  felt,  or  perhaps  heard, 
something  give  way  with  a  snap  and  experienced  sharp  pain, 
which  became  much  intensified  on  attempting  to  move  the  limb. 
On  examining  the  injured  part  and  contrasting  it  with  the  opposite 
side,  the  following  points  are  usually  noticed: 

1.  The  signs  of  a  local  trauma,  viz.,  pain,  bruising,  and  swelling, 
as  a  result  of  the  effusion  of  blood  from  the  torn  and  lacerated 
structures.  The  amount  of  this  may  be  so  great  as  to  obliterate 
all  the  ordinary  bony  prominences  and  landmarks.  Blebs  and 
bullae  sometimes  form  over  the  surface  in  the  course  of  a  day  or 
two,  and  these  should  be  carefully  protected  from  infection.  The 
discoloration  continues  for  some  time,  and  may  spread  to  parts 
far  removed  from  the  original  mischief.  This  infiltration  of  the 
parts  with  blood  often  leads  to  considerable  subsequent  thicken- 
ing, and  possibly  to  serious  adhesions  and  limitation  of  move- 
ment ;  this  fact  is  correctly  utilized  as  an  argument  in  favour  of 
the  treatment  of  fractures  by  an  open  operation.  It  is  unusual  for 
suppuration  to  occur  after  a  simple  fracture,  but  if  the  patient  is 
very  debilitated,  and  his  germicidal  powers  diminished,  auto- 
infection  and  abscess  may  result. 

2.  Preternatural  mobility  in  the  continuity  of  the  bone  may  be 
demonstrated  by  manipulation,  but  never  unnecessarily.  Im- 
paction of  the  fragments  prevents  its  occurrence. 

3.  Partial  or  complete  loss  of  function  also  follows. 

4.  Crepitus  is  obtained  by  moving  the  limb  and  rubbing  the 
rough  ends  against  one  another.  It  can  only  be  felt  when  the 
fragments  are  moveable  and  can  be  brought  into  contact,  but  not 
when  there  is  wide  separation  or  impaction.  When  an  epiphysis 
has  been  detached,  it  is  softer  in  character. 

5.  Change  in  shape  of  the  limb  or  deformity  from  displacement  is 
almost  always  present.  There  are  three  chief  factors  at  work  in 
producing  deformity,  viz.,  the  direction  of  the  violence,  the  weight 
of  the  limb,  and  the  contraction  of  muscles,  whilst  injudicious 
movement  or  rough  handling  may  aggravate  it.  It  is  always 
more  marked  in  oblique  than  in  transverse  fractures,  and  hence  is 
usually  greater  in  those  due  to  indirect  violence.  Various  types 
of  displacement  are  described,  viz.:    Angular,  usually  due  to  an 


422  A   MANUAL  OF  SURGERY 

increased  curvature  of  the  bone  from  the  unbalanced  action  of 
powerful  muscles,  especially  when  the  line  of  fracture  is  not  far 
from  the  end  of  the  shaft,  as  in  fracture  of  the  upper  third  of  the 
thigh  ;  lateral,  where  the  displacement  is  merely  to  one  or  the 
other  side,  and  most  common  in  transverse  fractures;  longitudinal, 
when  one  fragment  overlaps  the  other  or  is  forcibly  driven  into  it, 
causing  shortening  of  the  limb ;  it  may  also  occur  in  the  form 
of  wide  separation  of  the  fragments,  as  from  contraction  of  the 
quadriceps  in  fracture  of  the  patella ;  rotatory,  when  one  fragment 
is  twisted  on  the  other,  as  in  fractures  of  the  femur,  where  the 
weight  of  the  limb  causes  eversion  of  the  lower  end.  In  flat 
bones — e.g.,  the  skull — deformity  may  exist  in  the  shape  of 
depression  or  elevation. 

Such  are  the  typical  signs  of  a  fracture,  but  it  goes  without 
saying  that  all  of  them  are  not  present  in  every  case,  and  that  it 
is  not  always  easy  to  ascertain  the  existence  or  not  of  such  a 
lesion.  Comparison  with  the  opposite  limb,  and  gentle  manipula- 
tion to  demonstrate  abnormal  mobility  or  crepitus,  must  be  under- 
taken to  settle  this  point,  but  no  undue  violence  should  be  used. 

The  X  rays  have  proved  of  the  greatest  value  in  these  cases, 
and  where  there  is  any  doubt  as  to  the  existence  or  not  of  a 
fracture,  the  limb  should  be  at  once  skiagraphed. 

General  or  Constitutional  Effects. — These  may  be  divided  into 
two  groups : 

i.  Immediate  Effects,  consisting  of  shock  and  haemorrhage. 
Shock  is  greater  or  less  according  to  the  amount  of  violence 
and  the  seat  of  injury.  It  varies  from  a  mere  passing  faintness 
to  the  severest  prostration.  If  the  bones  of  the  head  or  spine  are 
injured,  special  symptoms  due  to  concussion  of  the  brain  or 
injury  to  the  spinal  cord  may  also  be  produced.  Hemorrhage 
always  occurs  either  in  simple  or  compound  fractures,  and  it  may 
progress  to  a  considerable  degree  from  laceration  of  important 
vessels  or  even  of  the  main  artery  of  a  limb. 

2.  Secondary  or  Remote  Effects. — Fracture  fever  is  met  with  in 
the  majority  of  cases,  commencing  twenty-four  hours  after  the 
accident  and  lasting  two  or  three  days.  As  a  rule,  it  is  not 
severe,  the  temperature  rarely  rising  above  ioo°  F.  in  uncom- 
plicated cases.  It  is  a  form  of  aseptic  traumatic  fever,  probably 
due  to  the  absorption  of  fibrin  ferment.  In  compound  fractures 
where  asepsis  is  not  attained,  any  form  of  wound  infection  may 
result,  and  even  general  septicaemia  or  pyaemia. 

Delirium  tremens  is  a  not  unusual  complication  of  fractures 
of  the  leg  in  debilitated  individuals  or  habitual  drinkers.  The 
general  characters  and  treatment  of  the  disease  are  dealt  with 
elsewhere  (p.  221).  As  regards  local  treatment,  the  limb  must  be 
fixed  by  splints  or  encased  in  plaster  of  Paris,  and  suspended  in  a 
Salter's  swing  so  as  to  prevent  the  patient  from  moving  the  upper 
fragment  independently  of  the  lower. 


INJURIES  OF  BONES— FRACTURES  423 

Fat  embolism  is  a  condition  resulting  from  the  absorption  of 
broken-up  fat  globules  after  any  injury  which  results  in  the  con- 
tusion or  laceration  of  fatty  tissue.  If  at  the  same  time  much 
tension  from  effusion  of  blood  is  present,  as  in  fractures  where  the 
medullary  fat  is  involved,  this  process  is  more  likely  to  occur. 
As  a  general  rule,  no  harm  results,  since  the  great  mass  of  the 
fat  is  filtered  off  by  the  lungs  or  eliminated  by  the  kidneys  (as 
can  be  demonstrated  after  death  by  staining  with  osmic  acid). 
The  pulmonary  obstruction  may,  however,  become  so  great  as  to 
lead  to  a  fatal  issue  from  dyspnoea ;  whilst  if  the  cerebral  vessels 
are  also  blocked,  syncope,  or  even  coma,  may  be  induced.  The 
symptoms,  which  are  gradual  in  their  onset,  usually  commence 
about  the  third  day,  but  may  not  be  evident  for  a  week  or  more. 

Complicated  Fractures. 

1.  Comminution  of  one  or  both  fragments  is  due  to  excessive 
violence,  or  perhaps  to  exceptional  brittleness  of  the  bones.  As 
long  as  the  skin  remains  unbroken,  sound  union  is  usually  ob- 
tained, though  with  an  increased  amount  of  callus.  Occasionally 
comminution  may  be  a  cause  of  non-union,  a  small  detached 
portion  of  dense  compact  tissue  being  wedged  cross-wise  between 
the  fragments,  especially  in  the  case  of  the  tibia  or  femur.  In  a 
compound  fracture  serious  mischief  may  result  from  sepsis. 

2.  Fracture  implicating  a  Joint. — In  healthy  individuals  no 
untoward  result  is  met  with  ;  the  joint  is  for  the  time  filled 
with  blood,  which,  however,  is  soon  absorbed,  and  the  fissure  in 
the  cartilage  closed  by  plastic  lymph.  Adhesions  are,  however, 
very  liable  to  form,  as  also  new  bony  deposits,  leading  to  defective 
mobility  or  even  locking  of  the  joint.  Early  passive  movement 
and  the  breaking  down  of  adhesions  under  chloroform  may 
improve  matters.  If  the  patient  has  a  tuberculous  tendency, 
arthritis  will  possibly  be  lighted  up,  whilst  osteo-arthritis  is  often 
induced  by  an  accident  of  this  nature. 

3.  The  same  violence  that  causes  the  fracture  may  at  the  same 
time  produce  a  Dislocation  in  a  neighbouring  joint.  Treatment 
should  be  undertaken  immediately ;  the  limb  is  firmly  fixed 
in  splints  commanding  both  fragments,  and  reduction  attempted 
under  chloroform.  Failing  this,  consolidation  must  be  allowed 
to  proceed,  and  then  the  case  dealt  with  as  one  of  old-standing 
dislocation  (p.  547).  If  the  fracture  involves,  or  is  close  to,  the 
articular  end  of  the  bone,  as  is  not  unfrequent  at  the  elbow  and 
shoulder,  it  may  be  advisable  to  operate  at  once,  opening  the 
joint,  reducing  the  dislocation,  and  wiring  the  fragments  ;  or  it 
may  be  better  to  remove  the  small  detached  articular  portion. 

4.  The  Main  Artery  of  a  limb  may  be  compressed,  contused, 
punctured,  or  ruptured.  Thrombosis  results,  with  or  without  such 
an  extravasation  of  blood  as  may  impede  the  venous  return.     If 


424  A   MANUAL  OF  SURGERY 


the  peripheral  vessels  are  healthy,  no  permanent  harm  need  follow, 
unless  the  vein  is  also  implicated,  and  then  moist  gangrene  is 
likely  to  supervene.  If  the  terminal  vessels  are  calcareous  and 
rigid,  so  that  there  has  been  a  preceding  condition  of  chronic 
anaemia,  dry  gangrene  will  probably  ensue.  In  the  slighter  cases 
an  aneurism  may  subsequently  develop.  For  further  details, 
see  Chapters  V.  and  X.  The  Treatment  must  necessarily  vary 
in  different  cases.  The  ideal  practice  would  be  to  cut  down  in 
every  case  where  a  large  artery  is  punctured  or  ruptured,  remove 
clots,  and  tie  above  and  below  the  injury  in  the  vessel ;  but, 
owing  to  the  extensive  laceration  and  displacement  of  the  parts, 
it  is  not  always  advisable  to  do  so,  and,  indeed,  it  should  never 
be  undertaken  without  the  most  rigid  asepsis.  If  it  is  considered 
unwise  to  lay  the  parts  open,  the  main  artery  may  be  compressed 
or  tied  above  the  fracture,  but  only  where  the  distal  circulation 
has  been  re-established  ;  in  the  absence  of  this  condition,  gangrene 
would  be  certain  to  ensue.  If  neither  of  the  above-mentioned 
expedients  can  be  adopted,  an  expectant  plan  of  treatment  must 
be  followed.  The  limb  is  thoroughly  purified,  wrapped  in  aseptic 
wool,  placed  on  appropriate  splints,  and  slightly  elevated.  Should 
gangrene  supervene,  amputation  is  the  only  resource ;  it  need  not 
be  undertaken  for  a  few  days  if  the  limb  is  aseptic,  so  as  to  allow 
a  distinct  line  of  separation  to  form ;  but  if  septic,  early  removal 
through  or  above  the  line  of  fracture  is  essential. 

5.  Laceration  of  the  Veins  of  a  limb  results  in  extravasation  of 
blood,  which  is  not  so  extensive  as  when  an  artery  is  wounded, 
from  the  fact  that  thrombosis  is  more  easily  determined  owing  to 
the  lesser  blood-pressure,  but  the  congestion  and  oedema  of  the 
distal  part  of  the  limb  which  follow  constitute  serious  additional 
elements  predisposing  to  gangrene.  Simple  compression  of  the 
veins  produces  oedema,  which,  even  in  favourable  cases,  may 
persist  for  some  time,  needing  for  its  removal  firm  bandaging, 
massage,  and  cold  douching. 

6.  The  Nerves  of  a  limb  may  be  injured  at  two  different  periods. 
(a)  Immediate  injury  is  due  to  laceration  or  rupture,  either  of  the 
whole  trunk,  or,  as  is  more  common,  of  the  nerve  fibrillae,  without 
loss  of  continuity  of  the  sheath.  Paralytic  and  anaesthetic  pheno- 
mena follow,  but  are  usually  recovered  from.  (b)  Secondary 
symptoms  result  from  inclusion  and  compression  of  the  nerve 
in  the  callus,  or  from  injudicious  splint  pressure.  Irritative 
symptoms  in  the  shape  of  neuralgia  and  muscular  spasms  are 
first  manifested,  followed  by  paralysis  and  anaesthesia.  This 
usually  occurs  about  three  or  four  weeks  after  the  accident, 
and  may  disappear  in  a  month  or  two,  or  persist.  Treatment  is 
always  for  a  time  of  the  expectant  type,  even  when  the  paralysis 
is  immediate,  since  total  rupture  of  a  nerve  is  rare,  and  restoration 
of  function  the  rule  rather  than  the  exception.  When,  however, 
the  symptoms  persist,  the  parts  must  be  laid  open,  the  nerve  freed 


INJURIES  OF  BONES— FRACTURES  425 

from  adhesions,  or  exuberant  callus  removed,  and  such  measures 
taken  as  will  best  secure  the  nerve  from  further  compression. 


Union  of  Fractures. 

The  union  of  fractures  is  brought  about  by  a  series  of  changes 
analogous  to  those  which  we  have  already  seen  occur  in  other 
wounds,  except  that  they  do  not  terminate  in  the  formation  of 
cicatricial  tissue,  but  go  on  to  the  farther  development  of  bone. 

When  a  fracture  has  occurred,  the  broken  ends  of  the  bone  are 
left  rough,  spiculated,  and  more  or  less  separated  one  from  the 
other ;  the  periosteum  is  torn,  but,  according  to  Oilier,  the 
rupture  is  not  always  complete  all  round,  a  '  periosteal  bridge ' 
perhaps  persisting,  and  playing  an  important  part  in  the  repara- 
tive process,  especially  if  the  fracture  is  not  accurately  set.  The 
muscles  and  neighbouring  tissues  are  also  lacerated,  and  a  varying 
amount  of  blood  is  extravasated,  occupying  the  interstices  of  the 
wound.  In  the  course  of  a  few  hours  after  the  parts  have  been 
immobilized,  the  process  of  repair  is  inaugurated  by  the  blood-clot 
becoming  invaded  by  leucocytes,  and  after  a  time  it  is  absorbed, 
the  haemoglobin  passing  through  various  stages  of  degeneration, 
and  thereby  staining  the  surrounding  tissues.  At  the  same  time, 
a  rarefying  inflammation  occurs  in  all  the  injured  and  lacerated 
structures,  as  a  result  of  which  there  is  an  exudation  of  plasma 
into  their  substance,  whilst  the  connective-tissue  cells  proliferate 
actively,  and  thus  a  cellulo-plastic  exudation  forms  around  and 
between  the  lacerated  tissues  and  broken  ends  of  the  bone,  which 
is  transformed  into  granulation  tissue  by  vascularization  from 
circumjacent  vessels.  Calcification  of  this  material  follows,  pre- 
ceded or  not  by  a  cartilaginous  or  fibrous  change,  and  this  calcified 
material  is  in  its  turn  replaced  by  bone,  which,  at  first  soft  and 
spongy,  becomes  after  a  time  firm  and  sclerosed.  Of  course, 
these  changes  do  not  occur  simultaneously  in  all  the  tissues 
involved,  and  we  must  refer  to  them  as  they  affect  the  periosteum, 
the  medulla,  and  the  bony  substance  itself. 

The  periosteum  becomes  thickened  and  more  vascular,  and  its 
connection  with  the  bone  is  loosened  for  a  short  distance  by  an 
exudation  of  plasma,  which  is  soon  followed  by  a  new  deposit  of 
spongy  bone  on  the  surface,  as  a  result  of  the  irritation.  The 
space  beneath  the  periosteum  is  quickly  occupied  by  granulation 
tissue,  which  unites  with  that  developed  from  surrounding  torn 
structures  and  with  that  coming  from  the  bone  itself,  and  this  ovoid 
mass  binding  the  fractured  ends  together  is  known  as  the  pro- 
visional or  enskeathing  callus.  The  transformation  of  this  callus  into 
bone  starts  from  the  periosteum  ;  if  it  has  been  totally  lacerated, 
ossification  commences  at  the  furthest  point  from  the  fracture 
where  the  irritation  caused  thereby  is  felt,  and  gradually  spreads 


426  A  MANUAL  OF  SURGERY 

in.  If  a  periosteal  bridge  is  left,  ossification  commences  on  its 
under  surface,  and  not  unfrequently  in  skiagrams  a  line  of  newly- 
formed  bone  can  be  seen  passing  from  one  fragment  to  the  other, 
and  evidently  due  to  this  cause.  Some  authorities  maintain  that 
new  bone  derived  from  periosteum  in  this  manner  is  always  pre- 
ceded by  cartilage,  but  this  is  probably  not  the  case,  although  the 
presence  of  cartilage  in  the  repair  of  fractures  is  more  common 
than  was  formerly  supposed.  It  is  most  likely  to  occur  in  cases 
where  absolute  immobilization  has  not  been  obtained — e.g.,  after 
fractures  of  the  ribs  and  in  children. 

The  changes  obtaining  in  the  medulla  consist  in  its  becoming 
hyperaemic  for  some  distance  from  the  seat  of  fracture  and  its 
transformation  into  granulation  tissue,  which  unites  with  that 
springing  up  from  the  opposite  fractured  surface.  Ossification 
commences  in  this,  probably  from  the  inner  aspect  of  the  compact 
shell,  from  which  fine  spicules  of  bone  gradually  permeate  the 
granulation  mass  until  the  whole  is  ossified,  constituting  the 
internal  callus,  or,  better,  the  medullary  plug.  There  is  here  no 
formation  of  cartilage. 

Naturally,  the  bony  tissue  involved  in  the  fracture  is  the  last 
to  engage  in  these  changes,  and  the  denser  the  bone,  the  longer 
they  are  in  being  completed.  The  fractured  end  becomes  hyper- 
aemic, and  practically  passes  into  a  condition  of  rarefying  osteitis, 
the  bone  cells  proliferating,  the  medullary  contents  of  the 
Haversian  canals  increasing  in  amount,  and  the  actual  osseous 
substance  being  absorbed,  until  the  rough  and  spiculated  surface 
becomes  smooth  and  covered  with  granulations.  These  unite 
with  the  medullary  plug,  of  which  they  may  indeed  be  looked 
on  as  an  extension  ;  but  the  union  with  the  periosteal  callus  is 
slower,  since  all  the  blood-clot  and  the  damaged  surface  of  the 
bone  must  be  entirely  removed  before  this  is  possible ;  indeed, 
the  annular  bond  of  union  between  the  two  layers  of  compact 
bone,  to  which  was  originally  applied  the  name  '  definitive  callus,' 
is  probably  of  periosteal  origin,  and  not  derived  at  all  from  the 
fractured  surface. 

It  will  thus  be  obvious  that  the  continuity  of  a  bone  is  restored 
long  before  the  act  of  repair  is  completed,  and  that  such  union 
depends  on  the  ossification  of  the  ensheathing  callus.  The 
rapidity  of  this  process  varies  with  the  amount  of  periosteal 
laceration,  but  in  many  cases  the  callus  is  sufficiently  firm  to 
allow  of  gentle  passive  movement  in  ten  to  twelve  days,  and  in 
three  or  four  weeks  it  may  be  so  firm  that  it  is  difficult  to  bend 
the  bone  with  the  fingers.  The  newly-formed  osseous  tissue  is 
at  first  soft  and  spongy,  but  gradually  becomes  denser.  As  the 
so-called  definitive  callus  becomes  stronger,  the  ensheathing 
callus  disappears,  and  finally,  if  the  ends  are  in  good  position, 
may  vanish  entirely,  whilst  the  medullary  plug  may  also  be 
totally  removed.     Thus  it  is  possible  for  the  bone,  under  these 


INJURIES  OF  BONES— FRACTURES 


42/ 


circumstances,  to  be  so  absolutely  restored  as  to  show  no  signs 
of  its  having  been  fractured. 

Thus  far  we  have  been  supposing  that  the  broken  ends  are 
accurately  apposed  and  the  limb  immobilized  ;  but  little  callus  is 
formed  (Fig.  123,  A),  and  that  equally  and  evenly  all  round  the 
site  of  the  fracture.  Where,  however,  movement  is  possible,  the 
amount  of  callus  is  much  increased. 

Where  the  ends  of  the  bones  partially  overlap  (Fig.  123,  B), 
the  amount  of  ensheathing  callus  (c)  is  correspondingly  increased, 
and  fills  up  all  the  spaces  left  by  the  overlapping  of  the  frag- 
ments.    The  projecting  margins  of  bone  are  rounded  off,  and  the 


Fig.  123. — Diagram  to  represent  Union  of  Fractures:  A,  when  the 
Ends  are  in  Close  Apposition  ;  B,  when  the  Ends  are  only  Par- 
tially Apposed;  and  C,  when  the  Fractured  Surfaces  are  not  in 
Contact  at  all. 

a,  True  or  definitive  callus  ;  b,  internal  or  medullary  callus  ;  c,  external  or 
provisional  callus. 

medullary  cavities  closed  by  plates  or  plugs  (b)  ;  the  amount  of 
definitive  callus  (a)  is  usually  small,  but  varies  with  the  actual 
conditions  present.  The  main  bond  of  union  is  the  ensheathing 
mass,  a  considerable  portion  of  which  persists.  Some  deformity 
is  sure  to  remain  after  such  an  accident,  and  it  is  unusual  for  the 
medullary  canal  to  be  restored  ;  frequently  one  or  more  plates  of 
bone  are  found  crossing  it- 

If  the  fractured  ends  are  not  placed  in  contact  at  all  (Fig.  123,  C), 
the  medullary  cavity  of  each  fragment  is  closed  by  a  plate  of 
internal  callus  (b),  and  union  is  secured  by  a  large  mass  of  en- 
sheathing callus  (c). 

Where  comminution  has  occurred,  the  splintered  fragments  are 
matted  together  by  an  abundant  formation  of  granulation  tissue, 
which  is  subsequently  transformed  into  callus. 


428  A  MANUAL  OF  SURGERY 


The  soft  tissues  around— muscles,  tendons,  etc. — are  repaired  in 
the  usual  way,  but  one  cannot  overlook  the  fact  that  such  repair 
is  often  very  imperfect,  owing  to  the  infiltration  of  the  parts  with 
blood  and  the  subsequent  adhesions  that  form.  In  fact,  although 
the  bones  may  unite  perfectly,  the  functional  result  may  be  most 
disappointing. 

The  removal  of  the  clot  and  the  formation  of  granulation  tissue 
usually  take  about  a  week  or  ten  days,  and  new  bone  formation 
commences  about  the  end  of  the  first  week.  By  the  fourth  or 
sixth  week,  according  to  the  size  and  vascularity  of  the  bone  and 
the  recuperative  power  of  the  individual,  the  fracture  will  be  con- 
solidated, but  in  the  lower  limb  it  is  often  eight  weeks  before  the 
patient  can  bear  any  weight  upon  it.  Months  may,  however,  pass 
before  the  final  stage  of  complete  repair  is  attained. 

In  conclusion,  one  must  allude  to  the  fact  that  a  sarcoma  some- 
times develops  at  the  site  of  fracture  within  a  comparatively 
short  time  of  the  accident,  and  is  presumably  derived  from  an 
overgrowth  of  the  callus. 

The  Treatment  of  simple  fractures  is  sometimes  a  matter  of  but 
little  difficulty,  although  when  the  bones  are  much  displaced  or 
comminuted,  it  may  not  be  easy  to  correct  the  deformity  or  to 
maintain  the  fragments  in  position.  Constitutionally ,  all  that  is 
needed  is  to  restrict  the  diet,  eliminating  all  stimulating  and 
unnecessary  articles,  at  the  same  time  attending  to  the  state  of 
the  bowels.  This  is  especially  needed  in  fractures  of  the  lower 
extremity,  where  the  patient  must  be  confined  to  bed  for  some 
time.  In  elderly  people  the  general  health  is  very  likely  to  suffer, 
partly  from  the  shock  of  the  accident,  partly  from  the  enforced 
and  sudden  change  of  habit,  necessitating  a  somewhat  generous 
diet  and  the  administration  of  a  certain  amount  of  stimulant. 

The  Local  Treatment  of  a  simple  fracture  consists,  first,  in  setting 
the  limb— that  is,  in  reducing  the  deformity  and  restoring  the 
fractured  ends  to  a  normal  position — and  then  in  fixing  it. 

First  Aid. — In  moving  the  patient  from  the  spot  where  the 
accident  happened,  it  is  necessary  to  temporarily  secure  the  limb 
in  as  good  a  position  as  possible  ;  splints  have  often  to  be  im- 
provised from  sticks,  umbrellas,  newspapers,  and  so  forth.  In  a 
railway  accident  the  splintered  debris  of  the  carriages  may  be 
employed  for  this  purpose,  and  the  upholstery  of  the  seats  as 
padding.  A  broken  leg  may  also  be  firmly  tied  to  the  other  limb, 
which  is  thus  converted  into  a  temporary  splint. 

Reduction  of  a  fracture  is  usually  accomplished  by  a  combination 
of  traction  or  extension  applied  to  the  lower  segment  of  the  limb, 
with  manipulation  of  the  fractured  ends,  counter-extension  being 
at  the  same  time  maintained  by  an  assistant.  In  some  cases  it  is 
necessary  to  relax  certain  muscles  in  order  to  facilitate  reduction ; 
thus,  in  fractures  of  the  leg,  the  lower  fragment  is  liable  to  be 


INJURIES  OF  BONES— FRACTURES  429 

drawn  up  by  the  muscles  attached  to  the  tendo  Achillis,  and  to 
obviate  this  the  knee  should  always  be  flexed  by  an  assistant, 
who  holds  up  the  leg  and  makes  counter-extension,  whilst  the 
surgeon  reduces  the  deformity  by  traction  on  the  lower  part  of 
the  limb  ;  section  of  this  tendon  is  sometimes  required  in  these 
cases.  The  manipulation  is  painful,  but,  if  possible,  an  anaesthetic 
should  be  dispensed  with,  as  one  can  never  be  certain  whether 
or  not  the  patient  will  struggle  during  its  administration.  It  is 
unwise  to  use  too  much  force  in  order  to  correct  decided  shorten- 
ing from  muscular  contraction  ;  it  is  better  to  relax  the  muscles 
by  the  adoption  of  a  suitable  position,  or  to  apply  continuous 
extension.  There  can  be  no  question  that  in  bygone  days  patients 
were  subjected  to  a  great  deal  of  unnecessary  pain  from  misguided 
efforts  to  '  set '  the  fracture. 

The  maintenance  of  the  limb  in  a  good  position  is  provided  for 
by  the  application  of  suitable  splints.  These  consist  of  materials, 
such  as  wood,  leather,  zinc,  poroplastic,  etc.,  according  to  the 
requisites  of  the  case.  If  of  wood,  zinc,  or  tin,  they  are  usually 
made  according  to  some  general  pattern,  and  fitted  to  the  patient 
by  means  of  pads  ;  if  formed  of  leather  or  poroplastic,  they  should 
be  shaped  so  as  to  meet  any  peculiarities  of  the  part.  A  paper 
pattern  is  first  fitted  to  the  opposite  limb,  and  the  splint  is  then 
cut  to  the  desired  shape  ;  it  is  softened  by  immersion  in  hot  or 
cold  water,  moulded  to  the  part,  and  allowed  to  dry.  Where 
leather  is  employed,  the  addition  of  a  little  vinegar  to  the  water 
assists  in  rendering  it  soft  and  supple.  The  edges  and  corners 
are  finally  rounded,  and  the  interior  padded  with  wool  or  lint. 
The  general  rules  relating  to  the  application  of  splints  are  as 
follows :  (i.)  The  joints  both  above  and  below  the  site  of  fracture 
should  always  be  immobilized  ;  (ii.)  the  splints  must  be  sufficiently 
large  to  firmly  encase  the  part,  or  if  flat,  to  project  a  little  beyond 
it,  so  that  the  limb  may  be  fixed  by  the  splint,  and  not  the  splint 
by  the  limb ;  (iii.)  careful  attention  must  be  given  to  the  padding 
so  as  to  prevent  irritation  or  sloughing  of  the  skin.  In  out- 
Datient  practice,  where  the  patients  are  not  too  careful  as  to 
personal  cleanliness,  it  is  advisable  to  pad  the  splint  with  some 
antiseptic  material,  such  as  boracic  lint,  in  order  to  prevent  the 
development  of  vermin.  It  is  better  not  to  apply  a  roller  bandage 
under  the  splint  in  the  situation  of  the  fracture.  The  splints  may 
often  with  advantage  be  first  fixed  to  the  limb  by  one  or  two  turns 
of  strapping,  and  then  secured  by  ordinary  calico  bandages ; 
these  must  not  be  applied  too  tightly,  since  the  swelling  of  the 
limb  not  unfrequently  increases  afterwards,  and  undue  constric- 
tion resulting  in  gangrene  may  ensue.  Moreover,  a  limb  en- 
sheathed  in  bandage  must  never  be  flexed,  but  the  flexion  should 
always  be  made  first  ;  if  this  is  not  attended  to,  the  bandage  may 
cut  into  the  soft  tissues,  and  by  compression  of  the  vessels  cause 
gangrene.     It  is  sometimes  advisable  to  bandage  the  whole  of  the 


430  A  MANUAL  OF  SURGERY 

limb  from  the  fingers  or  toes  upwards,  so  as  to  prevent  oedema 
from  the  pressure  of  the  apparatus  obstructing  the  venous  return. 
The  patient  should  always  be  seen  on  the  day  following  the 
application  of  the  splints,  and  the  condition  of  the  fingers  or  toes 
carefully  examined  ;  if  they  look  at  all  blue,  or  feel  numb  and 
cold,  the  bandages  must  be  slightly  relaxed. 

Various  forms  of  Fixed  Apparatus  are  used  in  the  treatment  of 
fractures,  especially  in  the  later  stages  when  the  swelling  has 
disappeared,  and  in  children.  The  materials  most  commonly 
employed  are  starch,  water-glass,  and  plaster  of  Paris. 

The  starch  bandage  is  utilized  only  in  cases  where  great 
strength  and  rigidity  are  not  required.  The  limb  is  carefully 
padded  with  cotton  wool,  and  over  this  are  applied  thin  strips  of 
cardboard  soaked  in  starch  so  as  to  fit  the  limb.  These  are  secured 
by  a  bandage,  the  meshes  of  which  are  well  impregnated  with  a 
starch  solution,  and  over  all  may  be  placed  another  bandage,  the 
under  surface  of  which  is  also  rubbed  with  starch.  When  this 
dries,  it  produces  a  firm  mass,  sufficient  to  immobilize  the  limb. 
It  should  be  put  on  fairly  tight,  the  wool  padding,  if  thick  enough, 
sufficing  to  prevent  injurious  constriction.  If  employed  in  the 
early  stages  of  fractures,  it  becomes  loose  when  the  swelling  of 
the  limb  diminishes,  and  must  then  be  readjusted  by  slitting  up 
and  paring  away  a  portion  on  one  or  both  sides. 

The  water-glass  bandage  is  applied  by  first  swathing  the  limb 
with  a  thick  padding  of  cotton  wool,  or  bandaging  it  with  boracic 
lint ;  around  this  a  coarse  canvas  bandage  soaked  in  a  solution  of 
silicate  of  soda,  strong  enough  to  be  of  the  consistency  of  treacle, 
is  applied ;  several  thicknesses  of  the  bandage  are  required  in 
order  to  give  it  the  necessary  strength.  The  great  advantage  of 
this  material  is  that  it  is  light,  easily  applied,  and  makes  very 
little  mess ;  the  chief  objection  is  that  it  dries  but  slowly,  taking 
fully  twenty-four  hours  to  become  hard  and  firm. 

Plaster  of  Paris,  though  rather  messy  and  increasing  con- 
siderably the  weight  of  the  limb,  is  one  of  the  best  means  of 
securing  prolonged  immobilization.  It  may  be  applied  directly 
to  the  outside  of  a  layer  of  cotton  wool  or  boracic  bandage  ;  but 
frequently  a  coarse  canvas  bandage  or  a  suitable  piece  of  house- 
flannel  is  employed  as  a  foundation  on  which  to  place  it.  (a)  The 
dried  plaster  may  be  rubbed  into  a  coarse  canvas  bandage,  which 
prior  to  use  is  soaked  for  a  few  minutes  in  cold  water,  to  which 
a  little  salt  or  alum  may  be  added  in  order  to  hasten  its 
setting ;  it  is  then  wound  round  the  limb,  wmich  has  been 
previously  padded  with  boric  lint  or  wool,  and  on  the  exterior  of 
this  fresh  plaster  of  the  consistency  of  cream  is  applied.  To 
make  this  cream  of  the  right  strength,  the  dried  powder  is  cast  in 
spoonfuls  into  a  bowl  of  cold  water  until  it  no  longer  sinks  im- 
mediately, but  a  portion  remains  floating  on  the  surface.  The 
mixture  is  then  stirred  with  an  iron  spoon,  and  is  ready  for  use. 


INJURIES  OF  BONES— FRACTURES  431 

(b)  It  may  also  be  fitted  to  any  part  of  the  body,  according  to  a 
method  introduced  by  Mr.  Croft,  of  St.  Thomas's  Hospital.  If 
required  for  a  limb,  pieces  of  flannel  are  cut  into  the  shape  of 
lateral  splints,  two  for  each  side,  and  sufficiently  large  to  encase  it 
comfortably.  After  protecting  the  limb  with  wool  or  lint,  one  of 
the  lateral  segments,  the  outer  side  of  which  is  well  soaked  with 
plaster,  is  placed  in  position,  and  the  second  portion,  which  has 
been  totally  immersed  in  the  plaster,  is  then  placed  over  it,  a  little 
extra  plaster  being  perhaps  rubbed  in  ;  the  two  are  now  secured 
by  a  muslin  bandage.  After  this  has  set,  the  opposite  side  of 
the  limb  is  dealt  with  in  exactly  the  same  way,  and  when  the 
whole  is  solid,  the  muslin  bandage  is  cut  through  in  front,  but  is 
left  untouched  behind  so  as  to  form  a  hinge.  If  it  is  considered 
necessary,  thin  strips  of  wood  or  tin  may  be  incorporated  in  any 
of  these  arrangements,  so  as  to  add  to  their  strength. 

Early  immobilization  by  means  of  plaster  of  Paris  has  been 
advocated  by  certain  Continental  and  American  authorities,  and  so 
much  confidence  have  they  in  it  that  even  fractures  of  the  femur 
are  dealt  with  in  this  way  within  a  few  days  of  the  accident,  and 
the  patient  allowed  to  walk  about.  Such  ambulatory  treatment  has 
not  received  much  support  in  this  country,  and  does  not  seem  to 
us  in  accord  with  the  principles  that  guide  us  in  restoring  a  limb 
to  functional  as  well  as  mechanical  soundness. 

A  most  valuable  adjuvant  in  the  treatment  of  fractures  is 
Massage,  advocated  so  forcibly  by  Lucas-Championniere,  whilst 
in  some  cases  Early  Mobilisation  is  also  desirable.  The  part  is 
kept  in  splints  only  long  enough  to  ensure  the  non-recurrence  of 
displacement,  and  the  patient  is  encouraged  to  use  the  limb.  It 
has  long  been  recognised  that  after  an  accident  of  this  nature  the 
limb  is  likely  to  remain  for  some  considerable  period  weak  and 
stiff,  owing  partly  to  atrophy  of  muscles,  partly  to  cicatricial 
adhesions  between  various  divided  structures,  and  in  part  to  con- 
traction of  ligaments  in  neighbouring  joints.  It  is  the  object  of 
massage  to  prevent  or  obviate  these  disabilities.  In  a  fracture 
with  displacement  through  the  shaft  of  a  long  bone,  massage  of 
the  soft  tissues  should  commence  about  three  weeks  after  the 
injury  (for  the  femur  a  little  later),  and  be  conducted  methodically 
day  by  day,  the  splints  being  removed  for  the  purpose  and  re- 
applied subsequently  ;  neighbouring  joints  will  also  be  rubbed, 
and  passive  movements  of  the  same  commenced  as  soon  as  advis- 
able. Possibly  some  pain  may  be  noticed  at  first,  but  it  soon 
disappears,  and  the  patient  experiences  a  sense  of  comfort. 
Repair  is  hastened,  but  of  course  the  patient  must  not  put  any 
strain  on  the  bone  until  it  is  quite  consolidated.  In  fractures  near 
joints  or  through  the  articular  ends  of  bones,  it  is  sometimes  pos- 
sible to  discard  splints  entirely,  or  at  any  rate  to  use  them  only  for 
a  short  time,  steadying  the  part  by  some  simple  contrivance,  such 
as  a  sling  or  strapping.     Massage  is  commenced  within  a  few  days 


43?  A  MANUAL  OF  SURGERY 


and  regularly  persisted  in.  For  such  injuries  as  fracture  of  the 
anatomical  neck  of  the  humerus,  the  simpler  varieties  of  Colles's 
or  Pott's  fracture,  and  for  some  fracture-dislocations  in  the  neigh- 
bourhood of  the  elbow,  this  plan  of  treatment  has  been  already 
proved  to  be  of  the  greatest  service.  In  one  case  of  the  first  men- 
tioned of  these  lesions,  which  we  treated  by  this  means  at  hospital, 
the  result  was  most  gratifying  ;  the  limb  was  merely  kept  in  a 
sling,  and  massage  was  commenced  within  three  days  of  the 
accident  ;  within  a  fortnight  the  patient  was  able  to  raise  his  arm 
without  help  to  a  right  angle,  and  he  went  out  subsequently  with 
a  limb  the  movements  of  which  were  almost  perfect. 

During  the  last  few  years  considerable  impetus  has  been  given 
to  the  Early  Operative  Treatment  of  fractures  in  order  to  secure 
complete  fixation  and  the  restoration  to  health  and  usefulness  in 
as  short  a  space  of  time  as  possible.  At  first  this  plan  was  only 
utilized  for  such  bones  as  the  patella  or  olecranon,  but  the  excellent 
results  which  followed,  and  the  increased  confidence  with  which 
antiseptic  methods  were  employed,  soon  removed  all  the  fears  of 
opening  up  a  so-called  simple  fracture  in  order  to  deal  directly  with 
the  ends  of  the  bone.  Moreover,  it  soon  became  obvious,  when 
once  sepsis  had  been  excluded,  how  much  better  results  often 
followed  compound  fractures  which  had  been  operated  upon  than 
simple  fractures  which  had  been  treated  by  the  routine  immo- 
bilization, especially  after  oblique  fractures  of  the  larger  bones. 
The  reason  for  this  was  that  accurate  apposition  of  the  fragments 
apart  from  operation  is  almost  impracticable  in  such  cases,  whilst 
the  infiltration  of  the  tissues  with  blood  leads  to  much  fibrosis  and 
the  formation  of  many  adhesions  ;  moreover,  the  more  lengthy 
immobilization  results  in  greater  atrophy  of  muscles  and  stiffness 
of  joints,  and  hence  the  commercial  value  of  a  working  man 
after  a  fracture  of  the  thigh  or  leg  is  very  considerably  depreci- 
ated, owing  partly  to  persistent  deformity,  partly  to  the  joints 
being  stiff,  whilst  the  period  of  convalescence  is  reckoned  by 
months  rather  than  weeks.  Should,  such  a  case  be  operated  on, 
the  blood  being  removed,  and  the  end  of  the  bones  freed  from 
intervening  tissues  and  securely  united  by  wires,  screws,  or  pegs, 
convalescence  may  be  anticipated  in  a  comparatively  short  time  ; 
the  bone  retains  its  normal  length  ;  early  massage  of  the  muscles 
and  joints  above  and  below  becomes  practicable,  owing  to  the 
fixity  of  the  limb,  and  thus  atrophy  on  the  one  hand,  and  stiffness 
on  the  other,  are  avoided. 

At  the  same  time  one  must  emphasize  the  gravity  of  these 
operations,  which  are  only  justifiable  when  complete  asepsis  can  be 
maintained,  whilst  the  manipulative  dexterity  required  in  order  to 
bring  them  to  a  successful  issue  is  such  that,  in  our  opinion,  the 
general  practitioner,  who  undertakes  but  little  operative  work  in 
the  year,  is  not  justified  in  performing  them. 

As   to   the  actual  operation,  the  incision  to  expose  the  bone 


INJURIES  OF  BONES— FRACTURES  433 

should  be  extensive,  so  as  to  give  plenty  of  room  and  allow  exit 
to  as  much  of  the  extravasated  blood  as  possible.  The  ends  of 
the  fragments  are  then  cleared,  and  brought  into  position,  attention 
being  directed  to  make  certain  that  there  is  no  abnormal  rotation, 
and  fixed  by  suitable  forceps  with  a  large  grasp,  e.g.,  Peters'. 
The  fragments  are  drilled  in  one  or  two  places,  and  silver  wire  or 
plated  screws  introduced  ;  the  ends  of  the  wires  are  twisted  up, 
cut  short,  and  the  knot  hammered  down  into  the  periosteum. 
Various  encircling  contrivances  of  the  collar  type  have  been  sug- 
gested in  order  to  assist  in  the  fixation  of  the  bone,  and  may  prove 
useful  under  certain  circumstances. 

Complications  arising  during  Treatment. —  (i)  If  an  elderly 
patient  is  kept  in  bed  for  any  length  of  time  in  the  recumbent 
posture,  hypostatic  pneumonia  is  likely  to  ensue.  It  occurs  most 
commonly  after  intracapsular  fractures  of  the  cervix  femoris,  and 
non-union  often  results,  since  the  patients  must  be  allowed  to  get 
about  on  crutches  at  an  early  date,  the  limb  being  merely  fixed 
by  a  Thomas's  splint.  (2)  Bedsores  are  very  liable  to  supervene  in 
old  people  with  fractures  which  need  treatment  in  the  recumbent 
posture.  (3)  Crutch  palsy  is  the  result  of  compression  of  the 
brachial  nerves  between  the  head  of  the  humerus  and  the  pad  of 
a  crutch.  It  may  affect  all  the  nerves  of  the  upper  extremity,  or 
may  pick  out  any  one  of  them,  and  then  most  commonly  the 
musculo-spiral.  It  can  usually  be  prevented  by  the  use  of  spring- 
padded  crutches  with  cross-pieces  for  the  hands,  so  as  to  allow 
the  patient  to  partially  relieve  the  axillary  pressure  by  supporting 
the  weight  of  the  body  by  means  of  the  arms.  When  it  has 
occurred,  the  use  of  crutches  must  be  discontinued,  and  faradism 
and  massage  employed  to  the  affected  muscles.  (4)  When  the 
muscles  of  a  part  have  been  firmly  compressed  by  splints,  they 
may  undergo  a  rapid  intrinsic  atrophy  with  contraction,  con- 
stituting what  is  known  as  Ischemic  contraction.  This  is  observed 
most  frequently  in  the  hand,  and  is  then  due  to  the  direct  pressure 
of  the  splints  on  the  muscles  of  the  forearm.  The  fingers  become 
clawed  and  flexed,  and  the  wrist  is  sometimes  hyper-extended. 
It  is  recognised  from  the  results  of  a  nerve  lesion  by  the  absence 
of  sensory  or  trophic  phenomena.  Treatment  consists  in  exposing 
and  lengthening  the  contracted  tendons,  if  massage  fails.  The 
outlook  is,  however,  not  very  promising.  (5)  Gangrene  may  arise 
from  fractures  in  a  variety  of  ways  :  (i.)  From  the  immediate 
effects  of  the  injury,  either  by  its  direct  action  on  the  tissues,  or  by 
causing  arterial  thrombosis  in  a  limb  with  atheromatous  vessels, 
or  from  rupture  of  the  artery  with  consequent  venous  thrombosis, 
owing  to  the  pressure  of  the  extravasation  ;  (ii.)  by  the  super- 
vention of  spreading  gangrene  in  a  compound  fracture  ;  (iii.)  from 
errors  in  the  course  of  treatment,  as  by  bandaging  the  limb  too 
tightly,  so  as  to  constrict  the  vessels  ;  or  by  the  bandage  becoming 
unduly  tight,  owing  to  the  subsequent  swelling  of  the  limb  ;  or  by 

28 


434  A  MANUAL  OF  SURGERY 

flexing  a  joint  after  bandaging  it,  the  bandage  cutting  into  the 
soft  tissues ;  or  by  the  localized  pressure  of  a  splint  which  has 
been  insufficiently  padded.  Moist  gangrene  is  the  type  met  with 
in  all  cases,  except  when  the  limb  has  been  previously  drained  of 
its  fluids  by  an  atheromatous  condition  of  its  vessels.  (For  rules 
of  treatment,  see  Chapter  V.) 

Compound  Fractures. 

A  compound  fracture  is  one  in  which  there  is  a  communication 
between  the  external  air  and  the  site  of  injury.  It  is  produced  by 
direct  or  indirect  violence,  and  any  of  the  complications  or  modifi- 
cations met  with  in  simple  fractures  can  be  present.  The  bones 
may  be  but  little  displaced,  or  protrude  through  the  opening  in 
the  skin,  and  under  such  circumstances  may  be  much  bruised  or 
comminuted,  and  even  contaminated  with  dirt  or  mud. 

The  chief  dangers  of  compound  fractures  are,  firstly,  hemorrhage, 
the  blood,  instead  of  collecting  within  the  tissues  of  the  limb, 
escaping  externally,  although  subcutaneous  extravasation  is  not 
uncommon  ;  and  secondly,  the  advent  of  sepsis.  The  latter  is  the 
more  important,  and  may  lead  to  the  most  serious  consequences. 
Portions  of  muscle  and  periosteum,  which  in  a  simple  fracture 
would  be  removed  or  incorporated  in  the  new  formation  of 
callus,  become  inflamed  in  septic  cases,  and  even  slough.  Small 
isolated  fragments  of  bone  are  almost  certain  to  necrose  if  sup- 
puration ensues,  whilst  the  severest  forms  of  septic  osteomyelitis 
may  occur,  endangering  the  patient's  life  by  pyaemia.  Such 
results  are  more  likely  to  follow  when  the  external  wound  is 
small  and  insufficient  provision  has  been  made  for  drainage. 
Immense  advances  in  the  treatment  of  these  conditions  have 
been  made  since  the  introduction  of  antiseptic  surgery,  and 
where  such  is  regularly  and  efficiently  practised,  these  dangerous 
complications  are  rarely  seen. 

The  Method  of  Union  of  a  compound  fracture  is  practically  the 
same  as  that  occurring  in  simple  fractures.  If  the  wound  can  be 
rendered  aseptic,  and  there  is  not  much  bruising,  it  may  be 
closed  by  suture  except  at  the  spot  where  a  drainage-tube  is  in- 
serted. Primary  union  may  thus  be  obtained,  and  then  repair 
according  to  the  details  already  described  will  follow.  If,  however, 
suppuration  occurs,  it  is  probably  attended  with  a  greater  or  less 
amount  of  necrosis,  and  possibly  diffuse  suppuration  in  the  soft 
parts ;  the  wound  will  therefore  remain  open  for  a  tine,  varying 
with  the  acuteness  of  the  local  phenomena.  It  is  gradually  closed 
by  granulations,  which  extend  upwards  from  below,  and  the 
deepest  part  of  this  granulation  tissue,  which  is  derived  from  the 
bone  and  periosteum,  and  contains  osteoblastic  elements,  will  be 
transformed   into   callus,    and    finally   into   true   osseous   tissue. 


INJURIES  OF  BONES—FRACTURES  435 

Repair  is  much  slower  under  these  circumstances  than  in  a 
simple  fracture,  since  the  suppuration  may  have  interfered  with 
the  osteogenetic  powers  of  the  periosteum,  and  thus  the  new  bone 
formation  is  dependent  solely  on  the  osseous  tissue  itself,  which  is 
always  slow  to  react. 

The  Constitutional  Symptoms  following  compound  fractures  are 
much  more  marked  than  in  simple  cases.  Even  where  sepsis 
is  prevented  by  efficient  treatment,  some  amount  of  aseptic 
traumatic  fever  is  certain  to  supervene  for  a  few  days,  whilst, 
if  infection  occurs,  there  is  a  period  of  marked  febrile  disturbance 
for  a  week  or  ten  days,  similar  to  that  which  is  seen  in  all  septic 
lacerated  wounds  (p.  197). 

In  the  Treatment  of  compound  fractures,  the  main  object  is  to 
render  the  wound  aseptic  and  to  give  efficient  exit  to  the  dis- 
charges. For  this  purpose  the  patient  should  in  most  cases  be 
anaesthetized,  the  wound  enlarged  and  thoroughly  washed  out 
and  even  scrubbed  with  some  potent  antiseptic,  such  as  carbolic 
lotion  (1  in  20).  Loose  fragments  of  bone  are  removed,  and 
portions  denuded  of  their  periosteum  may  be  taken  away  lest 
necrosis  should  ensue ;  where  fragments  retain  any  considerable 
connection  with  the  soft  parts,  they  may  be  left  without  fear,  and 
of  course  as  little  periosteum  should  be  removed  as  possible. 
When  a  sharp  end  of  one  of  the  fragments  is  protruding  through 
a  small  opening  in  the  skin,  it  is  first  thoroughly  purified  before 
attempting  its  reduction,  and  then  replaced,  after  enlarging  the 
wound  in  the  skin,  or  a  portion  is  sawn  off.  Haemorrhage  is 
dealt  with  in  the  usual  way,  and  the  fragments  are  placed  as  nearly 
as  possible  in  their  normal  position.  If  there  is  no  comminution 
and  the  fragments  can  be  brought  accurately  into  position,  it  is 
well  to  fix  them  by  the  insertion  of  silver  wire,  or  of  ivory  pegs, 
or  plated  screws ;  but  where  the  ends  of  the  bones  are  com- 
minuted, the  small  portions  must  be  arranged  in  position  as  well 
as  possible,  and  no  attempt  made  to  wire  them.  A  good-sized 
drainage-tube  is  inserted,  and,  if  need  be,  counter-openings  are 
made ;  the  limb  is  then  placed  on  appropriate  splints,  and  the 
external  wound  closed  or  not  according  to  circumstances.  Under 
such  a  regime  the  majority  of  uncomplicated  cases  will  do  well. 
Immoveable  apparatus  may  be  applied  after  a  time,  windows  being 
left  in  the  plaster  casing  to  allow  wounds  to  be  dressed. 

In  compound  fractures  which  have  been  attended  with  com- 
plications directed  to  vessels,  nerves,  and  neighbouring  soft  parts 
or  joints,  the  prognosis  and  course  of  the  case  may  be  consider- 
ably modified  ;  treatment  suitable  to  each  of  these  conditions  must 
be  adopted. 

The  question  of  Amputation  will  necessarily  be  raised  in  the 
more  serious  cases  ;  but  it  is  unnecessary  to  add  anything  here  to 
what  has  already  been  stated  in  Chapter  VIII.  (p.  199). 

28—2 


436 


A   MANUAL  OF  SURGERY 


Ununited  Fractures. 

Three  varieties  of  ununited  fracture  have  been  described  : 
(i)  Absolute  non-union  is  said  to  be  present  when  no  attempt  at 
repair  is  made.  This  rarely  occurs  except  when  some  definite 
bone  disease  exists,  such  as  sarcoma  or  osteo-malacia,  or  when  in 


v" 


Fig.  124. — Ununited  Fracture  with  False  Joint. 
Surgeons'  Museum.) 


(From  College  of 


a  very  debilitated  patient  there  has  been  no  attempt  to  fix  the 
limb.  (2)  Fibrous  union  consists  in  the  development  of  a  more  or 
less  firm  mass  of  connective  tissue  as  the  bond  of  union  between 
the  ends  of  the  bones,  which  are  either  rounded  off  and  closed  by 
a  thin  plate  of  bone  or  cartilage,  or  are  sometimes  atrophic  and 
pointed.  (3)  A  false  joint,  or  pseudarthrosis,  is  a  condition  in 
which  the  ends  of  the  fragments  are  covered  either  by  bone  or 
cartilage,  and  more  or  less  altered  in  shape,  so  as  to  form  a 
shallow  ball-and-socket  joint,  the  capsule  being  represented  by 
the  surrounding  fibrous  tissue,  and  the  synovial  cavity  by  an 
adventitious  bursa,  which  results  from  the  friction  of  the  two  ends 
(Fig.  124). 

The  most  common  situations  for  ununited  fractures  are  project- 
ing processes  of  bone  to  which   powerful  muscles  are  attached, 


INJURIES  OF  BONES— FRACTURES  437 

such  as  the  patella,  olecranon,  coracoid  process,  posterior  half  of 
the  os  calcis,  etc.  ;  whilst  in  long  bones  the  middle  of  the  shaft  of 
the  humerus  and  the  upper  and  lower  thirds  of  the  femur  are  the 
favourite  sites. 

Many  different  Causes  may  be  associated  in  determining  the 
defective  union  of  fractures,  but  the  following  are  the  more 
important :  (1)  Want  of  apposition  of  the  bony  ends,  owing  to 
muscular  action — e.g.,  in  the  patella,  when  the  two  fragments 
are  widely  separated,  or  in  the  femur,  where  they  may  over- 
lap ;  (2)  the  interposition  of  fluid  or  such  substances  as  muscular 
or  aponeurotic  tissue,  or  detached  fragments  of  compact  bone ; 
(3)  want  of  rest,  one  of  the  most  common  causes,  as  in  the 
middle  of  the  shaft  of  the  humerus,  where,  unless  the  elbow  is 
well  supported,  complete  immobility  cannot  be  obtained,  and 
non-union  is  likely  to  result ;  (4)  defective  blood-supply  to  one  or 
both  fragments,  as  by  injury  to  the  nutrient  artery,  or  as  in  intra- 
capsular fracture  of  the  cervix  femoris,  where  the  only  source  of 
supply  to  the  upper  fragment  is  a  small  twig  derived  from  the 
obturator  artery  running  along  the  ligamentum  teres  ;  (5)  local 
affections  of  the  bone,  such  as  malignant  tumours,  destruction  of 
the  periosteum  by  inflammation,  or  the  undue  pressure  of  pads 
upon  the  newly-formed  callus ;  (6)  general  bone  disease,  as  osteo- 
malacia ;  and  (7)  general  constitutional  weakness  or  debility, 
sometimes  due  to  definite  diseases,  such  as  scurvy  or  severe 
syphilis,  sometimes  to  general  asthenia  or  alcoholism.  It  has 
been  proved  that  senility,  pregnancy,  and  the  cancerous  cachexia 
do  not,  as  used  formerly  to  be  stated,  predispose  to  this  condition. 

The  Signs  of  an  ununited  fracture  are  usually  obvious,  mobility 
between  the  fragments  being  easily  obtained,  although  without 
crepitus. 

The  Prognosis  is  good  if  suitable  treatment  is  adopted.  In 
children,  however,  the  condition  is  often  maintained  even  after 
operation,  and,  in  fact,  may  be  aggravated  by  it,  the  ends  of  the 
bone  becoming  atrophic,  rounded,  and  covered  by  cartilage ;  in 
such  the  final  resource  is  not  unfrequently  amputation. 

The  Treatment  of  ununited  fractures  is  now  conducted  on  per- 
fectly definite  lines.  (1)  The  parts  are  refixed  in  an  immoveable 
apparatus,  preferably  plaster  of  Paris,  for  six  weeks,  whilst  means 
are  adopted  to  improve  the  general  health,  as  by  a  stay  at  the 
seaside  and  the  administration  of  tonics.  (2)  Failing  this,  the 
ends  of  the  bones  may  be  well  rubbed  together,  so  as  to  excite 
local  action,  and  the  parts  again  fixed.  Regular  massage  is  useful, 
and  enforced  congestion  of  the  limb  by  an  elastic  tourniquet 
applied  for  an  hour  or  two  daily  has  also  been  recommended. 
(3)  Should  this  be  unsuccessful,  operative  measures  must  be 
undertaken.  If  the  bone  is  tolerably  superficial,  and  the  ends 
not  very  far  apart,  they  should  be  exposed,  sawn  into  shape, 
fitted  together  (preferably  by  a  dove-tailing  process),  and  secured 


438 


A   MANUAL  OF  SURGERY 


by  stout  silver  wire,  which  may  be  left  in  situ  permanently,  and 
if  aseptic,  becomes  encapsuled.  If,  however,  the  bones  are  deeply 
placed,  so  that  the  operation  to  expose  the  ends  and  fit  them 
together  becomes  a  very  severe  one,  it  is  often  better  practice  to 
leave  them  in  their  bad  position,  and  merely 
fix  them  by  the  insertion  of  ivory  pegs  or 
nickel-plated  screws.  Thus,  in  the  upper  end 
of  the  femur  non-union  is  usually  associated 
with  overlapping  of  the  ends  of  the  bone  to 
a  considerable  extent.  To  expose  and  fit 
these  together  would  necessitate  a  very  ex- 
tensive dissection ;  it  is  wiser  in  such  cases 
merely  to  cut  down  in  front  upon  the  upper 
anterior  fragment,  drill  two  holes  in  different 
directions  through  both  fragments,  and  into 
these  insert  suitable  ivory  pegs.  Two  holes 
should  always  be  employed,  to  prevent  slip- 
ping of  the  fragments  during  the  many  neces- 
sary manipulations ;  whilst  one  drill  is 
removed  for  the  insertion  of  the  peg,  the 
other  holds  the  bone  steady.  As  a  rule,  the 
pegs  may  be  allowed  to  remain  permanently, 
but  occasionally  they  become  loose  in  three 
or  four  weeks,  and"  need  removal.  Their 
presence  causes  the  formation  of  a  large 
amount  of  callus,  and  by  this  means  the  frac- 
ture is  consolidated.  It  is  well  to  examine  the 
fracture  by  the  X  rays  from  time  to  time  to 
see  that  the  bones  are  still  in  position,  and 
for  this  purpose  the  dressings  need  not  be 
removed,  if  metal  splints  are  not  used. 

Disunited  Fracture  is  the  term  applied  to 
a  rare  condition,  in  which  a  fracture  which 
had  been  firmly  united  becomes  separated 
again.  It  is  only  met  with  when  the  indi- 
vidual develops  some  extremely  debilitating  disease,  such  as 
scurvy,  and  may  be  recovered  from  under  suitable  treatment 
directed  to  the  cause,  and  by  fixation  of  the  parts. 

Vicious  Union  (Fig.  125)  of  fractures  results  either  from  imper- 
fect readjustment  of  the  ends  of  the  bone  prior  to  placing  the  limb 
on  an  immoveable  apparatus,  or  from  the  parts  not  being  kept  at 
rest,  and  hence  becoming  subsequently  displaced.  Various  kinds 
of  deformity  and  disfigurement,  accompanied  or  not  by  loss  of 
function,  may  result  from  this  accident.  In  some  cases  it  may 
be  advisable  to  leave  things  alone,  but  where  the  deformity  or 
functional  disability  is  serious,  means  must  be  taken  to  remedy 
matters.  If  observed  early,  it  is  not  difficult  to  readjust  the  parts 
by  simple  pressure  under  an  anaesthetic,  if  necessary  re-fracturing 


Fig.  125. — Old  Frac- 
ture of  Femur 
with  Vicious 
Union. 


INJURIES  OF  BONES— FRACTURES  439 

the  bone ;  but  this  should  only  be  undertaken  whilst  the  callus 
is  soft,  ue.,  within  three  or  four  weeks  of  the  accident.  Some 
surgeons  apply  this  method  of  osteoclasia  even  when  consolidation 
has  been  accomplished,  using  for  the  purpose  levers  and  powerful 
clamps  ;  but  in  our  opinion  such  treatment  is  most  undesirable 
and  highly  unscientific,  since  it  is  difficult  to  accurately  gauge  the 
amount  of  damage  concurrently  inflicted  on  the  soft  parts.  We 
much  prefer  the  open  method,  cutting  down  on  the  bone,  re-divid- 
ing it,  removing  redundant  callus,  and  fixing  the  fragments  by 
silver  wires,  pegs,  or  screws. 

Special  Fractures. 

Bones  of  the  Face.— The  Nasal  bones  are  broken  as  a  result  of 
direct  violence,  by  the  fist,  a  cricket-ball,  stick,  etc.  The  fracture 
is  generally  transverse,  and  situated  just  above  their  free  margins; 
occasionally,  when  greater  force  is  used,  it  occurs  close  to  the  root 
of  the  nose,  and  may  then  be  associated  with  fracture  of  the  frontal 
bone  or  base  of  the  skull.  In  young  people  the  cartilages  alone 
may  be  separated.  There  is  usually  considerable  deformity  from 
depression  or  lateral  displacement  of  the  fragment,  although  it 
may  at  first  be  masked  by  the  amount  of  bruising.  Severe 
epistaxis,  surgical  emphysema,  and  cerebral  symptoms,  are  some- 
times met  with  as  complications.  The  fracture  very  readily 
becomes  consolidated,  and  the  deformity  is  thus  often  irremediably 
fixed.  It  is  most  important,  therefore,  to  determine  the  presence 
or  not  of  a  fracture  at  once,  and  this  can  only  be  made  out,  when 
much  swelling  is  present,  by  grasping  the  organ  and  moving  it 
from  side  to  side  to  elicit  crepitus.  The  Septum  is  sometimes 
broken  and  depressed  in  association  with  the  above  injury,  but  it 
may  occur  alone  in  other  instances,  giving  rise  to  lateral  displace- 
ment. This  need  not  result  in  obvious  deformity,  but  may  lead 
to  considerable  nasal  obstruction  and  discomfort.  The  Treatment 
of  these  cases  consists  in  immediate  replacement  of  the  bones, 
advisably  under  an  anaesthetic  ;  this  may  be  accomplished  by  the 
pressure  of  some  blunt  instrument,  such  as  a  pair  of  padded 
dressing  forceps,  the  blades  of  which  are  introduced  within  the 
nostril,  or  by  distension  of  a  suitable  indiarubber  bag  with  air  or 
water.  A  pad  of  lint  or  gauze  soaked  in  carbolized  oil  is  then 
inserted  to  maintain  the  position,  and  a  guttapercha  or  zinc  splint 
moulded  to  fit  the  bridge.  In  old-standing  cases,  where  there  is 
much  depression,  but  little  can  be  done,  although  the  deformity 
has  been  remedied  by  bone-grafting.  Lateral  displacement  can 
usually  be  remedied  by  mechanical  appliances  or  operation. 

The  Lachrymal  bone  has  been  broken  by  direct  violence,  the 
fracture  usually  extending  from  the  nasal  bone  to  the  lateral  mass 
of  the  ethmoid.  Interference  with  the  flow  of  tears  and  surgical 
emphysema  are  the  two  most  marked  symptoms. 


440 


A  MANUAL  OF  SURGERY 


The  Malar  bone  is  but  rarely  fractured  without  the  other  bones 
of  the  face  being  involved.  When  it  does  occur,  it  is  almost  always 
associated  with  damage  to  the  anterior  wall  of  the  antrum  and  con- 
siderable depression  of  the  fragments.  An  attempt  should  be 
made  to  replace  the  parts  by  pressure  from  within  the  mouth. 

The  Zygoma  is  fractured  by  direct  violence  applied  from  with- 
out ;  the  broken  portion  may  be  depressed  below  the  surface, 
but  vertical  displacement  is  limited  by  the  attachment  of  the  mas- 
seter  below  and  of  the  temporal  fascia  above.  Reposition,  either 
by  manipulation  from  within  the  mouth,  or  even  by  operation,  is 
.essential  in  order  to  prevent  interference  with  the  subsequent 
mobility  of  the  jaw.  Perhaps  the  simplest  plan  to  adopt  is  to 
encircle  the  zygoma  subcutaneously  with  a  loop  of  silver  wire 
and  drag  it  up  to  its  natural  level. 

The  Superior  Maxilla  is  invariably  broken  as  a  result  of  direct 
injury,  such  as  a  gunshot  wound  or  a  blow;  it  is  almost  always  com- 
pound, and  often  bilateral.  The  alveolar  portion  is  either  partially 
or  entirely  detached,  or  a  transverse  fissure,  extending  as  far  as 
the  pterygoid  processes  on  each  side,  may  render  the  whole  palate 
and  lower  part  of  the  facial  skeleton  moveable.  Not  unfrequently 
all  the  bones  of  the  face  are  smashed  and  comminuted,  severe 
haemorrhage  sometimes 
resulting  from  wounds  of  the 
internal  maxillary  artery  or 
its  terminal  branches.  As 
a  rule,  Treatment  consists  in 
merely  keeping  the  patient 
quiet  and  applying  cooling 
lotions ;  union  occurs  with 
great  readiness,  but  is  some- 
times associated  with  sup- 
puration and  necrosis.  The 
patient  must  be  fed  by  a 
tube,  and  a  carefully  fitted 
dental  plate  should  be  ap- 
plied to  a  broken  alveolus. 

The  Inferior  Maxilla  is  usually  fractured  by  direct  violence,  but 
occasionally  by  force  applied  indirectly,  as  when  a  carriage  passes 
over  the  bone,  laterally  compressing  the  two  sides,  and  leading  to 
a  fracture  in  the  middle  line.  Most  frequently  the  lesion  is  a 
little  in  front  of  the  mental  foramen  (Fig.  126),  this  being  a  weak 
spot  at  the  junction  of  two  strong  parts,  viz.,  the  symphysis  menti 
and  the  alveolar  process  carrying  the  molar  teeth  ;  the  bone  is 
further  weakened  by  the  long  narrow  alveolus  which  lodges  the 
canine  tooth.  This  fracture  may  sometimes  be  double  when  great 
violence  has  been  applied  to  the  symphysis."  A  solution  of  con- 
tinuity also  occurs  close  to  the  angle  behind  the  molar  teeth, 
whilst  the  coronoid  process  and  condyle  have  occasionally  been 


Fig.  126. — Lower  Jaw,  indicating  the 
Most  Common  Sites  of  Fracture. 


INJURIES  OF  BONES— FRACTURES 


441 


broken,  the  former  only  as  a  result  of  great  force,  e.g.,  a  gunshot 
wound,  the  latter  from  either  direct  or  indirect  violence. 

The  Signs  of  fracture  are  very  evident  if  the  lesion  is  situated 
anteriorly ;  but  when  behind  the  teeth,  diagnosis  may  be  much 
more  difficult.  The  usual  variety  is  almost  always  compound, 
owing  to  the  firm  attachment  of  the  muco-periosteum  to  the 
alveolar  border.  Laceration  of  the  gums,  the  blood-stained 
saliva  soon  becoming  foetid,  the  irregularity  in  the  line  of  the 
teeth,  and  the  easily  elicited  crepitus,  all  constitute  a  typical 
picture.  There  is  often  considerable  pain,  owing  mainly  to  the 
tearing  of  the  mucous  membrane,  but  possibly  due  to  implication 

of  the  inferior  dental  nerve.  The 
main  trunk,  however,  generally 
escapes,  owing  to  the  position  of  the 
fracture  in  front  of  the  mental  fora- 
men, whilst  in  those  behind  there 
is  but  little  displacement.  Smart 
haemorrhage  sometimes  occurs  from 
laceration  of  the  accompanying 
artery.  The  posterior  fragment  is 
often  somewhat  raised,  whilst  the 
anterior  portion  is  depressed  by  the 
action  of  the  hyoid  muscles,  and  may 
override  the  other,  owing  to  the 
direction  of  the  fracture,  the  anterior 
fragment  including  more  of  the  outer 
surface  of  the  bone  than  the  pos- 
terior. The  direction  of  the  displace- 
ment is  reversed  in  some  cases. 
When  situated  at  the  angle  or  in  the  vertical  ramus,  there  is  such 
equal  muscular  support  on  the  two  sides  that  but  little  displacement 
results.  When  the  fracture  passes  through  the  neck  of  the  condyle, 
that  process  is  drawn  forwards  and  inwards  by  the  external 
pterygoid,  whilst  the  body  of  the  bone  is  freely  moveable  antero- 
posteriorly,  and  displaced  towards  the  fractured  side.  When  the 
coronoid  process  is  detached,  it  is  dragged  upwards  by  the  temporal 
tendon,  but  no  great  displacement  can  occur,  owing  to  the  exten- 
sive attachment  of  the  tendinous  fibres. 

In  those  cases  of  fracture  which  are  compound  (and  this  includes 
the  great  majority),  septic  inflammation  of  the  ends  of  the  bone 
often  ensues,  leading  to  localized  necrosis,  and  sometimes  to 
septic  pneumonia,  or  even  to  general  pyaemia. 

The  Treatment  of  a  fractured  mandible  is  frequently  a  matter 
of  difficulty,  owing  partly  to  the  septic  element,  and  partly  to 
the  difficulty  of  fixing  the  jaw  without  interfering  with  the 
patient's  nutrition  ;  hence  the  co-operation  of  a  skilled  dentist 
should  always  be  secured. 

1.  As  a  temporary  measure,  and  indeed  as  a  permanent  appli- 


Fig.  127.  —  Application  of 
Four-Tailed  Bandage  for 
Fracture  of  Lower  Jaw. 


442 


A   MANUAL  OF  SURGERY 


ance  in  simple  cases,  without  much  displacement  of  the  fragments, 
and  where  dental  assistance  is  not  to  hand,  all  that  is  needed  is 
an  efficient  four-tailed  bandage.  This  is  made  by  taking  a  piece 
of  calico  4  inches  wide  and  i  yard  in  length,  and  splitting  each 


Fig. 


128. — Leather  Splint 
for  Lower  Jaw. 


Fig    129. — Leather  Splint 
applied 

end  into  two,  leaving  about  8  inches  undivided,  and  in  the  centre 
of  this  a  small  longitudinal  cut  is  made,  into  which  the  point  of 
the  chin  is  inserted.  The  two  lower  tails  are  then  drawn  up  and 
tied  over  the  vertex,  whilst  the  two  upper  ends  are  secured 
behind  the  occiput,  and  then,  to  prevent  slipping,  are  knotted  to 
the  ends  of  the  former  (Fig.  127).  This  apparatus  is  maintained 
firmly  in  position  for  three  weeks,  the  patient  being  fed  on  fluids 
passed  between  the  teeth  or  through  the  gap  behind  the  last 
molar,  and  all  movement  of  the  jaw  prohibited.  The  mouth 
should  be  frequently  washed  out  with  some  antiseptic  lotion. 
Union  is  usually  secured  in  five  weeks. 

2.  If  patients  are  unruly,  or  if  the  above  apparatus  fails  to 
maintain  the  fragments  in  position,  a  moulded  guttapercha  or 
leather  splint  may  be  applied,  made  in  the  shape  indicated  in 
Fig.  128,  the  upper  portion  being  folded  back,  and  the  lower 
portion  drawn  up  around  the  bone.  It  is  lined  with  lint,  and 
secured  by  bandages  or  tapes  passed  through  holes,  and  tied  as 
shown  in  Fig.  129. 

3.  Where  there  is  much  displacement,  the  fragments  must  be 
fixed.  Wire  sutures  passed  around  or  between  the  teeth  and  tied 
are  distinctly  objectionable,  causing  the  teeth  to  become  loose  and 
perhaps  diseased.  Hammond's  ivive  splint  is  the  best  apparatus  to 
employ.  It  consists  of  a  firm  wire  collar  or  framework  (Fig.  130), 
which  encircles  the  whole  series  of  teeth  in  the  lower  jaw.  It  is 
accurately  fitted  by  a  dentist,  firstly,  to  a  cast  of  the  jaw,  sub- 
sequently to  the  jaw  itself,  and  is  fixed  by  several  wires  passing 
from  one  half  to  the  other  between  the  teeth. 


INJURIES  OF  BONES— FRACTURES 


443 


4.  In  cases  where  a  Hammond's  splint  fails  in  remedying  the  dis- 
placement, or  where  the  teeth  are  defective,  a  Kingsley's  apparatus 
(Fig.  131)  may  be  used  with  advantage.  It  consists  of  a  vulcanite 
splint  fitted  over  the  teeth  or  alveolar  process  of  the  mandible. 


Fig.  130. — Hammond's  Splint  for  Fracture  of  Lower  Jaw. 


and  extending  for  a  sufficient  distance  on  each  side  of  the  fracture 
to  steady  the  fragments.  To  the  front  of  this  are  attached  curved 
metal  bars,  which  extend  sideways  from  the  angles  of  the  mouth 
over  the  cheeks.  It  is  kept  in  position  by  passing  a  bandage  over  the 
bars  and  under  the  chin  (Fig.  132),  and  secures  thereby  excellent 
immobilization  of  the  fragments,  even  when  the  mouth  is  opened. 

5.  Wiring  of  the  fragments  together  may  be  required  in  a  few 
cases.  The  wires  must  be  passed  either  through  the  bone  below 
the  teeth — a  task  not  easy  to  accomplish  without  an  external 
wound — or  through  the  empty  alveoli  of  neighbouring  teeth, 
which  are  extracted  for  the  purpose. 

When  septic  inflammation  occurs  of  such  severity  as  to  lead  to 
necrosis,  it  is  often  best  to  delay  all  operative  treatment  until  the 
sequestrum  has  been  detached,  and  the  parts  are  more  healthy, 
the  patient's  mouth  in  the  meantime  being  frequently  cleansed 
with  antiseptic  lotions.  Wiring  of  the  fragments  may  then,  if 
necessary,  be  undertaken  with  good  hope  of  success. 

Fracture  of  the  Hyoid  Bone  is  uncommon,  arising  usually  from 
direct  violence,  such  as  a  forcible  grasp  or  the  constriction  of  the 
neck  in  hanging.  Either  the  body  may  be  broken,  or  one  of  the 
cornua  separated.  The  symptoms  produced  are:  Pain  on  attempt- 
ing to  move  the  tongue,  jaw,  or  neck  ;  a  husky  voice ;  and  de- 
formity, which  can  sometimes  be  detected  from  without.  Occa- 
sionally the  mucous  membrane  is  perforated,  and  bleeding  into 


444 


A  MANUAL  OF  SURGERY 


the  pharnyx  may  occur,  whilst  oedema  of  the  glottis  may  super- 
vene. The  fragments  should  be  approximated  as  well  as  possible 
by  manipulation  between  one  finger  in  the  mouth  and  the  hand 
outside,  and  the  neck  then  fixed  by  a  poroplastic  collar. 


Fig.  131. 
Kingsley"s  Splint  for  Fracture 
of  Lower  Jaw. 


Fig.  132. 
Kingsley's  Splint  applied. 


Fracture  of  the  Ribs  may  arise  in  two  distinct  ways:  (1)  By 
direct  violence,  as  by  blows  or  stabs,  the  fragments  being  driven 
inwards,  and  damage  to  the  underlying  pleura,  lungs,  liver,  or 
diaphragm,  being  very  likely  to  occur  ;  or  (2)  much  more  fre- 
quently by  indirect  violence,  as  when  the  chest  is  compressed 
between  a  cart-wheel  and  the  ground,  or  between  a  wall  and  the 
back  of  a  waggon.  The  ends  of  the  ribs  are  then  approximated 
beyond  the  limits  of  natural  elasticity,  and  they  give  way  at  the 
most  convex  part — i.e.,  near  the  angle.  The  viscera  may  be  con- 
tused, but  less  often  than  in  the  former  class,  although  haemo- 
thorax  from  rupture  of  the  parietal  pleura  is  not  uncommon. 
One  or  several  ribs  may  be  broken,  but  the  displacement  is  rarely 
marked,  except  in  cases  due  to  direct  violence  where  several  ribs 
have  been  '  staved  in.'  The  fifth  to  the  eighth  ribs  are  those 
usually  injured,  being  more  prominent  and  fixed  at  both  ends; 
the  first  and  second  ribs  are  so  well  protected  by  the  clavicle  as 
to  be  seldom  broken  by  direct  injury,  although  great  violence 
from  above  downwards  to  the  outer  end  of  the  clavicle  may  lead 
to  such  an  accident ;  the  lower  ribs  often  escape  on  account  of 


INJURIES  OF  BONES— FRACTURES 


445 


their  greater  mobility.  Elderly  women  and  persons  suffering 
from  general  paralysis  of  the  insane  are  specially  prone  to  this 
fracture. 

The  Symptoms  are  tolerably  obvious,  viz.,  a  sensation  of  some- 
thing snapping  or  giving  way,  a  sharp  localized  catching  pain  at 
the  site  of  the  injury,  increased  on  deep  breathing  and  coughing, 
and  possibly  some  local  extravasation  and  swelling.  Pain  is  also 
elicited  by  conjoined  pressure  upon  the  sternum  and  spinal  column, 
whilst  the  fracture  may  be  evident  on  palpation,  or  crepitus 
detected  when  the   patient  coughs   or   on   auscultation.     When 

several  ribs  are  driven  in,  a  marked 
depression  results,  but  if  a  single 
bone  is  broken  in  a  fat  individual,  the 
diagnosis  may  be  extremely  obscure. 
For  the  clinical  history  of  lesions  of  the 
lungs  or  pleura?,  see  Chapter  XXX. 

Treatment. — The  affected  side 
should  be  firmly  strapped  with  broad 
strips  of  adhesive  plaster,  so  as  to 
limit  its  movements.  The  strips, 
i^  to  2  inches  wide,  should  extend 
beyond  the  middle  line,  both  front 
and  back,  and  are  applied  from  below 
upwards  whilst  the  chest  is  in  a  state 
of  forcible  expiration,  each  strip  over- 
lapping the  preceding  one  and  cross- 
ing the  direction  of  the  ribs  (Fig.  1 33). 
A  firm  woollen  bandage  should  then 
be  applied  over  all.  If  the  ends  of 
the  bone  are  driven  inwards,  strapping  can  rarely  be  borne,  as  it 
tends  still  further  to  irritate  or  compress  the  lung.  Under  such 
circumstances  all  constriction  of  the  chest  must  be  avoided,  the 
patient  being  confined  to  bed  with  a  sandbag  between  the 
shoulders,  and  the  arm  bound  to  the  side.  When  the  lower  ribs 
are  broken,  tight  applications  are  generally  contra-indicated,  since 
the  diaphragm  is  likely  to  be  irritated,  and  troublesome  hiccough 
may  result.  Ribs  unite  readily,  but  a  considerable  amount  of 
callus  is  formed  owing  to  the  difficulty  of  satisfactorily  fixing  the 
broken  ends. 

Separation  of  a  Costal  Cartilage  sometimes  occurs,  giving  rise  to 
the  same  symptoms  and  requiring  the  same  treatment  as  a  broken 
rib.  Occasionally  the  cartilage  itself  may  be  fractured.  In  each 
case  the  resulting  bond  of  union  is  osseous. 

Fracture  of  the  Sternum  is  almost  always  due  to  direct  violence, 
although  it  has  been  known  to  yield  from  excessive  flexion  of 
the  body  after  fracture  of  the  spine,  or  from  muscular  strain 
during  parturition.  The  line  of  fracture  is  usually  transverse,  the 
bone  giving  way  either  between  the  manubrium  and  gladiolus 


Fig. 


133. — Method  of    strap- 
ping Broken  Ribs. 


446  A   MANUAL  OF  SURGERY 

or  a  little  below  this  level.  The  fragments  may  remain  in  situ  or 
the  upper  portion  be  displaced  backwards,  the  deformity  in  such 
cases  being  very  evident,  and  great  dyspnoea  resulting.  As  a  late 
effect,  aneurism  of  the  arch  of  the  aorta  may  occur. 

Treatment. — The  patient  should  be  kept  in  bed  with  a  pillow 
between  the  shoulders,  and  the  chest  strapped  as  for  fractured 
ribs.  If  the  patient  cannot  bear  this  position,  he  should  be 
allowed  to  sit  up  with  the  body  leaning  forwards.  Reposition 
can  sometimes  be  effected  by  manipulation  and  extension  of  the 
spine. 

Fractures  of  the  Upper  Extremity. 

Fracture  of  the  Clavicle. — No  bone  in  the  body,  with  the  ex- 
ception of  the  radius,  is  broken  more  frequently  than  the  clavicle ; 
this  is  due  to  its  exposed  position  and  its  buttress-like  action  in 
keeping  out  the  point  of  the  shoulder,  so  that  every  shock  to  the 
arm  is  transmitted  through  it  to  the  trunk.  Hence,  although 
fractures  from  direct  violence  do  occur,  it  is  more  usually  broken 
as  the  result  of  force  directed  to  the  hand  or  shoulder,  such  as  a 
fall  from  a  horse.  The  injury  is  very  common  in  children,  being 
then  often  of  a  greenstick  nature,  and  more  frequent  in  men 
than  in  women.     The  bone  may  yield  in  four  different  spots,  viz. : 

i.  At  the  Sternal  End,  an  unusual  occurrence,  due  to  direct 
or  indirect  violence.  The  displacement  varies  with  the  line  of 
fracture ;  if  transverse,  it  is  slight,  but  if  oblique,  and  this  is  most 
usual,  the  outer  fragment  is  drawn  downwards  and  forwards  as 
in  the  next  variety,  though  to  a  less  degree. 

2.  Through  the  Greater  Convexity,  the  commonest  situation. 
The  bone  yields  about  its  centre,  or  a  little  external  to  it,  and  the 
line  of  fracture  is  slightly  oblique,  running  from  before  backwards 
and  inwards.  The  displacement  is  quite  characteristic,  and  is 
present  in  any  fracture  situated  between  the  rhomboid  ligament 
on  the  inner  side  and  the  coraco-clavicular  ligaments  on  the  outer, 
being  less  marked,  however,  when  the  fracture  is  nearer  the 
extremities  than  in  the  centre  of  this  space.  The  patient  presents 
himself  with  a  history  of  injury  and  severe  pain,  supporting  the 
elbow  with  the  other  hand,  the  head  being  bent  over  to  the  affected 
side,  so  as  to  relax  the  muscles  of  the  neck,  and  the  arm  being 
powerless.  On  closer  examination,  one  finds  that  the  point  of  the 
shoulder  is  less  prominent  than  usual,  being  approximated  to  the 
middle  line,  and  on  a  lower  level  than  the  other,  whilst  at  the  seat 
of  fracture  is  a  slight  bony  projection.  This  deformity  is  accounted 
for  by  a  displacement  of  the  whole  outer  fragment  downwards, 
forwards,  and  inwards  (Fig.  134) ;  the  outer  end,  however,  is 
more  displaced  than  the  inner,  so  that  the  fractured  surface  of  the 
outer  fragment  looks  upwards,  inwards,  and  backwards,  although 
it  is  placed  immediately  below  the  inner  fragment.     The  deformity 


INJURIES  OF  BONES— FRACTURES 


447 


is  mainly  due  to  the  weight  of  the  arm  acting  upon  the  outer 
fragment  when  the  buttress-like  action  of  the  bone  is  gone, 
allowing  the  scapula,  to  which  it  is  firmly  united  by  ligaments, 
to  embrace  the  curved  thor- 
acic wall,  from  which  it 
is  usually  separated.  The 
action  of  the  muscles  passing 
from  the  trunk  to  the  upper 
arm  may  have  some  effect, 
but  can  only  be  looked  on 
as  an  accessory,  and  not  the 
main  cause  of  this  displace- 
ment. The  position  of  the 
inner  fragment  is  probably 
but  little  altered,  since  it  is 
held  in  place  by  the  rhom- 
boid ligament ;  the  apparent 
projection  of  its  outer  end  is 
due  rather  to  the  depression 
of  the  outer  fragment  than 
to  elevation  of  the  inner  by 
the  sterno-mastoid. 

3.     Between    the    Coraco- 


Fig.    134.  —  Fracture     of     Clavicle 
through  Greater  Convexity.  (Till- 

MANNS.) 


St,  Sterno-mastoid  ;  S,  subclavius  ;  P  mi, 
pectoralis  minor;  S  m.serratus  magnus. 


clavicular  Ligaments,  usually 
arising  from  direct  violence, 
and  with  but  little  displace- 
ment, owing  to  the  tension  of  the  ligaments  and  to  the  fact  that 
the  periosteum  is  not  torn  across.     The  signs  of  local  trauma  and 
crepitus  are,  however,  present,  though  not  very  obvious. 

4.  At  the  Acromial  End,  external  to  the  trapezoid  ligament,  and, 
again,  usually  produced  by  direct  violence.  The  inner  fragment 
retains  its  position  unaltered,  but  the  outer  fragment  is  dragged 
down  by  the  weight  of  the  arm,  and  forwards  by  the  action  of  the 
muscles,  so  that  it  lies  at  right  angles  to  the  rest  of  the  bone. 

Complications  arise  most  frequently  in  cases  produced  by  direct 
violence.  The  subclavian  vein  may  be  injured,  or  the  brachial 
plexus ;  and  even  the  dome  of  the  pleura  and  the  subjacent  lung 
have  been  wounded.  Gangrene  of  the  arm  has  resulted  from 
obstruction  to  the  vessels. 

Treatment. — Where  there  is  little  or  no  displacement,  all  that 
is  needed  is  to  immobilize  the  arm  in  a  sling  and  to  keep  the 
patient  quiet. 

For  fractures  with  displacement  many  different  plans  of  treat- 
ment have  been  adopted.  In  order  to  replace  the  fragments,  the 
surgeon  should  stand  behind  the  patient,  who  is  seated,  with 
his  knee  between  the  scapulae  ;  traction  is  then  made  upon  the 
shoulders,  and  the  point  of  the  acromion  is  drawn  upwards  and 
backwards.     To   maintain  the  fractured  ends  in  apposition  the 


448 


A   MANUAL  OF  SURGERY 


following  methods  have  been  recommended:  (a)  The  simplest, 
which  can  always  be  applied  on  an  emergency,  and  perhaps  the 
best  even  for  a  permanent  application,  is  that  known  as  the  three- 
handkerchief  plan.  Two  large  handkerchiefs,  folded  double  and 
rolled  into  bands,  are  placed  vertically,  one  over  each  shoulder 
and  under  each  axilla  ;  each  is  lightly  knotted  behind,  and  the 
ends  firmly  tied  to  the  opposite  handkerchief  across  the  middle 


\    \ 

4 

■ 

dl  1 

•Z--*r*mi 

^- — .-  -^y,-*f^^y*^ 

-^A — . 

M 

s.                    iM^""""""* 

1 

iBi~^ 

Fig.   135. — Sayre's  Method  of  Strapping  for  Fractured  Clavicle. 

line.  By  this  means  the  point  of  the  shoulder  is  kept  outwards 
and  backwards.  The  third  handkerchief  is  now  folded  crosswise 
and  used  as  a  sling  to  support  the  elbow,  which  is  drawn  well 
forwards,  the  hand  being  placed  over  the  sound  clavicle.  If  this 
apparatus  is  employed  permanently,  the  knots  must  be  examined 
every  few  days,  especially  at  first,  as  the  handkerchiefs  always 
stretch  a  little,  and  require  occasional  tightening,  (b)  Sayre's  method 
is  very  useful,  especially  in  treating  children.  A  long  strip  of 
adhesive  plaster,  3^  inches  wide  or  less,  according  to  the  size  of 
the  patient,  is  passed  round  the  arm  a  little  below  the  axilla,  as 
a  loop,  with  the  sticky  side  out,  and  then  around  the  body  with 
the  adhesive  side  inwards,  the  arm  being  drawn  well  back,  and 
the  loop  and  ends  secured  by  stitches  (Fig.  135).  If  this  has 
been  firmly  applied,  it  may  now  be  used  as  a  fulcrum,  so  that  as 
the  elbow  is  drawn  forwards,  the  point  of  the  shoulder  is  directed 
backwards  and  outwards,  and  thus  the  main  deformity  is  overcome. 
Another  strip  of  a  similar  width  is  applied  over  the  elbow  (a  small 
hole  being  cut  to  receive  the  point  of  the  olecranon),  and  by  this 
means  the  arm  is  raised  and  drawn  forwards  and  the  hand  placed 
on  the  opposite  shoulder,  and  the  desired  position  is  thus  main- 
tained. In  children  more  than  one  strip  of  plaster  will  be 
needed  in  order  to  secure  the  arm,  whilst  an  additional  bandage 
is  also  useful.     Excellent  results  follow  this  plan  of  treatment. 


INJURIES  OF  BONES— FRACTURES  449 

(c)  In  ladies,  where  even  the  slightest  deformity  is  undesirable,  it 
is  better  to  confine  them  to  bed ;  the  head  is  kept  low  without  a 
pillow,  and  a  sandbag  placed  between  the  scapulae,  the  arm  being 
bandaged  to  the  side.  This  position  must  be  maintained  for 
three  weeks,  and  even  then  only  very  limited  movement  allowed. 

(d)  The  old-fashioned  plan  of  treatment  by  means  of  an  axillary 
pad,  a  figure-of-8  bandage  crossing  behind  the  shoulders,  and  an 
elbow  sling,  has  been  to  a  large  extent  superseded  by  Sayre's  and 
other  methods.  Union  is  probably  attained  in  four  weeks,  but 
the  movements  of  the  arm  should  be  restricted  for  some  time 
longer.  A  considerable  amount  of  callus  is  usually  formed,  and 
there  is  very  likely  to  be  some  slight  persistent  deformity. 

Fractures  of  the  Scapula. — 1.  The  Acromion  Process  may  be 
broken  by  direct  violence  applied  to  the  point  of  the  shoulder. 
The  arm  hangs  powerless  at  the  side,  supported  by  the  other 
hand,  and  the  shoulder  is  flattened.  The  irregularity  of  the  bone 
can  be  readily  detected,  and  crepitus  can  be  elicited  by  raising 
the  elbow  and  rotating  the  arm.  Occasionally  merely  the  tip  is 
detached,  and  then  the  above  signs  will  not  be  present.  The 
Treatment  consists  in  raising  the  elbow,  and  bandaging  the  arm 
to  the  side. 

2.  The  Coracoid  Process  is  rarely  fractured,  and  only  from  direct 
violence.  There  is  but  little  displacement,  on  account  of  the  many 
powerful  ligaments  attached  to  it,  and  the  only  treatment  needed 
is  to  raise  the  arm  by  a  sling,  and  to  keep  it  at  rest  by  the  side. 

3.  The  Body  of  the  scapula  is  broken  as  a  result  of  considerable 
direct  violence,  which  is  often  primarily  received  by  the  spine, 
and  also  bruises  the  thick  muscles  above  and  below  it.  There 
is  but  little  displacement,  if,  as  is  usually  the  case,  the  fracture 
is  transverse  just  below  the  spine.  A  longitudinal  fracture  may, 
however,  result  in  the  inner  or  vertebral  fragment  being  drawn 
upwards  and  outwards  in  front  of  the  axillary  portion  by  the 
serratus  magnus  and  levator  anguli  scapulae.  The  diagnosis  is 
made  by  grasping  the  bone  firmly,  and  moving  one  fragment  on 
the  other ;  crepitus  may  thus  be  obtained.  The  Treatment  con- 
sists in  bandaging  the  arm  to  the  side,  and  possibly  applying 
strapping  to  support  the  fragments. 

4.  Fracture  of  the  Neck  of  the  bone  is  usually  due  to  great 
violence  directed  to  the  shoulder,  but  it  is  a  rare  accident.  A 
portion  of  the  articular  surface  is  broken  off  and  displaced  down- 
wards in  some  few  cases  of  dislocated  shoulder  (Fig.  136,  A);  or 
the  fracture  has  been  known  to  run  through  the  anatomical  neck 
(Fig.  136,  B),  either  condition  causing  slight  lengthening  of  the 
arm,  and  displacement  downwards  of  the  head  of  the  humerus. 
Treatment. — The  arm  must  be  kept  to  the  side  and  raised. 

More  commonly,  however,  the  fracture  involves  the  Surgical 
Neck   (Fig    136,    C),   extending    from    the  suprascapular   notch 

29 


450 


A   MANUAL  OF  SURGERY 


above  to  just  below  the  origin  of  the  triceps  muscle,  so  that  the 
detached  fragment  includes  the  coracoid  process.     Flattening  of 

the  shoulder  results, 
with  prominence  of  the 
acromion,  lengthening 
of  the  arm  as  measured 
from  the  acromion  to 
the  external  condyle, 
and  crepitus  on  raising 
and  rotating  the  limb. 
Treatment. — The  bone 
is  replaced  by  pressure 
in  the  axilla,  if  neces- 
sary under  chloroform, 
and  fixed  by  an  axillary 
pad  or  the  f\  -  shaped 
leather  splint  recom- 
mended by  Erichsen, 
whilst  the  arm  is  kept 
to  the  side. 

Fractures  of  the  Upper 
End  of  the  Humerus. — 
i.  Of  the  Anatomical 
Neck,  the  so-called  '  In- 
tracapsular Fracture  ' 
(Plate  XL).  This  is 
always  due  to  blows  or 
falls  on  the  shoulder, 
never  to  indirect  vio- 
lence. It  is  evidenced 
by  signs  of  a  severe 
local  trauma,  with  loss  of  mobility  of  the  arm.  The  head  of  the 
humerus  is  found  to  be  irregular  in  shape  on  examination  from 
the  axilla,  and  the  fragment,  if  detached,  may  be  distinctly  felt. 
Crepitus  is  obtained  on  moving  the  arm,  and  there  is  some  slight 
shortening,  but  not  more  than  half  an  inch.  In  most  cases  the 
upper  fragment  is  not  totally  detached,  but  remains  connected 
with  the  rest  of  the  bone  by  a  few  shreds  of  capsule,  and  thus 
necrosis  is  prevented.  Should  impaction  occur,  the  small  upper 
fragment  is  driven  into  the  lower,  and  marked  deformity  of  the 
head  of  the  bone  results.  The  acromion  becomes  unduly  pro- 
minent, and  the  rounded  projection  of  the  deltoid  is  diminished, 
unless,  as  often  happens,  the  swelling  due  to  extravasation  is 
considerable.  Repair  takes  place  mainly  from  the  lower  end, 
and,  owing  to  the  difficulty  of  apposing  and  immobilizing  the 
fragments,  a  considerable  mass  of  callus  is  usually  formed. 
Examination  must  be  conducted  with  great  care  lest  impaction 


Fig.  136. — Fractures  of  the  Neck  of   the 
Scapula. 

A,  Through  the  glenoid  fossa  ;  B,  through  the 
anatomical  neck ;  C,  through  the  surgical 
neck. 


PLATE  XI. 


Impacted  Fracture  of  Anatomical  Neck  of  Humerus. 


To  face  p.  450.] 


PLATE  XII. 


Fracture  of  Surgical  Neck  of  Humerus. 


To  follow  Plate  XI. .] 


INJURIES  OF  BONES— FRACTURES 


451 


be  disturbed,  or  any  capsular  attachments  broken  through.  The 
Treatment  usually  recommended  is  to  bind  the  arm  to  the  side, 
and  apply  evaporating  lotion  for  a  few  days  if  great  ecchymosis 
exists.  A  pad  or  f~|-shaped  splint  is  then  placed  in  the  axilla, 
and  retained  in  position  by  a  soft  bandage  or  handkerchief  passing 
over  the  top  of  the  shoulder,  and  tied  under  the  opposite  axilla  ;  this 
assists  in  raising  the  arm,  which  is  also  supported  by  an  elbow- 
sling.  Finally,  a  comfortable  poroplastic  or  leather  cap  is  fitted 
over  the  shoulder  and  buckled  on.  Union  generally  occurs  in 
about  six  weeks,  but  often  results  in  great  stiffness,  for  the 
removal  of  which  massage  and  even  manipulation  under  chloro- 
form are  required.  To  obviate  these  sequelae,  it  is  well  to  treat 
the  case  by  early  massage  and  manipulation,  the  limb  being 
merely  supported  in  a  sling ;  the  massage  should  commence 
about  the  third  day  (see  page    431 ). 

2.  Of  the  Surgical  Neck,  the  '  Extracapsular  Fracture ' 
(Plate  XII.).  The  bone  yields  in  this  case  below  the  muscles 
attached  to  the  tuberosities,  but  above 
the  insertions  into  the  bicipital  groove 
and  its  margins  of  the  latissimus 
dorsi,  pectoralis  major,  and  teres 
major.  It  usually  results  from 
violence  applied  directly  below  the 
point  of  the  shoulder,  but  also  from 
falls  on  the  hand  or  elbow.  The 
fracture  is  more  or  less  transverse, 
and  the  displacement  a  double  one  : 
the  upper  fragment  is  rotated  out- 
wards, and  generally  adducted  by 
the  muscles  inserted  into  the  tuber- 
osities, especially  the  subscapularis ; 
whilst  the  lower  fragment  is  drawn 
inwards  by  those  attached  to  the 
bicipital  groove,  and  upwards  by  the 
deltoid,  coraco-brachialis,  biceps,  and 
triceps  (Fig.  137).  The  appearance 
of  the  patient  is  sufficiently  charac- 
teristic ;  the  head  of  the  bone  is  still 
in  the  glenoid  cavity,  so  that  there 
is  no  loss  of  the  fulness  of  the 
shoulder  (Fig.  138,  C),  although  there  is  a  depression  just  below, 
unless  it  is  obliterated  by  the  extensive  haemorrhagic  effusion. 
The  elbow  is  directed  away  from  the  side,  and  the  axis  of  the 
lower  fragment  is  upwards  and  inwards.  Crepitus  can  be 
obtained  by  extending  and  rotating  the  arm,  which  is  shortened 
an  inch  or  more.  This  fracture  is  often  very  painful  from  pressure 
of  the  upper  end  of  the  lower  fragment  against  the  brachial 
nerves.     If  impaction  occurs,  the  signs  are  much   less  evident, 

29 — 2 


PM 


Fig.  137. — Fracture  of  Sur- 
gical Neck  of  Humerus. 

S,  Subscapularis;  L.D,  latissi- 
mus dorsi ;  D,  deltoid  ;  P.M, 
pectoralis  major. 


452 


A   MANUAL  OF  SURGERY 


and,  indeed,  may  be  very  equivocal ;  the  lower  fragment  is  usually 
driven  into  the  upper,  and  only  slight  shortening  or  displacement 
may  be  present. 

Complications. — The  axillary  vessels  may  be  seriously  damaged, 
or  more  commonly  some  of  the  nerves  sustain  injury,  especially 
the  circumflex,  which  winds  round  the  neck  of  the  bone  close  to 
the  site  of  the  fracture. 

Treatment.  —  Immobilization  of  the  fragments  is  absolutely 
necessary  in  this  fracture.  It  may  be  secured  by  the  application 
of  an  axillary  pad  and  a  shoulder-cap,  whilst  the  arm  is  kept  to 
the  side,  and  the  hand  supported  by  a  sling.  The  elbow  should 
be  allowed  to  hang  to  overcome  the  shortening.     Middeldorpf's 


Fig.  138. — Outlines  of  Shoulder. 

A,  Normal  shoulder  ;  B,  dislocation  of  shoulder  ;  C,  fracture  of  surgical  neck 

of  humerus. 

triangle  (Fig.  140)  may  be  used  with  advantage  in  this  fracture. 
Firm  union  usually  results  in  four  and  a  half  to  six  weeks,  but 
with  the  formation  of  a  good  deal  of  callus  ;  massage  and  passive 
manipulations  should  be  daily  employed  from  the  third  week 
onwards,  the  apparatus  being  taken  off  for  the  purpose  and 
reapplied,  if  necessary. 

3.  Separation  of  the  Upper  Epiphysis  occurs  up  to  the  age  of 
eighteen  to  twenty  years  and  involves  the  head  and  both  the 
tuberosities.  The  upper  end  of  the  shaft  is  somewhat  conical 
in  shape,  the  apex  of  the  cone  fitting  into  a  depression  in  the 
middle  of  the  epiphysis  (Fig.  139).  The  lesion  usually  follows  the 
line  of  the  cartilage  ;  but  the  displacement  is  often  incomplete, 
partly  from  the  conical  projection  hitching  against  the  inner  edge 
of  the  epiphysis  (a  doubtful  occurrence),  but  mainly  from  the 
persistence  of  a  well-marked  periosteal  sleeve  or  bridge  on  the 
outer  and  posterior  side.     The  shaft  usually  travels  forwards,  its 


INJURIES  OF  BONES— FRACTURES 


453 


upper  end  projecting  so  as  to  be  felt  and  sometimes  seen  beneath 
the  skin  an  inch  or  more  below  the  acromion ;  occasionally  a  well- 
marked  inward  displacement  is  superadded  so  that  the  condition 
somewhat  resembles  a  subcoracoid  dislocation.  The  presence  of 
the  head  of  the  bone  in  the  glenoid  cavity  should  prevent  this 
mistake,  whilst  the  softness  of  the  crepitus  distinguishes  it  from  a 
fracture. 

Treatment. — It  is  most  important  to  reduce  this  displacement, 
since  otherwise  interference  with  the  growth  of  the  limb  is  almost 
certain  to  ensue.  This  may  be  effected  by  traction  upon  the  arm 
under  an  anaesthetic,  assisted  perhaps  by  slight  rotary  movements 
or  abduction ;  but  should  these  manoeuvres  not  be  successful,  it  is 
quite  permissible  to  open  the  joint  antiseptically,  and  restore  the 
parts  to  their  correct  position.    After  reduction  the  limb  is  treated 


Fig.  139. — Separation  of  the  Upper  Epiphysis  of  the  Humerus. 


as  for  a  fracture  of  the  neck.  Should  union  occur  in  the  displaced 
position,  considerable  limitation  of  movement  results  from  the 
projecting  edge  of  the  diaphysis  ;  this  may  be  improved  by  cutting 
down  and  chiselling  it  away. 

4.  The  Great  Tuberosity  is  occasionally  torn  off  as  a  result 
of  direct  or  muscular  violence,  or  as  a  complication  of  fracture 
through  the  neck.  If  the  whole  tuberosity  is  separated,  there  is 
marked  deformity,  resulting  in  a  great  increase  in  the  breadth  of 
the  shoulder.  The  fragment  is  displaced  upwards  and  backwards 
by  the  unopposed  action  of  the  supra-  and  infra-spinatus,  whilst 
the  shaft  of  the  humerus  is  drawn  forwards  and  partially  dislocated 
(or  subluxated)  by  the  subscapulars  and  other  muscles.  A  dis- 
tinct sulcus  is  felt  between  the  two  bony  masses,  and  if  they  can 
be  brought  together,  crepitus  is  obtained.  Treatment. — A  pad  is 
placed  in  the  axilla,  and  the  elbow  kept   to  the  side  so  as  to 


454 


A   MANUAL  OF  SURGERY 


throw  the  upper  end  of  the  bone  outwards,  whilst  the  tuberosity 
is  drawn  down  to  this  as  far  as  is  possible  by  the  pressure  of 
a  pad  strapped  on,  the  elbow  being  also  supported  by  a  sling. 
Another  plan  suggested  is  to  elevate  and  extend  the  arm  above 
the  head,  keeping  it  supported  by  pillows,  till  union  has  occurred 
— a  most  uncomfortable  and  tedious  proceeding.  A  much  more 
efficacious  method,  and  one  that  need  not  be  feared  where  asepsis 
is  maintained,  is  to  cut  down  on  the  fragment,  and  wire  or  peg  it 
in  position. 

Fractures  of  the  Shaft  of  the  Humerus  may  arise  from  any 
form  of  violence,  whether  direct  or  indirect,  whilst  it  is  the 
commonest  site  for  fracture  of  the  shaft  of  a  long  bone  from 
muscular  violence,  as,  e.g.,  in  throwing  a  cricket-ball.     The  signs 


Fig.  140. — Middeldorpf's  Triangle  for  Fractured  Humerus. 

For  the  sake  of  clearness,  the  bandages,  etc.,  have  been  represented  as  much 
smaller  than  would  be  the  case  in  the  living  subject ;  a  Gooch  splint  may 
also  with  advantage  be  applied  to  the  forearm. 

of  the  injury  are  very  obvious,  and  most  typical.  The  displace- 
ment depends  largely  on  the  position  of  the  fracture.  If  it  occurs 
above  the  insertion  of  the  deltoid,  but  below  that  of  the  muscles 
inserted  into  or  around  the  bicipital  groove,  the  upper  fragment  is 
drawn  inwards,  and  the  lower  upwards  and  outwards.  If,  how- 
ever, it  is  below  the  deltoid,  the  upper  fragment  is  drawn  outwards, 
and  the  lower  upwards  and  inwards.  As  the  line  of  fracture  ap- 
proaches the  elbow,  the  displacement  tends  to  become  more  antero- 
posterior than  lateral,  following  the  change  in  direction  of  the  bone. 
The  most  common  complication  is  injury  to  the  musculo-spiral 
nerve  which  winds  round  the  shaft  close  to  its  centre. 


INJURIES  OF  BONES—FRACTURES  455 


Treatment. — An  internal  angular  splint  reaching  from  the  axilla 
to  the  wrist  must  be  applied,  together  with  three  small  lateral 
splints  to  fix  the  fragments,  or  a  piece  of  Gooch  or  kettle-holder 
splint ;  the  limb  is  kept  to  the  side  in  a  sling.  Union  is  usually 
complete  in  five  weeks. 

It  is  not  at  all  uncommon  to  meet  with  an  ununited  fracture  of 
the  shaft  of  this  bone ;  this  is  probably  due,  not  to  any  anatomical 
reasons,  but  simply  to  the  fact  that  the  necessity  for  fixing  and 
supporting  the  elbow-joint  has  not  been  appreciated,  the  forearm 
being  allowed  to  hang  loose  on  the  false  plea  of  tending  to 
diminish  the  shortening. 

A  very  useful  appliance  for  all  fractures  of  the  humerus  is  the 
Middeldorpf  triangle  (Fig.  140).  It  is  carefully  padded  all  round 
so  that  the  angles  and  edges  are  protected,  and  applied  so  that 
its  base  is  in  contact  with  the  body-wall  and  its  obtuse-angled 
apex  in  the  elbow.  It  is  fixed  by  a  strap  or  bandage  passed  from 
the  axillary  angle  over  the  same  shoulder  and  under  the  opposite 
axilla,  as  also  by  a  sheet  or  bandage  round  the  trunk.  Pieces  of 
Gooch  splinting  can  be  applied  to  the  arm,  thus  completely  im- 
mobilizing the  humerus,  and  the  forearm  is  also  fixed.  The 
fingers  are  left  free,  or  if  there  is  any  tendency  to  swelling  they 
are  bandaged.  One  great  advantage  of  this  apparatus  is  that  it 
is  equally  efficacious  when  the  patient  is  standing  as  when  he  is 
recumbent. 

Fractures  of  the  Lower  End  of  the  Humerus. — In  dealing  with 
any  injury  in  the  vicinity  of  the  elbow,  it  is  absolutely  essential 
that  the  relative  position  of  the  bony  points,  which  can  there 
be  felt,  should  be  accurately  established,  and  a  comparison  made 
with  those  of  the  opposite  side.  Both  arms  are  stripped  and 
examined  in  similar  positions,  a  good  plan  being  to  place  (if 
possible)  the  hands  on  the  top  of  the  head,  so  that  the  elbows 
look  forwards.  Normally  four  bony  prominences  can  be  made 
out,  viz.,  the  two  condyles,  the  olecranon,  and  the  head  of  the 
radius.  The  relation  of  the  olecranon  to  the  condyles  varies  with 
the  position  of  the  elbow.  If  the  forearm  is  extended,  the  tip  of 
the  olecranon  just  touches  the  intercondyloid  line,  but  is  placed 
nearer  the  inner  than  the  outer  condyle,  whilst  in  flexion  of 
the  forearm  it  lies  below  that  line.  The  head  of  the  radius  in  all 
positions  of  the  arm  is  immediately  below  the  outer  condyle,  and 
can  be  felt  rotating  beneath  a  dimple  in  the  skin  which  appears 
at  that  spot.  When  the  arm  is  flexed  to  a  right  angle,  the  tip  of 
the  olecranon  is  a  little  in  front  of  the  posterior  surface  of  the 
upper  arm,  so  that  a  ruler  placed  along  that  surface  misses  the 
olecranon  ;  this  is  a  useful  guide  in  ascertaining  if  the  bones  of  the 
forearm  have  been  displaced  backwards  or  forwards. 

Another  important  feature  depends  on  the  fact  that  the  axis  of 
the  forearm  does  not  correspond  with  that  of  the  arm,  the  former 
being  in  a  position  of  slight  abduction  (about   150),  constituting 


456 


A  MANUAL  OF  SURGERY 


what  is  known  as  the  'carrying  angle'  (Fig.  141,  A).  Lateral 
deviation  following  fractures  in  the  neighbourhood  of  the  elbow 
results  in  modifications  of  this  angle,  and  if  these  are  allowed  to 
persist,  conditions  of  cubitus  varus  or  valgus  (Fig.  141,  B,  C) 
ensue,  which  much  interfere  with  the  utility  of  the  limb. 

1.  Transverse  Supracondyloid  Fracture,  involving  the  shaft 
about  1  or  2  inches  above  the  joint,  is  due  either  to  a  fall  on  the 
hand  with  the  arm  bent,  when  the  lower  fragment  is  usually  dis- 
placed backwards,  or  much  less  commonly  to  a  fall  on  or  violence 
directed  to  the  point  of  the  elbow,  when  the  displacement  is  either 
forwards  or  backwards.  When  the  lower  fragment  is  displaced 
backwards,  it  is  also  drawn  up  by  the  action  of  the  triceps  upon 
the  olecranon,  a  certain  amount  of  angular  as  well  as  vertical 


Fig.  141. — Outlines  of  Upper  Extremity  to  show  A,  Normal  carrying 
Angle  (a  =  15°);  B,  Cubitus  Varus;  C,  Cubitus  Valgus. 

deformity  being  thus  produced  ;  when  displaced  forwards,  ap- 
parent lengthening  of  the  forearm  results,  with  a  loss  of  prominence 
of  the  olecranon.  The  former  of  these  conditions  is  likely  to  be 
mistaken  for  a  dislocation  of  both  bones  backwards  at  the  elbow 
(cf.  Fig.  142,  A  and  B),  but  may  be  recognised  by  the  following 
facts :  (a)  The  relative  position  of  the  bony  points  at  the  elbow 
is  unimpaired  ;  in  a  dislocation  they  are  necessarily   disturbed. 

(b)  The  upper  arm  measured  from  a  tubercle  which  can  be  easily 
felt  at  the  back  of  the  acromion  to  the  outer  condyle  is  shortened 
in  a   fracture,  but   remains    the   same   length   in  a  dislocation. 

(c)  The  forward  projection  of  the  lower  end  of  the  upper  frag- 
ment is  felt  above  the  crease  of  the  joint,  whilst  in  a  dislocation 
it  corresponds  with  it.     (d)  The  deformity  is  easily  reduced  with 


INJURIES  OF  BONES— FRACTURES 


457 


crepitus,  but  readily  reappears  ;  in  a  dislocation  the  bones  are 
replaced  with  difficulty,  but  after  replacement  they  usually  remain 
in  position.  It  may  be  difficult  and  at  times  almost  impossible  to 
recognise  this  condition  at  once,  owing  to  the  amount  of  swelling 
and  ecchymosis  present ;  the  application  of  a  cooling  lotion  for  a 
few  days  will  so  reduce  this  as  to  permit  a  thorough  examination, 
and  this  is  most  essential,  as  a  wrong  diagnosis  probably  leads  to 
bad  treatment  and  much  subsequent  impairment  of  function  of 
the  limb.  Skiagraphy  will  at  once  determine  the  nature  of  the 
lesion.  Lateral  deviation  sometimes  occurs,  and  the  restoration 
of  the  normal  '  carrying  angle '  must  always  be  aimed  at. 

Much  care  is  needed  in  the  Treatment  of  these  cases  in  order  to 
prevent  ankylosis  or  deformity,  and  the  stereotyped  application  of 


A  B 

Fig.  142. — Fracture  of  Lower  End  of  Humerus  (B)  compared  with  Dis- 
location of  Radius  and  Ulna  backwards  at  Elbow  (A).     (Tillmanns.) 

an  internal  angular  splint  is  by  no  means  sufficient.  To  correct 
the  backward  deformity  tne  elbow  must  be  flexed,  and  traction 
made  upon  the  forearm,  which  is  placed  in  a  position  of  full 
supination.  It  may  then  suffice  to  apply  an  anterior  angular 
splint  in  the  bend  of  the  elbow,  and  a  straight  posterior  splint 
reaching  below  the  tip  of  the  olecranon,  so  as  to  keep  it  well 
forwards  ;  or  perhaps  it  would  be  better  to  apply  a  carefully- 
moulded  gutter-shaped  posterior  splint  reaching  well  above  and 
below  the  elbow,  and  a  shorter  anterior  splint  fitting  down  to  the 
bend  of  the  joint.  In  these  fractures  the  elbow-joint  is  not  as  a 
rule  involved,  and  therefore  passive  movement  is  not  commenced 
too  early,  for  fear  of  deformity  owing  to  yielding  of  the  callus. 
In  displacements  of  the  bone  forwards  an  anterior  angular  splint 
should  be  employed,  and  possibly  a  short  posterior  one  in  addition. 


458 


A  MANUAL  OF  SURGERY 


2.  Separation  of  the  Lower  Epiphysis  of  the  Humerus  is  a  very 
common  accident  in  children.  At  birth  and  for  some  years 
afterwards  the  epiphysis  consists  of  a  single  mass  of  cartilage, 
including  the  two  condyles  as  well  as  the  articular  surface,  and 
these  are  all  involved  in  any  separation,  together  possibly  with  a 
fragment  of  the  diaphysis  (Fig.  143).  As,  however,  growth  and 
ossification  proceed,  the  shaft  encroaches  rapidly  upon  the  inner 
portion  of  the  epiphysis,  so  that  the  epiphyseal  line  becomes  almost 
rectangular  (Fig.  144),  the  internal  condyle  being  isolated  from 


Fig.  143. — Separation  of  the 
Lower  Epiphysis  of  the  Humerus 
in  an  Infant  under  Three  Years. 
(Museum  of  Royal  College  of 

Surgeons.) 

A,  Epiphysis,  including  both  con- 
dyles ;  B,  small  portion  of  the 
diaphysis  detached  with  epiphysis ; 
C,  diaphysis;  D,  loose  periosteal 
bridge. 


Fig.  144. — A  and  B,  Lower  End 
of  the  Humerus  at  Three 
Years  and  Fifteen  Years  of 
Age.  (Semi -diagrammatic  ; 
after  Quain's  Anatomy.) 

In  A,  there  is  only  one  centre  of 
ossification;  in  B,  all  the  centres 
in  the  lower  epiphysis  have 
united  with  the  exception  of  that 
for  the  internal  condyle. 


the  rest  of  the  epiphysis.  As  a  result  of  this,  separations  of  the 
epiphysis  after  puberty  do  not  include  the  internal  condyle ;  the 
accident  at  this  period  is  situated  relatively  much  nearer  the  joint 
than  in  infants,  and  consequently  is  more  likely  to  be  followed 
by  impairment  of  movement.  The  displacement  is  generally 
backwards,  with  some  amount  of  lateral  deviation  (Plate  XIII.). 
Treatment. — Reduction  can  usually  be  accomplished  by  flexion, 


PLATE  XIII. 


Separation  of  the  Lower  Epiphysis  of  the  Humerus,  with  Displacement 
Outwards  in  a  Young  Person,  a  little  over  the  Age,  of  Puberty. 

The  outer  condyle  has  been  broken  off,  as  well  as  the  epiphysis,  and  displaced 
upwards  and  outwards  ;  above  this  fragment  is  seen  a  shadow  caused  by  the 
stripping  up  of  the  periosteum.  The  ulna  and  radius  accompany  the  lower 
epiphysis  of  the  humerus  outwards. 

To /ace  p.  458.] 


INJURIES  OF  BONES—FRACTURES 


459 


splints    may  suffice  to 
it  is  an  open   question 


Fig.  145. — Fractures 
of  Internal  Con- 
dyle  AND  EPICONDYLE 

of    Humerus.     (Till- 

MANNS.) 


and  the  application  of  antero-posterior 
maintain  the  fragment  in  position  ;  but 
whether  it  is  not  wiser,  at  any  rate  in 
small  children,  to  avoid  splints  and  trust 
to  full  and  complete  flexion  alone,  the 
hand  being  bandaged  down  to  the  shoulder 
on  the  same  side.  Passive  movements 
should  commence  from  about  the  eighth 
day. 

3.  The  Condyles  have  been  broken  off 
both  by  direct  and  indirect  violence, 
though  more  commonly  by  the  former. 
This  particularly  applies  to  the  inner  con- 
dyle, since  the  outer  is  sometimes  broken 
by  indirect  violence,  such  as  a  fall  on  the 
hand,  owing  to  the  laxity  of  the  elbow- 
joint  on  this  side  allowing  considerable 
mobility  between  the  radial  head  and  the 
capitellum  of  the  humerus.  Fracture  of 
the  external  condyle  always  involves  the 
elbow-joint,  and   is  more  common  than 

that  of  the  inner.  The  line  of  fracture  runs  from  the  condylar 
ridge  downwards  and  inwards  so  as  to  separate  the  capitellum, 
or  even  encroach  upon  the  trochlear  surface.  The  fragment  is 
but  little  displaced,  and  can  be  felt  to  move  on  the  rest  of  the 
bone  with  crepitus,  which  may  also  be  produced  by  rotation  of 
the  hand  and  radius.  The  accident  is  associated  with  much  pain 
and  ecchymosis.  Fracture  of  the  internal  condyle  may  be  intra- 
or  extra-capsular.  The  extra-articular  variety  (Fig.  145)  consists 
of  a  mere  displacement  of  the  tip  of  the  condyle  (or  epicondyle), 
probably  a  separation  of  the  epiphysis,  since  it  occurs  mainly  in 
children.  The  small  fragment  is  drawn  a  little  downwards  by 
the  muscles  attached  to  it,  and  the  fracture  is  readily  detected  by 
the  usual  signs ;  it  may  be  associated  with  injury  of  the  ulnar 
nerve.  The  intra-artictdar  form  is  the  more  common,  and  extends 
from  the  condylar  ridge  to  the  trochlear  surface,  implicating  the 
coronoid  and  olecranon  fossae.  The  fragment  is  displaced  a  little 
upwards  and  backwards,  the  ulna  usually  accompanying  it,  so 
that  on  extending  the  elbow  the  olecranon  appears  unduly 
prominent,  the  lower  end  of  the  humerus  projects  anteriorly,  and 
the  forearm  is  slightly  adducted  (cubitus  varus).  The  ulnar 
nerve  may  also  be  injured  in  this  case. 

Treatment. — Flex  the  forearm  and  place  it  on  an  angular  splint, 
using  a  pad  and  strapping  to  maintain  the  fragments  in  position. 
If  the  joint  has  been  involved,  there  is  a  great  tendency  to 
impairment  of  its  usefulness,  and  passive  movement  should  be 
started  early.  Possibly  in  these  cases  it  would  be  wiser  to  apply 
no  splints,  and  treat  the  fracture  by  early  massage,  or  perhaps 
even  better  to  operate  and  fix  the  fragment  by  wire  or  screw. 


460  A  MANUAL  OF  SURGERY 

4.  T-  or  Y-shaped  Fracture  usually  occurs  as  the  result  of  direct 
injury.  A  fissure  extends  into  the  joint  between  the  condyles, 
and  may  either  bifurcate  to  either  side  in  a  Y-shaped  manner, 
detaching  partially  or  completely  the  two  condyles,  or  it  may  be 
connected  with  a  transverse  supracondyloid  fissure,  constituting 
the  T-shaped  variety.  If  the  fragments  are  not  totally  detached, 
there  will  be  much  bruising  and  pain,  but  no  crepitus  ;  but  if  the 
fragments  are  separated,  the  condyles  will  move  on  each  other 
with  crepitus,  and  the  elbow  will  be  widened  with  much  deformity. 
In  these  cases  the  joint  is  very  likely  to  become  stiff,  owing  not 
only  to  adhesions  within  it,  but  also  to  the  filling  up  of  the  fossae 
in  the  lower  end  of  the  humerus  with  callus.  Excess  of  violence 
leads  to  comminution,  and  luxation  of  the  bones  of  the  forearm 
may  also  occur.  A  marked  feature  of  these  cases  is  the  rapidity 
with  which  swelling  supervenes,  owing  to  haemorrhage  into  and 
around  the  joint,  rendering  accurate  diagnosis  difficult.  Treat- 
ment must  be  directed  towards  reducing  the  swelling,  and  then, 
after  manipulating  the  fragments  into  as  good  a  position  as 
possible,  antero-posterior  angular  splints  are  applied,  and  passive 
motion  started  early.  Possibly  an  antiseptic  incision  and  wiring 
or  pegging  of  the  fragments  would  give  better  results,  whilst  in 
some  cases  excision  of  the  ends  of  the  bones  may  be  required. 

Fractures  of  the  Ulna. — 1.  The  Olecranon  is  frequently  broken 
by  direct  violence,  the  patient  falling  on  the  bent  elbow,  but 
occasionally  by  muscular  action.  The  displacement  is  often 
very  considerable,  the  fragment  being  drawn  up  by  the  triceps 
and  tilted  backwards  (Plate  XIV.)  ;  but  if  the  ligamentous  fibres 
passing  from  the  tendon  to  the  fascia  of  the  forearm  remain 
intact,  there  is  but  little  separation.  When  complete,  the  bones 
of  the  forearm  are  displaced  forwards,  and  almost  dislocated.  The 
line  of  fracture  usually  runs  through  the  base  of  the  process  at  its 
attachment  to  the  shaft,  and  is  for  the  most  part  transverse. 
Great  swelling  in  and  around  the  joint  comes  on  early  ;  on  exami- 
nation, the  detached  fragment  can  be  readily  distinguished,  and 
between  it  and  the  shaft  a  sulcus,  which  increases  on  flexion  and 
diminishes  on  extending  the  forearm.  The  nature  of  the  union 
depends  on  the  amount  of  separation  of  the  fragments,  and  the 
treatment  adopted.  If  the  fragments  are  not  brought  accurately 
into  apposition,  fibrous  union  is  likely  to  occur,  and  although  the 
new  cicatricial  tissue  may  stretch  considerably,  a  useful  elbow 
sometimes  results  ;  in  some  cases  the  fragment  is  drawn  up 
and  fixed  to  the  humerus,  and  a  false  joint  is  developed  below 
it.  If,  however,  the  fragments  are  brought  in  contact,  bony  union 
follows,  though  even  then  some  impairment  of  function  may  ensue 
owing  to  the  callus  encroaching  on  the  articular  surface,  which 
is  always  involved.  In  all  cases  the  ulnar  nerve  is  exposed  to 
injury. 


PLATE  XIV. 


Fracture  of  Olecranon  before  Operation. 


To  face  p.  460. 


PLATE  XV. 


Fracture  of  Olecranon  Two  Weeks  after  Operation. 

From  the  same  patient  as  Plate  XIV.     It  will  be  noted  that,  though  the  fragments 
are  in  apposition,  they  are  not  united. 
To  follow  Plate  XIV.] 


PLATE  XVI. 


Fracture  of  Olecranon  (Six  Weeks  after  Operation). 
From  the  same  patient  as  Plates  XIV.  and  XV.     The  fragments  are  now  united 

by  bone. 

[To  follow  Piatt  XV. 


INJURIES  OF  BONES— FRACTURES  461 

Treatment. — The  most  satisfactory  plan  is  to  lay  the  parts 
freely  open,  to  thoroughly  clear  the  joint  of  all  blood  and 
exudation,  remove  shreds  of  tendon  and  ligaments  which  may 
be  placed  between  the  fragments,  and  then  wire  them  together, 
the  wire  just  extending  down  to  the  articular  cartilage  (Plate  XV.). 
The  same  precautions  and  after-treatment  must  be  followed  as  in 
dealing  with  the  patella.  A  similar  plan  should  be  adopted  in  all 
compound  cases,  and  in  those  where  loose  fibrous  union  has 
occurred  with  a  resulting  weak  and  relaxed  elbow ;  in  the  latter 
instance  the  new  fibrous  tissue  must  be  entirely  dissected  away 
and  the  bony  surfaces  freshened.  If  an  operation  is  not  under- 
taken, the  arm  should  be  put  up  on  a  straight  anterior  splint,  the 
fragment  being  drawn  into  position  as  well  as  possible  by  means 
of  a  pad  and  figure-of-8  bandage.  Gentle  passive  movement  and 
massage  should  commence  at  the  end  of  a  fortnight. 

2.  The  Coronoid  Process  is  so  deeply  placed  and  so  well  pro- 
tected that  fractures  must  necessarily  be  very  uncommon,  except 
as  an  accompaniment  of  dislocation  of  the  ulna  backwards.  The 
signs  relied  on  in  making  a  diagnosis  are  that  reduction  of  the 
dislocation  is  easier  than  usual  and  associated  with  crepitus,  and 
that  the  deformity  is  likely  to  recur.  The  Treatment  consists  in 
apposing  the  bony  surfaces,  if  possible,  by  flexing  the  forearm. 
Bony  union  is,  however,  less  important  than  a  freely  moveable 
elbow,  and  therefore  passive  movement  is  commenced  early. 

3.  The  Shaft  of  the  Ulna  is  often  fractured  by  itself  as  a  result 
of  direct  violence,  to  which  its  exposed  position  renders  it  pecu- 
liarly liable.  Fracture  also  occurs  as  a  complication  of  several 
of  the  forms  of  dislocation  of  the  radius  alone  (Plate  XXVII. ). 
The  superficial  position  of  the  posterior  border  renders  examina- 
tion of  the  bone  easy ;  if  displacement  or  a  breach  of  substance 
occurs,  it  is  readily  detected,  but  when  merely  a  fissure  exists,  it 
is  not  so  easy  to  make  out.  The  constant  pain  referred  to  one 
spot,  the  slight  mobility,  and  possibly  crepitus,  indicate  the  char- 
acter of  the  lesion.  No  longitudinal  displacement  can  occur  if  the 
radius  remains  intact,  and  under  such  circumstances  the  only 
deformity  consists  in  a  slight  drawing  forwards  of  the  upper  frag- 
ment by  the  brachialis  anticus,  whilst  the  lower  fragment  is 
approximated  to  the  radius  by  the  pronator  quadratus.  Treat- 
ment.— The  arm  is  placed  midway  between  pronation  and  supina- 
tion, the  deformity  corrected,  and  the  limb  kept  at  rest  between 
anterior  and  posterior  splints,  or  in  plaster  of  Paris. 

4.  The  Styloid  Process  may  be  detached  by  direct  violence,  or 
as  a  complication  of  fracture  of  the  lower  end  of  the  radius.  The 
displacement  may  be  considerable  and  very  evident,  being  governed 
by  the  direction  of  the  violence.  Treatment  consists  in  replacing 
the  fragment  by  manipulation,  and  fixing  it  by  adhesive  plaster ; 
an  anterior  splint  is  applied  with  the  hand  adducted. 


462  A   MANUAL  OF  SURGERY 


Fractures  of  the  Radius. — i.  The  Head  of  the  Radius  is  rarely 
broken  alone,  such  an  accident  being  usually  associated  with 
other  injuries  to  the  elbow,  as,  for  instance,  fracture  of  the  outer 
condyle  or  some  form  of  dislocation.  The  upper  epiphysis  may 
be  separated,  or  there  may  be  merely  a  transverse  or  vertical 
fissure ;  but  under  any  circumstances  the  displacement  is  slight  if 
the  orbicular  ligament  remains  intact.  In  complete  separation 
the  head  is  immoveable,  and  crepitus  is  produced  when  the  arm 
is  rotated ;  bony  union  usually  follows  with  more  or  less  im- 
pairment of  function,  but  sometimes  the  head,  or  a  portion  of  it, 
remains  detached  as  a  loose  body  in  the  joint.  All  that  is  needed 
is  the  application  of  a  splint,  the  limb  being  kept  midway  between 
pronation  and  supination,  and  early  passive  movement  instituted. 
Excision  of  the  head  may  be  required  for  comminution,  or  for 
fixation  of  the  joint  by  excessive  formation  of  callus. 

2.  The  Neck,  i.e.,  the  portion  between  the  orbicular  ligament 
and  the  biceps  tuberosity,  is  occasionally  broken.  The  lower  frag- 
ment is  drawn  upwards  and  forwards  by  the  biceps,  causing  a 
bony  projection  on  the  front  of  the  elbow,  especially  evident  on 
attempting  to  flex  the  joint,  whilst  the  forearm  is  pronated  with 
loss  of  the  power  of  rotation,  and  the  head  of  the  bone  does  not 
accompany  the  shaft  on  passively  rotating  it.  Treatment. — The 
arm  is  flexed  to  relax  the  biceps,  and  the  limb  placed  on  a 
posterior  angular  splint,  with  a  pad  over  the  front  of  the  lower 
fragment.  Passive  movement  should  not  be  commenced  too  early, 
as  the  lesion  is  extra-articular,  and  the  biceps  may  produce  per- 
manent deformity  if  allowed  to  act  upon  unconsolidated  callus. 

3.  The  Shaft  of  the  radius  is  broken  either  by  direct  violence 
or  by  falls  on  the  palm  ;  the  latter  accident,  however,  rarely 
causes  fracture  except  at  the  lower  end.  The  signs  are  sufficiently 
evident,  owing  to  the  superficial  position  of  the  bone,  consisting 
of  localized  pain,  loss  of  power  of  active  rotation,  whilst  passive 
rotary  movements  are  accompanied  by  crepitus,  the  head  of  the 
bone  and  upper  fragment  remaining  immobile  below  the  outer 
condyle  unless  impaction  is  present. 

The  displacement  is  somewhat  characteristic.  If  the  fracture  is 
situated  above  the  insertion  of  the  pronator  teres,  the  upper  fragment  is 
flexed  and  fully  supinated  by  the  action  of  the  biceps  and  supinator 
brevis,  whilst  the  lower  fragment  is  drawn  towards  the  ulna  and  fully 
pronated  by  the  unopposed  action  of  the  two  pronator  muscles. 
Treatment. — Inasmuch  as  it  is  practically  impossible  to  command 
the  small  upper  fragment,  the  lower  must  be  brought  into  apposi- 
tion with  it  by  fully  supinating  the  forearm  and  hand  after  flexing 
the  elbow,  and  applying  a  posterior  splint,  the  patient  being  pre- 
ferably kept  in  bed  for  a  time  and  the  arm  laid  on  pillows.  It 
may  afterwards  be  supported  in  a  hollow  leather  splint  carried 
across  the  body,  and  with  the  palm  directed  upwards. 

When  the  fracture  is  placed  below  the  insertion  of  the  pronator  teres, 


PLATE  XVII. 


Fracture  of  Shaft  of  Radius  (Anteroposterior  View; 


To  face  /.  462. 


PLATE  XVIII. 


Fracture  of  Shaft  of  Radius  (Lateral  View). 

From  the  same  patient  as  Plate  XVII.,  and  showing  excellently  the   necessity  for 
taking  skiagraphs  from  two  points  of  view. 
To  follow  Plate  A7V/.] 


PLATE  XIX. 


Colles"s  Fracture:    a  Simple  Case,  wtthoct  much  Lateral  Displacement 

oj    Hand. 

To  follow  Plo>.  xvm  | 


PLATE  XX. 


Colles's  Fracture:    a  Bad  Case,  with  the  Styloid  Process  of  the  Ulna 
torn  off  and  much  or  i  ward  displacement  ok  hand. 


To  follow  Plato  XIX.} 


INJURIES  OF  BONES— FRACTURES  463 

the  upper  fragment  is  drawn  forwards  by  the  action  of  the  biceps, 
and  inwards  by  the  pronator,  assuming  a  position  midway  between 
pronation  and  supination  ;  the  lower  fragment  is  approximated  to 
the  ulna  partly  by  the  direct  action  of  the  pronator  quadratus,  partly 
by  the  supinator  longus  tilting  the  upper  end  inwards;,  the  hand  is 
fully  pronated  looking  downwards.  Union  to  the  ulna  by  callus 
thrown  across  the  interosseous  space  is  not  unlikely  to  occur.  Treat- 
ment by  anterior  and  posterior  splints  may  here  be  adopted,  with  a 
good  interosseous  pad  interposed  between  the  limb  and  the  splints, 
the  arm  being  placed  midway  between  pronation  and  supination, 
and  the  hand  fully  adducted. 

4.  The  Lower  End  of  the  Radius  is  broken  with  extreme  fre- 
quency, constituting  what  is  known  as  Colles's  Fracture.  This 
injury  occurs  most  commonly  in  women  of  advanced  years, 
although  it  may  happen  at  any  age  or  to  either  sex.  It  is  almost 
invariably  due  to  falls  upon  the  outstretched  palm,  when  the  hand 
is  completely  pronated  and  extended.  The  line  of  fracture  is 
placed  about  1  inch  from  the  wrist,  though  rather  under 
than  over  this.  It  is  usually  transverse,  but  occasionally 
oblique  in  an  antero-posterior  direction,  sloping  from  above  down- 
wards and  forwards,  so  that  the  fracture  is  nearer  the  wrist-joint 
in  front  than  it  is  behind,  and  also  not  uncommonly  oblique  later- 
ally, slanting  from  without  downwards  and  inwards  (Plate  XIX.). 

The  displacement  is  somewhat  complicated,  (a)  The  lower 
fragment  is  carried  backwards  and  a  little  upwards,  a  condition 
resulting  from  the  direction  of  the  violence,  viz.,  a  fall  on  the 
palm  of  the  outstretched  hand,  the  radius  being  thus  compressed 
between  the  ground  and  the  weight  of  the  body,  and  yielding  at 
what  is  evidently  a  weak  spot ;  this  deformity  is  maintained  by 
the  action  of  the  radial  extensor  muscles  of  the  wrist,  and  often 
by  impaction  of  the  fragments,  (b)  From  the  fact  that  the  main 
violence  is  received  by  the  ball  of  the  thumb,  owing  to  the  extreme 
pronation  of  the  hand,  the  outer  side  of  the  lower  fragment  is 
displaced  more  than  the  inner,  which,  moreover,  remains  fixed  to 
the  ulna  by  the  strong  inferior  radio-ulnar  ligaments.  This 
position  is  in  part  kept  up  by  the  tension  of  the  extensors  of  the 
thumb  and  the  supinator  longus,  but  mainly  by  impaction  of  the 
fragments.  The  hand  and  carpus  always  follow  the  lower  frag- 
ment, and  hence  the  former  becomes  markedly  abducted,  causing 
the  styloid  process  of  the  ulna  to  become  unduly  prominent,  and 
lower  than  that  of  the  radius,  whereas  it  is  normally  placed  on  a 
slightly  higher  level.  Occasionally  the  styloid  process  of  the  ulna 
is  actually  torn  off,  or  the  internal  lateral  ligament  ruptured, 
allowing  displacement  outwards  of  the  whole  hand  (Plate  XX.). 
(c)  The  lower  fragment  is  also  rotated  around  a  transverse  axis, 
so  that  the  lower  articular  surface  looks  backwards  as  well  as 
downwards,  a  displacement  due  to  the  fact  that  in  falling  the 
force  is  directed,  through  the  carpus,  more  to  the  posterior  than 


464  A  MANUAL  OF  SURGERY 


to  the  anterior  aspect  of  the  bone,  (d)  The  upper  fragment  is 
pronated  and  approximated  to  the  ulna  by  the  pronator  quadratus 
muscle.  The  deformity  produced  by  the  fracture  is  therefore  very 
characteristic.  The  hand  is  in  a  position  of  radial  abduction,  and 
usually  pronated,  with  the  fingers  somewhat  flexed  (dinner-fork 
deformity).  Three  abnormal  osseous  projections  are  present  : 
(i)  The  styloid  process  or  head  of  the  ulna  is  very  marked,  owing 
to  the  radial  abduction  of  the  hand  (Fig.  147) ;  (ii.)  on  the  back  of 
the  wrist  is  a  prominence  which  terminates  abruptly  above, 
caused  by  the  projection  of  the  lower  fragment  (Fig.  146) ;  and 
(iii.)  corresponding  to  this  dorsal  projection  there  is  a  well- 
marked  depression  on  the  palmar  surface,  and  above  it  a  less 
sharply-defined  swelling,  which  gradually  shelves  into  the  fore- 
arm, due  to  the  upper  fragment.  Pronation  and  supination  are 
lost,  and,  as  a  rule,  there  is  neither  crepitus  nor  preternatural 
mobility,  owing  to  impaction  of  the  fragments.     In  doubtful  cases 


Fig.  146. — Colles's  Fracture  :  Fig.   147. — Colles's  Fracture  : 

Lateral  View.  Palmar  View.     (Tillmanns.) 

help  in  diagnosis  may  be  obtained  by  observing  the  relative 
position  of  the  two  styloid  processes  ;  normally,  that  of  the  radius 
is  well  below  that  of  the  ulna,  but  in  cases  of  fracture  the  ulnar 
projection  is  below  that  of  the  radius. 

As  already  stated,  the  fracture  is  commonly  impacted,  the 
upper  fragment  being  firmly  driven  into  the  cancellous  tissue  of 
the  lower  end  ;  excess  of  violence  may,  however,  disimpact,  but 
often  at  the  expense  of  comminution  of  the  lower  fragment. 
Union  is  effected  without  difficulty,  but  the  patient  should  always 
be  warned  at  an  early  date  to  expect  some  deformity  about  the 
wrist,  as  well  as  considerable  impairment  in  the  subsequent 
mobility  of  the  fingers  and  hand,  owing  partly  to  adhesions  in  the 
joint,  partly  to  blood  trickling  down  the  tendon  sheaths  and  fixing 
the  tendons. 

Treatment. — To  reduce  the  deformity,  extension  and  manipula- 
tion are  both  needed.  The  patient  should  be  seated  on  a  chair, 
and  the  surgeon,  standing  in  front,  should  grasp  the  hand  firmly, 
using  the  right  hand  for  fractures  on  the  right  side,  and  the  left 
for  those  on  that  side.  Counter-extension  is  made  from  the  flexed 
elbow,  and  the  hand  is  then  forcibly  extended    and   adducted ; 


INJURIES  OF  BONES— FRACTURES  465 

disimpaction  is   thus   brought   about,  and  a  little  manipulation 
enables  the  fragments  to  be  moulded  into  position. 

Many  plans  have  been  adopted  in  the  application  of  splints  for 
this  fracture:  (1)  A  piece  of  Gooch  splint  is  perhaps  the  most 
simple  and  efficacious.  It  is  shaped  so  as  to  cover  the  radius 
front  and  back  as  far  as  the  middle  line  of  the  arm,  and  extends 
nearly  from  the  elbow  to  the  front  and  back  of  the  knuckles  of 
the  index  and  middle  fingers  :  its  lower  end  is  hollowed  out  in  a 
horseshoe  manner,  so  as  not  to  reach  beyond  the  end  of  the 
metacarpal  bone  of  the  thumb.  This  is  well  padded  and  firmly 
bandaged  on  ;  it  grasps  the  radius  and  steadies  the  hand  in  a 
position  of  adduction,  without  in  any  way  interfering  with  the 
movements  of  the  fingers.  (2)  Caw's  splint  (Fig.  148)  consists  of 
two  shaped  pieces  of  wood  fitting  the  front  and  back  of  the  radial 
side  of  the  forearm,  whilst  to  the  palmar  one  is  attached  an  oblique 
rod  to  be  grasped  by  the  fingers,  and  thus  the  hand  and  wrist  are 


^y;/i/iiinii!!iiiiiiii/ii,iiiiiiff/if/i/iiii/rf///,7////// 


Fig.  148. — Carh's  Splint  for  Colles's  Fracture  of  Left  Hand. 

maintained  in  a  position  of  adduction,  whilst  the  fingers  can  be 
freely  moved.  (3)  The  Pistol  splint  consists  of  a  straight  portion 
fitted  to  the  front  of  the  forearm,  whilst  the  handpiece  is  bent  at 
an  angle  like  the  butt-end  of  a  pistol.  It  may  also  be  applied  to 
the  back  of  the  forearm,  together  with  a  short  straight  splint  on 
the  palmar  aspect  reaching  to  the  wrist.  It  keeps  the  hand  and 
arm  in  excellent  position,  but  is  objectionable  because  the  fingers 
are  also  restrained.  If,  however,  it  is  shortened  at  the  end  of  four 
or  five  days  so  as  not  to  extend  beyond  the  knuckles,  it  may  be 
used  without  doing  harm.  (4)  Two  straight  splints  may  be 
applied  to  the  front  and  back  of  the  forearm,  which  is  kept  mid- 
way between  pronation  and  supination  ;  neither  should  extend 
beyond  the  knuckles,  so  that  the  fingers  are  free.  The  weight  of 
the  hand,  when  the  arm  is  slung,  keeps  it  in  a  position  of  adduc- 
tion. 

Union  is  usually  firm  enough  in  a  fortnight  to  permit  the 
removal  of  the  splints,  the  arm  being  kept  in  a  leather  or  gutta- 
percha support  for  some  time  longer.  Massage  and  passive 
movement  should  be  employed  after  the  first  week,  and  the 
fingers  left  free  and  exercised  after  the  first  day  or  two. 

5.  Separation  of  the  Lower  Epiphysis  of  the  radius  occurs  in  young 

30 


466 


A   MANUAL  OF  SURGERY 


people  under  twenty,  and,  when  the  lower  fragment  is  displaced 
backwards,  simulates  somewhat  closely  a  Colles's  fracture.  The 
lower  end  of  the  diaphysis  projects  anteriorly  to  a  much  greater 
extent,  and,  indeed,  may  protrude  through  the  skin  of  the  wrist, 
causing  the  fracture  to  become  compound.  The  lower  end  of  the 
ulna  may  also  be  involved  in  the  accident,  either  the  epiphysis 
being  separated,  or  the  shaft  broken  a  little  above.  This  condi- 
tion may  also  be  mistaken  for  a  backward  dislocation  of  the  wrist, 
but  a  diagnosis  can  be  readily  made  by  observing  the  relative 
position  of  the  styloid  processes  to  the  carpal  bones.  Lateral 
displacement  also  occurs  in  some  cases  (Fig  149).  Treatment  is 
practically  the  same  as  for  Colles's  fracture. 


Fig.  149. — Skiagram  of  Displacement  of   Lower   Epiphysis   of  Radius, 
and  of  the  hand  outwards. 


Should  arrest  of  growth  result  from  this  accident,  the  hand 
retains  its  connection  with  the  stunted  radius,  but  the  ulna  con- 
tinues to  grow  downwards,  and  its  lower  end  is  found  on  the 
inner  and  posterior  aspect  of  the  carpus,  which  is  pushed  en  bloc 
towards  the  radial  side,  but  without  any  marked  abduction. 

Fracture  of  both  Bones  of  the  Forearm  may  result  from  direct 
or  indirect  violence,  but  more  commonly  from  the  former.  Any 
part  of  the  bones  may  yield,  but  the  middle  and  lower  thirds 
are  most  frequently  affected,  owing  to  their  greater  exposure. 
The  line  of  fracture  may  be  transverse  or  oblique,  and  the  dis- 
placement varies  both  with  this  and  with  the  force  employed. 
Occasionally  both  bones  are  broken  close  to  the  wrist  by  a  fall 


PLATE  XXL 


Fracture  of  both  Bones  of  the  Forearm,  with  Displacement  outwards. 
To/ace  p.  466.] 


INJURIES  OF  BONES— FRACTURES  467 

on  the  palm  of  the  hand  (Plate  XXL).  The  upper  fragments  are 
usually  drawn  together  and  pronated,  whilst  the  lower  end  of  the 
radius  is  drawn  up  by  the  supinator  longus.  The  diagnosis  of 
these  fractures  is  very  simple,  since  there  is,  as  a  rule,  obvious 
deformity.  Treatment  consists  in  reduction  by  extension  con- 
joined with  manipulation,  and  the  application  of  splints  which  will 
prevent  cross-union  of  the  bones.  If  the  fracture  is  above  the 
insertion  of  the  pronator  teres,  the  arm  must  be  put  up  in  full 
supination,  as  suggested  for  a  similar  fracture  of  the  radius  alone 
(p.  462),  whilst  below  that  spot  the  usual  position  midway 
between  pronation  and  supination  may  be  allowed.  Union  is 
generally  complete  in  five  or  six  weeks. 

Fractures  of  the  Metacarpal  Bones  and  Phalanges  are  not  un- 
common, being  due  to  direct  violence,  and  hence  usually  trans- 
verse in  direction.  There  is  generally  but  little  displacement, 
though  occasionally  the  fragments  may  overlap.  An  oblique 
fracture  sometimes  occurs  through  the  base  of  the  first  meta- 
carpal, separating  the  anterior  portion,  which  remains  in  situ, 
whilst  the  rest  of  the  shaft  is  drawn  upwards  and  backwards. 
There  is  always  a  certain  amount  of  localized  swelling  and 
tenderness  in  these  fractures.  The  only  treatment  required 
is  immobilization  for  a  short  time,  and  for  the  phalanges  a  small 
zinc  splint  moulded  along  the  front  of  the  finger  acts  admirably. 

Fractures  of  the  Pelvis. 

Fractures  of  the  pelvic  bones  are  almost  always  the  result 
of  direct  injury,  such  as  blows,  gunshot  wounds,  and  railway, 
carriage,  or  cart  accidents.  For  convenience  they  may  be  de- 
scribed under  the  following  headings  : 

1.  Fractures  of  the  False  Pelvis. — A  portion  of  the  crista  ilii 
may  be  broken  off,  or  the  anterior  or  posterior  spines  separated, 
or  merely  a  fissure  in  the  bone  produced.  But  little  importance 
attaches  to  such  conditions,  as  the  displacement  can  never  be  great, 
although  a  portion  of  the  crest  may  be  drawn  down  by  the  glutei 
muscles,  or  the  anterior  superior  spine  displaced  by  the  sartorius; 
in  severer  cases,  when  the  bones  are  crushed  and  comminuted, 
the  true  pelvis  is  likely  to  be  also  affected,  and  more  serious  con- 
sequences may  then  arise.  Considerable  pain  is  always  produced 
by  these  conditions,  especially  on  any  vigorous  respiratory  move- 
ments. Union  occurs  readily,  all  the  treatment  required  being  to 
keep  the  patient  quiet  in  bed  with  the  shoulders  raised,  and  the 
legs  supported  to  relax  the  muscles.  A  flannel  bandage  round 
the  pelvis  gives  comfort  and  support. 

2.  Fracture  of  the  True  Pelvis  is  a  much  more  serious  accident. 
The  line  of  fracture  usually  runs  into  the  obturator  foramen,  and 
may  detach  both  the  horizontal  ramus  of  the  pubes  and  the 
ascending  ramus  of  the  ischium  from  the  rest  of  the  innominate 

30—2 


468 


A   MANUAL  OF  SURGERY 


Fig.  150. — Fracture  of  the  Pelvis. 
(Bryant.) 


bone   (Fig.    150).     This   is   frequently  conjoined  v/ith   a   fracture 
through   the   sacro- iliac   synchondrosis   either   on   the   same   or 

opposite  side,  but  more 
frequently  the  latter ; 
whilst  a  double  fracture, 
front  and  back,  may  also 
occur  at  these,  the  weakest 
points.  The  cause  of  the 
posterior  fracture  is  that, 
when  the  pelvic  ring  has 
yielded  anteriorly  from 
the  violence,  the  con- 
tinued strain,  whether  di- 
rected from  the  front  or 
from  the  sides,  must 
necessarily  fall  on  the 
part  where  the  ilium  is 
most  closely  connected 
with  the  sacrum,  and  the  bones  then  give  way  rather  than  the 
unyielding  and  powerful  sacro-iliac  ligaments.  The  Symptoms 
are  those  of  shock  and  pain  in  and  around  the  pelvis,  especially 
on  movements  of  the  legs  or  on  coughing.  There  may  be  local 
ecchymosis,  and  tenderness  over  the  pubic  ramus,  and  the  patient 
either  cannot  stand,  or  feels  as  if  he  were  falling  to  pieces  on 
attempting  to  do  so.  There  is  rarely  any  deformity,  although 
occasionally  such  an  occurrence  is  noted.  Crepitus  may  be 
elicited  on  grasping  the  iliac  bones,  and  moving  them  one  on  the 
other  ;  but  such  a  method  of  investigation  must  be  very  sparingly 
indulged  in.  Complications  frequently  arise  from  injury  to  the 
internal  viscera,  especially  the  bladder,  rectum,  urethra,  or  vagina, 
as  indicated  by  haemorrhage  into  or  from  these  organs.  An  aseptic 
catheter  should  be  passed  as  a  routine  proceeding,  and  if  the 
urine  is  blood-stained,  it  is  tied  in. 

Treatment. — The  patient  should  be  moved  with  the  greatest 
care,  for  fear  of  producing  or  increasing  visceral  complications. 
He  is  put  to  bed,  and  any  obviously  displaced  fragments  reduced, 
if  practicable,  possibly  under  an  anaesthetic.  A  broad  flannel 
bandage  should  be  applied,  the  knees  tied  together,  and  a  leather 
or  poroplastic  splint  moulded  to  the  pelvis.  Visceral  complica- 
tions must  receive  attention,  as  indicated  elsewhere.  Union  may 
be  expected  in  about  six  weeks,  but  the  patient  should  be  kept  in 
bed  for  at  least  eight,  and  even  then  only  allowed  to  get  about  on 
crutches,  wearing  a  padded  belt. 

3.  Fracture  of  the  Acetabulum  is  of  two  types :  either  the 
posterior  lip  is  broken  off  as  a  result  of  violence  directed  against 
it  by  the  head  of  the  femur,  which  is  dislocated  backwards  by  the 
same  accident ;  or  a  fall  on  the  trochanter  may  cause  a  simple 
fissure  extending  into  or  across  the  cavity,  or  may  resolve  it  into 


INJURIES  OF  BONES— FRACTURES  469 


its  three  constituent  elements,  or  may  even  drive  the  head  of 
the  bone  into  the  pelvis.  In  the  former  case,  the  limb  is  in  the 
position  of  a  dorsal  dislocation ;  this  can  be  reduced  without 
difficulty,  and  possibly  with  crepitus,  but  manifests  a  great 
tendency  to  recur.  Prolonged  extension  with  a  long  splint  is 
needed  in  such  cases.  In  the  latter  class  of  injury  a  mere  fissure 
of  the  acetabulum  produces  but  few  symptoms  beyond  a  little 
pain  and  impairment  of  movement ;  but  if  the  head  of  the  bone 
is  driven  into  the  pelvic  cavity,  the  symptoms  are  much  more 
serious,  on  account  of  the  associated  injuries  to  the  viscera  and 
the  greater  amount  of  violence  employed.  The  case  will  resemble 
one  of  fracture  of  the  neck  of  the  femur,  but  there  is  usually  only 
very  slight  mobility,  and  the  head  of  the  bone  may  be  felt  within 
the  pelvis  on  rectal  examination.  An  attempt  should  be  made  to 
free  the  head  of  the  bone,  and  the  case  treated  as  one  of  fracture 
of  the  neck  of  the  femur ;  but  a  fatal  issue  is  very  likely  to  follow. 

4.  Fracture  of  the  Tuber  Ischii  results  from  falls  in  the  sitting 
position.     The  diagnosis  is  often  obscure. 

5.  Fracture  of  the  Sacrum  is  always  due  to  direct  violence  of 
considerable  severity,  such  as  kicks,  blows,  or  gunshot  wounds. 
It  is  not  unfrequently  comminuted,  and,  from  the  associated  injury 
to  the  lower  sacral  nerves,  may  result  in  loss  of  power  of  the 
bladder  and  rectum.  In  a  transverse  fracture,  the  lower  fragment 
is  usually  displaced  forwards,  and  may  cause  pressure  upon  the 
rectum ;  irregularity  in  the  shape  of  the  bone  may  be  detected 
from  within  (per  rectum)  or  from  without.  Treatment. — The 
lower  fragment  should  be  replaced,  if  possible ;  but  considerable 
difficulty  may  be  experienced  in  keeping  it  in  position.  A  well- 
fitting  pelvic  band,  with  rest  in  bed,  is  probably  all  that  is  necessary. 

6.  Fractures  of  the  Coccyx  are  by  no  means  uncommon  as  a 
result  of  falls  or  blows,  although  its  mobility  often  protects  it 
from  injury.  Great  pain  is  felt  on  walking,  or  on  any  movement 
which  increases  the  intra-abdominal  pressure,  such  as  straining, 
coughing,  defalcation,  etc.,  since  the  coccygeus  muscle  which  is 
attached  to  this  bone  forms  part  of  the  lower  diaphragm  of  the 
abdomen.  A  rectal  examination  reveals  preternatural  mobility 
of  the  lower  fragment,  angular  deformity,  and  perhaps  crepitus. 
The  Treatment  consists  in  keeping  the  patient  at  rest  until  union 
has  occurred ;  it  is  impossible  to  apply  any  apparatus  to  correct 
the  deformity.  Sometimes  the  bone  unites  at  an  angle,  causing 
much  pain  and  discomfort,  whilst  difficulty  in  parturition  may  also 
arise  from  this  cause.  Excision  of  the  bone  is  then  required.  The 
patient  lies  semi -prone  with  the  legs  slightly  flexed  or  in  the 
lithotomy  position,  and  a  longitudinal  incision  is  made  in  the 
middle  line.  The  apex  and  lateral  margins  of  the  bone  are 
cleared,  and  the  ligamentous  tissues  uniting  it  to  the  sacrum 
divided  by  the  knife ;  the  bone  is  now  laid  hold  of  by  sequestrum 
forceps,  and  its  remaining  attachments  severed,  due  precautions 


47o 


A   MANUAL  OF  SURGERY 


being  taken  not  to  encroach  on  the  rectum.  Two  or  three  stitches 
are  inserted,  and  also  a  drainage-tube  for  a  few  hours;  the  dressing 
is  secured  in  position  by  a  T-bandage,  but  it  is  not  common  to 
obtain  healing  by  first  intention.  The  bowels  should  be  confined 
for  some  days  after  the  operation. 

Falls  upon  the  coccyx,  unaccompanied  by  fracture,  sometimes 
give  rise  to  a  most  severe  and  intractable  type  of  neuralgia, 
known  as  coccydynia,  which  may  quite  prevent  the  patient  from 
following  his  avocations.  If  all  the  usual  sedatives  fail  in  giving 
relief,  the  bone  must  be  excised. 


Fractures  of  the  Upper  End  of  the  Femur. 

i.  Fractures  of  the  Neck  of  the  Femur  are  commonly  divided  into 
intra-  and  extra-capsular  varieties,  and,  although  this  is  by  no  means 
free  from  objections,  yet  it  constitutes  a  useful  working  basis. 

The  Intracapsular  Fracture,  or  fracture  near  the  head  (Fig.  151), 
though  it  has  occurred  in  children  and  adolescents,  is  almost  in- 
variably met  with  in  persons  in  advanced  life,  and  especially  in 
females.  This  is  explained  by  the  atrophic  changes  which  take  place 
in  the  cervix  femoris  of  elderly  people.  The 
spaces  between  the  bony  cancelli  are  en- 
larged, and  loaded  with  soft  fat,  whilst  the 
ensheathing  compact  tissue  is  thinned,  and 
the  '  calcar  femorale '  of  Merkel  (i.e.,  the 
process  of  thick  cortical  substance  running 
from  the  lesser  trochanter  to  the  under 
part  of  the  head)  is  atrophied.  The  neck 
of  the  bone  is  sometimes  more  horizontal 
than  usual,  and  the  head  sinks  below  its 
usual  position.  Under  such  circumstances, 
it  requires  but  little  violence  to  produce  a 
fracture,  the  direction  of  which  varies  ac- 
cording to  the  force  applied.  As  a  rule, 
the  accident  is  due  to  some  slight  stumble 
or  fall,  such  as  slipping  off  the  kerb  or 
tripping  upstairs ;  the  bone  yields  in  con- 
sequence, and  the  patient  falls  to  the  ground.  The  line  ol 
fracture  may  be  transverse  or  oblique,  and  is  mainly  intra- 
capsular. Some  of  the  fibres  reflected  from  the  under  surface  of 
the  capsule  to  the  head  of  the  bone  may  remain  untorn  at  first, 
but  later  on  they  may  give  way  from  inflammatory  softening  or 
injudicious  manipulation  or  attempts  to  use  the  limb.  The 
fracture  is  not  usually  impacted  ;  if,  however,  this  condition 
should  occur,  the  upper  end  of  the  neck  is  driven  into  the  loose 
cancellous  tissue  of  the  head.  The  displacement  is  necessarily 
limited  entirely  to  the  lower  fragment,  which  is  drawn  upwards 
by  the  glutei,  recti,  and  hamstring  muscles,  and  rotated  outwards 


Pig.  151. — Intracapsu- 
lar Fracture  of  the 
Cervix  Femoris. 


INJURIES  OF  BONES— FRACTURES 


47' 


and  somewhat  backwards,  so  that  the  fractured   surface   looks 
almost  directly  forwards. 

The  Method  of  Union  in  these  cases  depends  to  a  large  extent 
upon  the  general  condition  of  the  individual.  If  of  a  healthy 
temperament,  and  without  any  chronic  pulmonary  affection,  so 
that  he  can  be  kept  in  the  recumbent  posture  for  six  or  eight 
weeks,  bony  union  may  certainly  occur,  in  spite  of  the  fact 
that  at  first  synovial  fluid  finds  its  way  between  the  fractured 
surfaces.  The  main  process  of  repair  takes  place  from  the  lower 
end,  but  little  callus  being  formed  from  the  head  of  the  bone,  the 
vascular  supply  being  only  just  sufficient  to  maintain  its  vitality. 
If,  however,  the  patient  is  feeble  and  weakly,  and  especially  if  the 
subject  of  chronic  bronchitis  and  emphysema,  the  prognosis  is  by 
no  means  good,  since  hypostatic  pneumonia  and  extensive  bed- 


A  B 

Fig.  152. — Extracapsular  Fracture  of  Cervix  Femoris. 

A,   From  behind,  showing  detachment  of  both  trochanters  ;    B,  on  section, 

showing  impaction  of  head  and  neck  into  base  of  trochanter,  which  also  is 

detached, 
sores  may  carry  him  off  during  the  short  stay  in  bed,  which  is 
always  necessary,  in  order  to  relieve  the  more  urgent  symptoms 
of  pain.  Bony  union  is  never,  under  these  circumstances,  to  be 
expected,  and  a  loose  fibrous  union,  or  even  a  false  joint,  is  the 
best  that  can  be  looked  for,  the  patient  henceforth  walking  with 
the  assistance  of  a  stick  or  crutch.  The  prognosis  is,  of  course, 
much  improved  by  the  presence  of  impaction,  and  the  fear  of 
breaking  this  down  must  ever  be  in  the  mind  of  the  examining 
surgeon  ;  whilst  the  integrity  of  bridges  of  periosteum  and  re- 
flected fibres  from  the  capsule  also  improves  the  outlook. 

Extracapsular  Fracture  of  the  cervix  femoris  (fracture  near  the 
trochanter)  is  an  absolute  misnomer,  since  the  capsule  extends 
to  the  shaft  of  the  bone  along  the  anterior  intertrochanteric  line, 
and  leaves  no  portion  of  the  neck  uncovered  in  this  situation. 


472  A  MANUAL  OF  SURGERY 


The  line  of  fracture  is  placed  in  front,  either  along  the  attachment 
of  the  capsule  or  within  it,  and  is  really  only  extracapsular 
behind  ;  sometimes,  moreover,  the  shaft  itself  is  considerably 
encroached  on.  The  great  trochanter  is  often  involved  in  the 
fracture,  being  splintered  or  detached,  and  the  lesser  trochanter 
may  be  split  off  with  a  portion  of  the  shaft,  so  that  the  bone  is 
broken  into  at  least  three  different  fragments  (Fig.  152). 

Mechanism. — This  fracture  is  usually  the  result  of  direct  violence 
acting  transversely  upon  the  trochanter  major,  as  from  a  heavy 
fall  upon  the  hip.  The  posterior  part  of  the  neck,  being  weaker 
than  the  anterior,  first  gives  way,  being  more  or  less  crushed  and 
comminuted ;  the  whole  neck  then  yields,  and  the  severed  head 
and  neck  are  forcibly  impacted  into  the  junction  of  the  trochanter 
and  shaft  (Fig.  152,  B).  The  majority  of  these  cases  are  thus 
primarily  impacted,  continuation  of  the  violence  producing  dis- 
impaction,  coupled  either  with  detachment  of  one  or  both  tro- 
chanters, or  with  comminution  of  the  great  trochanter.  A  similar 
result  may  follow  from  the  inflammatory  exudation  causing  a  late 
separation  of  the  impacted  parts,  or  from  injudicious  manipulation. 

The  displacement  is  much  the  same  as  in  the  former  variety  ; 
the  upper  fragment  remains  in  statu  quo,  whilst  the  lower  is 
drawn  up  and  everted,  only  to  a  greater  extent.  Shortening 
may  at  first  be  slight,  but  is  likely  to  increase  at  the  end  of 
a  few  days,  as  a  result  of  disimpaction  of  the  fragments,  or 
from  the  yielding  of  the  reflected  fibres  of  the  capsule,  or  from 
the  tonic  action  of  the  muscles.  Later  on,  moreover,  the  shorten- 
ing may  again  increase  from  a  rapid  absorption  of  the  neck,  which 
occasionally  follows  this  accident,  or  is  possibly  due  to  the  super- 
vention of  chronic  traumatic  arthritis. 

The  Signs  and  Symptoms  of  these  two  fractures  may  well  be 
considered  together,  the  points  of  similarity  and  contrast  being  in 
this  way  more  effectually  emphasized. 

(a)  The  signs  of  local  trauma,  viz.,  pain,  bruising,  and  swelling, 
may  be  present  in  both  ;  but  whilst  slight  in  the  intracapsular 
variety,  they  are  very  marked  in  the  extracapsular.  It  must  not 
be  overlooked,  however,  that  even  in  the  former  the  patient  may 
fall  on  the  affected  hip  after  the  fracture  has  occurred,  and  thus 
cause  a  considerable  amount  of  bruising. 

(b)  Crepitus  is  evident  in  the  unimpacted  forms  of  each  ;  but  it 
is  unnecessary  and,  indeed,  extremely  unwise  to  elicit  it  by  forcible 
manipulation,  especially  in  the  intracapsular  variety. 

(c)  Loss  of  power  of  the  limb  exists  to  a  variable  extent,  and  is 
perhaps  more  marked  in  the  extracapsular  form  than  in  the 
intracapsular.  Cases  of  the  latter  in  which  the  patient  was  able 
to  walk  into  hospital  some  days  after  the  accident  are  not  unknown, 
and  are  probably  due  to  impaction. 

(d)  Eversion  is  a  most  characteristic  feature  in  both  varieties,  the 
limb  lying  absolutely  helpless  on  its  outer  side.     This  displace- 


INJURIES  OF  BONES— FRACTURES 


47; 


ment  is  accredited  to  the  natural  weight  of  the  limb,  to  the  greater 
fragility  of  the  back  of  the  cervix,  causing  it  to  be  more  com- 
minuted than  the  anterior  surface,  and,  lastly,  to  the  greater 
power  of  the  external  rotator  muscles.  Inversion  has  been  met 
with  in  a  few  rare  cases,  but  is  probably  due  to  the  violence  in 
the  particular  instance  being  directed  from  behind  forwards,  and 
to  impaction  of  the  fragments. 

(e)  Shortening  is  slight  in  the  early  stage  of  intracapsular,  and 
much  greater  in  the  extracapsular,  fractures.  In  the  latter  case 
the  shortening  usually  attains  its  maximum — viz.,  il  to  2h,  or 
even  3  inches — at  once  ;  but  such  is  not  always  the  case  in  the 
former.  It  is  indicated  by  displacement  of  the  trochanter  upwards, 
due  allowance  being  made  for  the  position  of  the  limb  as  regards 
abduction  or  adduction. 

(/)  The  position  of  the  great  trochanter  is  of    the  greatest  im- 


Fig.   153. — Nelaton's  Line  and  Bryant's  Measurement  for  ascertaining 
Position  of  Great  Trochanter. 

portance.  It  is  raised  above  its  ordinary  level  and  everted  ;  it  is 
approximated  to  the  middle  line  of  the  body  and  to  the  anterior 
superior  iliac  spine,  and  rotates  in  the  arc  of  a  smaller  circle  than 
usual,  the  radius  being  the  thickness  of  the  trochanter  alone, 
instead  of  including  also  the  length  of  the  neck.  The  demonstra- 
tion of  this  position  is  most  important,  and,  amongst  others,  the 
following  tests  are  employed  : 

Nelaton's  line  (Fig.  153)  is  one  drawn  from  the  anterior  superior 
spine  to  the  most  prominent  point  of  the  tuber  ischii  (AB).  The 
centre  of  this  (D)  corresponds  to  the  top  of  the  great  trochanter, 
if  the  limb  is  placed  in  the  axis  of  the  body  ;  but  if  either  abduc- 
tion or  adduction  is  present,  the  top  is  situated  slightly  above  or 


474  A   MANUAL  OF  SURGERY 

below  the  line.  Definite  elevation  of  the  bone  above  the  line 
indicates  shortening  of  the  limb  due  to  dislocation  backwards, 
fracture  of  the  neck,  or  absorption  of  the  neck  from  disease. 

Bryant's  Test  Line  (Fig.  153). — In  this  the  patient  lies  flat  on  a 
horizontal  couch,  and  a  vertical  line  (AC)  is  drawn  from  the 
anterior  superior  spine  ;  a  thin  wooden  rod  held  against  the  side 
answers  this  purpose  admirably.  The  perpendicular  distance  of 
the  top  of  the  great  trochanter  from  the  line  (CD)  is  compared 
with  a  similar  measurement  on  the  opposite  side ;  definite 
shortening  may  thus  be  discovered. 

Morris's  bitrochanteric  test  indicates  the  amount  of  inward  dis- 
placement. It  is  conducted  by  measuring  the  distance  between 
the  outer  surfaces  of  the  trochanters  and  the  middle  line  of  the 
body  by  means  of  a  rod  graduated  from  the  centre,  along  which 
two  pointers  work  outwards.  Shortening  in  this  direction  will 
also  be  observed  in  most  dislocations  of  the  hip-joint. 

One  other  change  in  the  great  trochanter  may  be  noted  in  the 
extracapsular  form  of  fracture,  which  can  be  utilized  as  a  useful 
diagnostic  feature  between  it  and  the  intracapsular  variety,  viz., 
the  great  amount  of  thickening  of  the  process  which  is  always  pro- 
duced, owing  to  the  excessive  development  of  callus.  In  the 
intracapsular  variety  it  is  rarely  fissured  or  injured,  and  therefore 
no  thickening  occurs. 

(g)  Lastly,  relaxation  of  the  fascia  between  the  crest  of  the  ilium 
and  the  great  trochanter  (that  is,  of  the  upper  part  of  the  ilio- 
tibial  band)  is  given  as  a  characteristic  feature  of  these  fractures. 

Diagnosis. — Simple  unimpacted  fractures  are  readily  detected,  and 
there  can  be  but  little  difficulty  in  distinguishing  the  two  forms, 
either  from  one  another  or  from  other  injuries.  The  fact  that  an 
impacted  fracture  has  occurred  can  also  be  easily  made  out  as  a 
rule,  the  pain,  eversion,  and  shortening  sufficing  to  indicate  its 
existence  ;  but  it  is  often  very  difficult  to  say  which  of  the  two 
forms  of  fracture  is  present,  especially  if  the  surgeon  is  not  called 
till  late  in  the  case.  The  character  of  the  accident  and  the  age 
of  the  patient  must  be  taken  into  account,  whilst  the  existence  of 
Assuring  or  thickening  of  the  trochanter,  or  an  excessive  amount 
of  shortening,  may  indicate  that  the  lesion  has  been  extracapsular. 
A  severe  contusion  of  the  hip,  which  may  be  associated  with  marked 
eversion,  is  known  from  a  fracture  by  the  absence  of  shortening 
and  crepitus  ;  there  is  no  displacement  of  the  trochanter,  which 
rotates  in  a  normal  manner.  The  shortening  which  sometimes 
follows,  owing  to  subsequent  atrophy  of  the  neck,  may,  however, 
complicate  matters.  In  a  dislocation  the  head  of  the  bone  can  be 
felt  in  an  abnormal  position,  and  hence  no  difficulty  should  be 
experienced  in  its  recognition.  In  chronic  osteo-arthritis  of  the  hip 
with  antecedent  shortening  and  marked  bony  crepitus,  there  may 
be  no  history  of  accident,  and  no  acute  eversion,  pain,  or  loss  of 
power ;  possibly  the  existence  of  similar  disease  in  other  joints 


INJURIES  OF  BONES— FRACTURES 


475 


may  assist  the  surgeon,  whilst  osteo-arthritis  of  the  hip  usually 
results  in  prominence  of  the  trochanter,  and  not  in  flattening,  as 
occurs  after  fracture.  Moreover,  the  fascia  above  the  trochanter 
is  never  relaxed  in  osteo-arthritis,  always  in  fractures.  It  must 
not  be  forgotten  that,  after  an  intracapsular  fracture,  the  patient 
may  fall,  not  on  the  injured  side,  but  on  the  sound  thigh,  and  cases 
have  been  known  where  the  surgeon's  attention  was  directed  to 
the  wrong  limb  owing  to  the  amount  of  bruising  there  manifested. 

The  Treatment  of  intracapsular  fractures  must  depend  in  great 
measure,  as  already  stated,  upon  the  individual. 

If  old,  weakly,  and  with  a  tendency  to  chronic  bronchitis,  long 
confinement  to  bed  would  have  a  most  deleterious,  if  not  fatal, 
effect.  In  such  cases  the  limb  is  put  at  rest  for  a  few  days 
between  sandbags,  and  cooling  lotions  applied.  A  Thomas's 
splint  should  be  fitted  as  early  as  possible,  and  the  patient 
encouraged  to  get  about  on  crutches. 


Fig.  154.- 


-Liston's  Splint  padded  and  applied. 
a.  Perineal  band. 


In  a  healthy  individual  with  good  physique,  where  bony  union 
may  be  expected,  the  patient  is  kept  at  rest  in  bed  for  six  or 
eight  weeks,  by  means  of  Liston's  splint  (Fig.  154).  This  needs 
careful  adjustment,  but  is  satisfactory  in  its  results  when  properly 
applied.  It  should  reach  from  the  axilla  to  about  6  inches  below 
the  ankle,  and  is  fixed  to  the  leg  and  body  either  by  bandages,  or 
much  better  by  two  broad  sheets,  which  first  firmly  envelop  the 
splint,  and  are  then  passed  round  the  body,  and  finally  secured  by 
pins  to  the  portion  surrounding  the  splint.  Carefully  padded 
poroplastic  foot-pieces  are  placed  on  either  side  of  the  ankle  so  as 
to  diffuse  the  pressure,  and  a  handkerchief  passed  round  the  foot, 
and  through  the  prongs  at  the  end  of  the  splint,  fixes  it  in  the 
desired  position.  A  well-padded  perineal  band  is  next  applied, 
taking  its  purchase  from  the  tuber  ischii,  and  with  its  free  ends 
passed  through  the  two  holes  at  the  upper  extremity  of  the  splint  ; 
by  tightening  and  tying  these  two  together,  the  upper  end  of  the 
splint  is  steadied.     Extension  of  the  limb  is  obtained  by  an  elastic 


476  A  MANUAL  OF  SURGERY 

accumulator,  or  by  weight  and  pulley  acting  from  the  knee  in  the 
usual  way.  Finally,  the  sheets  or  bandages  are  adjusted,  and  the 
lower  end  prevented  from  moving  laterally  or  rotating  by  slipping 
it  into  a  slot  between  two  rectangular  plates  of  metal  screwed  to 
a  substantial  wooden  base,  which  rests  on  the  bed.  The  handker- 
chief and  perineal  band  will  need  occasional  tightening  to  maintain 
the  required  position,  and  the  latter  must  be  renewed  from  time 
to  time  for  purposes  of  cleanliness,  and  the  parts  well  powdered 
with  boric  acid.  At  the  end  of  six  weeks  or  so  the  pelvis  should  be 
encased  in  poroplastic  material  or  plaster  of  Paris,  and  the 
patient  allowed  to  get  about  on  crutches,  or  a  Thomas's  splint 
applied. 

No  attempt  should  be  made  to  disimpact  fractures  in  old  people  ; 
rest  and  quiet  are  maintained  by  applying  a  long  splint  without 
extension,  and  bony  union  usually  follows. 

In  other  cases  it  may  suffice  to  simply  lay  the  limb  on  a  bed 
between  sandbags,  and  to  make  extension  from  the  foot.  The  leg 
is  first  swathed  with  a  boracic  lint  bandage,  and  then  a  piece  of 
broad  adhesive  plaster  is  applied  on  either  side  of  the  limb,  reach- 
ing nearly  as  high  as  or  above  the  knee,  and  with  a  loose  stirrup 
4  or  5  inches  long  below  the  foot ;  the  plaster  is  secured  by  one  or 
two  strips  of  strapping  f  inch  wide  wound  obliquely  round  the 
limb  above  and  below,  and  by  a  calico  bandage.  In  the  stirrup  a 
cross-piece  of  wood,  rather  broader  than  the  ankle,  is  inserted,  and 
a  knotted  cord  carried  through  a  hole  in  it.  The  cord  is  passed 
over  a  pulley  fixed  to  the  end  of  the  bed,  and  to  its  end  is  attached 
a  weight,  varying  with  the  requirements  of  the  case ;  the  lower 
portion  of  the  bed  is  usually  raised  by  placing  the  legs  on  blocks, 
so  as  to  utilize  the  weight  of  the  body  as  a  counter-extending  force. 
As  the  continuous  application  of  a  heavy  weight  may  stretch  the 
ligaments  of  the  knee  joint,  it  is  usually  advisable  to  distribute  a 
part  of  the  traction  above  the  knee.  Hodgen's  splint,  as  described 
below,  may  also  be  used  in  these  cases. 

Treatment  of  Extracapsular  Fracture. — The  long  splint  with 
extension  will  sometimes  suffice  for  this  condition,  good  bony 
union  usually  occurring,  though  with  some  shortening.  In  other 
cases  it  may  be  advisable  to  make  extension  from  the  knee,  and 
to  keep  the  limb  slightly  flexed,  as  on  a  double  inclined  plane. 
Probably  treatment  is  best  carried  out  by  the  use  of  the  splint  intro- 
duced by  Dr.  Hodgen,  of  St.  Louis,  U.S.A.,  the  value  of  which 
was  first  demonstrated  in  this  country  in  the  theatre  of  Guy's 
Hospital  by  the  inventor  in  1879.  For  our  description  of  it  we 
are  indebted  to  Mr.  Golding  Bird.  It  is  made  of  stout  iron  wire, 
quite  rigid,  and  is  in  the  form  of  the  letter  U,  the  outer  limb 
reaching  from  the  anterior  superior  spine  to  3  inches  below  the 
instep,  and  the  inner  from  the  adductor  longus  tendon  to  the  same 
spot,  where  the  two  limbs  unite  in  a  crossbar  3  inches  in  width. 


INJURIES  OF  BONES— FRACTURES 


477 


The  sides  taper  with  the  limb,  and  should  be  f  inch  further  apart 
than  the  diameter  of  the  limb  at  any  point.  At  the  upper  end  the 
bars  are  united  by  an  arch  of  the  same  material,  which  is  placed 
on  the  slant,  and  should  correspond  to  Poupart's  ligament ;  two 
simi'ar  arches  are  placed  at  equal  points  lower  down.  The  splint 
is  bent  at  the  knee  to  about  an  angle  of  1300. 

Before  applying  the  splint,  an  ordinary  extension  stirrup  should 
be  attached  to  the  limb,  and  a  piece  of  wood  introduced  therein  wide 
enough  to  take  any  pressure  off  the  malleoli ;  to  the  wood  is  tied  a 
piece  of  stout  cord.  Strips  of  house  flannel,  about  7  inches  wide, 
are  then  cut  and  arranged  beneath  the  limb  at  right  angles  to  its 
direction,  each  one  overlapping  the  next ;  the  length  of  the  strips 
should  be  rather  more  than  the  circumference  of  the  limb  at  the 


Fig.  155. — Hodgen'3  Splint  applied. 

spot  to  which  each  is  to  be  applied.  The  splint  is  then  adjusted, 
the  top  of  the  outer  bar  resting  against  the  anterior  superior 
spine,  and  the  inner  bar  against  the  adductor  tendon.  The 
strips  of  flannel  are  then  raised  in  succession,  and,  being 
lapped  over  the  bar,  are  pinned  or  stitched  there,  so  that  when 
completed  the  limb  lies  in  a  flannel  trough,  from  which  only 
the  upper  surface  projects,  and  there  should  be  an  interval  of 
fully  an  inch  between  Poupart's  ligament  and  the  upper  crossbar. 
The  short  cord  already  mentioned  as  being  attached  to  the  stirrup 
is  then  securely  tied  to  the  lower  end  of  the  splint.  Cords  are 
now  fixed  to  the  hooks,  two  of  which  are  soldered  to  each  side  of 
the  splint,  the  lengths  of  the  cords  being  such  that,  if  they  were 
raised  and  made  taut  with  the  finger,  the  finger  would  be  about 


478  A  MANUAL  OF  SURGERY 

8  or  10  inches  above  the  splint.  The  two  cords  are  then  brought 
together  over  the  limb,  and  to  them  is  tied  another  stout  cord, 
which  passes  over  a  pulley  attached  to  a  vertical  post  at  the 
end  of  the  bed,  and  is  weighted  to  a  sufficient  extent.  The  angle 
required  to  make  satisfactory  extension  is  determined  partly  by  the 
position  of  the  limb,  partly  by  the  sensations  of  the  patient.  The 
limb  when  the  weight  is  applied  should  lie  free  of  the  bed,  even  to 
its  extreme  upper  limit.  No  bandages  are  required  ;  the  limb  lies 
in  the  obliquely-set  flannel  trough,  which  is  maintained  in  position 
by  its  friction  against  the  limb  ;  the  splint  itself  is  pulled  upon  by 
the  extending  force,  and  this  is  transmitted  to  the  limb  through 
the  stirrup  cord  attached  to  the  lower  end  of  the  splint.  If 
correctly  applied,  this  stirrup  cord  is  taut  '  like  a  harp  string '; 
any  slipping  of  the  extension  or  of  the  apparatus  is  indicated  by 
laxity  of  this  cord,  and  involves  readjustment.  Some  authorities, 
however,  recommend  that  the  thigh  should  be  enclosed  in  Gooch 
splinting,  a  narrow  piece  in  front  between  the  bars,  and  a  broader 
piece  behind  encircling  the  limb.  These  are  well  padded  and 
bandaged  on,  the  bandages  extending  over  the  whole  length  of  the 
apparatus ;  finally,  starch  is  rubbed  in  so  as  to  fix  it  more  firmly. 
When  impaction  has  occurred  in  young  and  active  individuals, 
it  is  quite  justifiable  to  give  an  anaesthetic,  and  forcibly  break  it 
down,  so  as  to  prevent  subsequent  shortening. 

2.  Fracture  of  the  Great  Trochanter  is  very  rare,  and  always 
due  to  direct  violence  ;  in  the  young  it  occurs  as  an  epiphyseal 
lesion.  The  trochanter,  or  a  portion  of  it,  is  entirely  separated 
from  the  rest  of  the  bone  without  any  loss  of  the  continuity  of  the 
shaft.  Independent  movement  of  the  fragment  with  crepitus  is 
usually  obtainable  ;  and  if  the  displacement  is  at  all  marked,  an 
operation  to  fix  it  by  means  of  a  plated  screw  or  ivory  peg  should 
be  undertaken. 

3.  Fracture  through  the  Great  Trochanter  (the  per-trochantcric 
fracture  of  Kocher)  closely  resembles  the  extracapsular  fracture, 
the  lesion  running  from  the  inner  and  under  part  of  the  neck 
obliquely  upwards  and  forwards  through  the  base  of  the  trochanter. 
The  lower  fragment,  including  the  lesser  trochanter,  is  drawn 
upwards  and  backwards  towards  the  sciatic  notch,  and  forms  a 
projecting  mass  behind,  somewhat  simulating  a  dislocation  ;  the 
tip  of  the  trochanter  can,  however,  be  felt  separately,  not  moving 
with  the  shaft.  Such  cases  may  be  treated  by  extension  with 
the  long  splint,  or  perhaps  better  by  Hodgen's  apparatus. 

4.  Separation  of  the  Upper  Epiphysis  of  the  Femur. — The  upper 
cartilaginous  end  of  the  femur  in  infants  includes  not  only  the 
head,  but  also  both  trochanters,  and  there  is  no  case  on  record  of 
complete  detachment  of  this  portion.  Ossific  centres  early  appear 
for  each  of  these  three  projections,  and  by  the  rapid  growth 
upwards  of  the  shaft,  they  are  separated  from  each  other  by  the 


INJURIES  OF  BONES— FRACTURES 


479 


fourth  year,  the  neck  thus  being  really  constituted  as  an  outgrowth 
of  the  shaft.  The  epiphysis  of  the  head  has  been  completely 
detached  in  a  considerable  number  of  cases,  but  the  accident  is  not 
so  common  as  in  the  humerus,  owing  to  the  protection  given  by 
the  depth  of  the  acetabulum.  The  phenomena  closely  simulate 
those  of  an  intracapsular  fracture,  but  are  less  obvious.     Impair- 


Fig.  157.- — Fracture  of  Lower  Third 
of  Femur,  showing  Displacement 
of  Lower  Fragment  Backwards 
(From  Gray's  'Anatomy.') 


Fig.  156. — Fracture  of  Utper  Third 
of  Femur,  showing  Displacement 
of  Bone.     (From  Gray's  'Anatomy.') 

ment  of  growth  may  follow,  and  possibly  the  shape  of  the  head 
and  neck  may  be  so  altered  subsequently  as  to  simulate  the  con- 
dition known  as  coxa  vara.  Treatment  of  the  lesion  is  by  exten- 
sion, and  possibly  the  use  of  the  long  splint. 

Fractures  of  the  Shaft  of  the  Femur  are  extremely  common 
accidents,  in  spite  of  the  apparent  strength  of  the  bone.  Any  part 
may  be  involved,  particularly  the  centre,  whilst  they  occur  at  the 


48o  A   MANUAL  OF  SURGERY 


lower  end  more  frequently  than  at  the  upper.  In  the  latter  situa- 
tion they  are  usually  due  to  indirect  violence,  whilst  at  the  lower 
end  they  generally  result  from  direct  injury ;  either  form  of  violence 
may  lead  to  a  fracture  about  the  middle  of  the  bone. 

In  almost  every  case  displacement  occurs,  the  direction  and 
amount  of  which  depends  not  only  on  the  line  of  fracture,  but 
also  on  the  situation.  In  the  upper  third  (Fig.  156),  the  small 
upper  fragment  is  usually  tilted  forwards  by  the  ilio- psoas,  and 
abducted  and  everted  by  the  gluteus  minimus  and  external 
rotators  ;  whilst  the  lower  fragment  is  drawn  upwards  and  to  the 
inner  side  of  the  upper  by  the  hamstrings  and  adductor  muscles, 
marked  eversion  also  resulting  partly  from  the  weight  of  the  foot, 
and  partly  from  the  action  of  the  adductors  ;  but  such  a  com- 
plicated displacement  is  not  always  present. 

In  the  middle  third,  if  due  to  direct  violence,  the  line  of  fracture 
slants  from  above  downwards  and  backwards,  causing  a  simple 
over-riding  of  the  fragments,  or  an  angular  deformity.  The  lower 
fragment  is  drawn  upwards  and  inwards,  either  in  front  of  or 
behind  the  upper  fragment,  and  is  usually  everted.  The  upper 
fragment  is  sometimes  tilted  forwards.  If  due  to  direct  violence, 
the  fracture  is  more  often  transverse,  and  any  form  of  displace- 
ment may  then  occur. 

In  the  lower  third  the  fractures  often  arise  from  direct  force,  and 
are  transverse  ;  the  lower  fragment  may  then  be  tilted  backwards 
by  the  gastrocnemii  muscles,  and  compress  or  rupture  the  popliteal 
vessels,  perhaps  causing  gangrene  (Fig.  157).  Oblique  fractures 
from  indirect  violence,  sloping  from  above  downwards  and  for- 
wards, are  also  met  with ;  the  upper  fragment  is  driven  into  the 
substance  of  the  quadriceps  muscle  and  may  become  fixed  in  it, 
projecting  immediately  beneath  the  skin,  whilst  the  lower  frag- 
ment is  drawn  up  behind.  If  such  a  case  is  left  unreduced, 
ununited  fracture  is  likely  to  ensue ;  the  knee-joint  is  generally 
penetrated  by  the  lower  end  of  the  upper  fragment. 

Treatment. — In  the  upper  third,  where  the  upper  fragment  is 
tilted  forwards,  constituting  a  projection  under  the  skin,  and  when 
it  is  too  short  to  be  controlled  by  any  splint,  reduction  of  the 
deformity  is  accomplished  by  flexing  the  thigh,  and  making 
extension  from  the  knee,  the  lower  fragment  being  thus  brought 
into  the  same  axis  as  the  upper.  Manipulation  will  usually 
correct  any  lateral  displacement.  The  limb  must  be  confined 
in  this  position  by  some  form  of  inclined  plane,  such  as  a  Mac- 
intyre's  splint,  with  a  long  thigh-piece,  and  with  small  straight 
wooden  splints  or  a  piece  of  Gooch's  splinting  fixed,  if  necessary, 
to  the  front  and  outer  sides  of  the  limb,  over  the  seat  of  fracture. 
The  splint  is  slung  at  the  knee,  the  foot-piece  being  fixed  to  blocks 
of  wood,  a  little  lower  than  the  level  of  the  knee.  If  these  pre- 
cautions are  not  taken,  an  ununited  fracture,  with  the  upper  frag- 
ment in  front  of  the  lower,  is  likely  to  occur.  Hodgen's  apparatus 
also  answers  admirably  in  these  cases. 


INJURIES  OF  BONES— FRACTURES  481 

In  the  middle  third  of  the  thigh,  where  the  upper  fragment  can 
be  controlled  by  splints,  shortening  is  prevented  by  simple,  exten- 
sion (p.  476),  the  thigh  being  surrounded  by  pieces  of  Gooch's 
splinting,  which  grasp  the  muscles  and  keep  the  parts  at  rest. 
The  limb  is  then  placed  between  sandbags,  or  secured  on  a 
Liston's  splint.  Where  the  fracture  is  oblique,  with  a  good  deal 
of  tendency  to  overlap,  Hodgen's  apparatus  should  be  utilized. 

In  the  lower  third,  if  there  is  any  tendency  to  displacement  of 
the  lower  fragment  backwards,  a  Macintyre's  splint,  with  a  long 
thigh-piece  and  the  knee  well  flexed,  may  sometimes  be  employed, 
together  with  a  short  anterior  thigh-piece  of  Gooch's  splinting; 
but  if  the  upper  fragment  projects  anteriorly  beneath  the  skin 
through  the  quadriceps,  operation  alone  holds  out  any  prospect 
of  bringing  the  parts  into  apposition,  the  muscular  fibres  being 
divided  sufficiently  to  allow  the  projecting  end  of  the  bone  to  be 
replaced,  and  if  necessary  wired  or  pegged.  In  other  cases  the 
ordinary  long  splint  or  Hodgen's  will  be  required. 

In  children,  Bryant's  plan  of  treatment  is  excellent ;  it  consists 
in  slinging  the  limb  from  a  crossbar  at  right  angles  to  the  body, 
with  or  without  a  back-splint  reaching  from  the  heel  to  the  nates 
and  short  lateral  splints,  thus  obtaining  extension  by  utilizing  the 
weight  of  the  body,  whilst  the  bandages,  etc.,  are  kept  from  being 
soiled.  If  a  long  splint  is  used  for  children,  a  double  one  (e.g., 
Hamilton's  splint)  with  a  crossbar  below  is  the  best.  Plaster  of 
Paris  or  starch  bandages  may  be  early  applied  in  adults,  but  only 
in  the  later  stages  in  young  children,  as  they  are  difficult  to  keep 
clean. 

Fractures  of  the  Lower  End  of  the  Femur. 

1.  Transverse  Supracondyloid  Fracture  is  practically  identical 
with  that  involving  the  lower  third  of  the  femur  ;  the  lower  frag- 
ment is  rotated  backwards  by  the  action  of  the  gastrocnemii,  thus 
endangering  the  integrity  of  the  popliteal  vessels,  and  predisposing 
to  non-union,  if  the  deformity  is  overlooked. 

2.  T-  or  Y-shaped  Fracture  of  the  Condyles. — In  this  a  trans- 
verse fracture  is  complicated  by  a  fissure,  which  runs  into  the 
joint,  separating  the  two  condyles.  The  symptoms  are  much 
the  same  as  the  above,  but  the  joint  is  distended  with  blood,  the 
bone  may  feel  broader  than  usual,  and  crepitus  may  be  detected. 
The  Treatment  is  the  same  as  for  transverse  fracture. 

3.  Separation  of  either  Condyle  always  results  from  direct 
violence,  the  line  of  fracture  being  oblique.  There  is  no  shorten- 
ing, but  the  leg  may  be  deflected  towards  the  side  injured,  and 
the  joint  is  distended  with  blood.  It  may  move  separately  from 
the  shaft,  and  give  rise  to  crepitus.  Treatment. — Reposition  is 
easily  effected  when  the  limb  is  slightly  flexed,  and  it  is  best  put 
up  in  this  position. 

Occasionally  a  small  portion  of  the  condyle  may  be  detached 

3i 


482  A   MANUAL  OF  SURGERY 

and  lie  loose  in  the  knee-joint ;  when  the  immediate  symptoms 
due  to- the  injury  have  subsided,  the  signs  of  a  foreign  body  in  the 
joint  may  become  evident. 

4.  The  Lower  Epiphysis  of  the  Femur  is  separated  from  the 
shaft  in  young  people;  it  is  net  a  very  rare  accident,  and  closely 
simulates  in  its  signs  those  of  a  transverse  fracture,  even  occasion- 
ing gangrene  in  some  cases.  The  epiphysis  is  generally  displaced 
forwards  by  the  traction  of  the  quadriceps  on  the  tibia,  and  the 
vessels  are  then  compressed  by  the  lower  end  of  the  diaphysis. 
Suppuration  occurs  in  a  fair  proportion  of  the  cases.  This  con- 
dition has  been  mistaken  for  disease  of  the  knee-joint.  Treat- 
ment.— Reduction  is  effected  by  an  assistant  making  traction  on 
the  tibia  in  the  line  of  the  limb  so  as  to  stretch  the  quadriceps ; 
then  the  thigh  is  gradually  flexed  by  the  surgeon,  standing  above 
and  with  both  hands  clasped  beneath  it.  The  epiphysis  is  by  this 
means  restored  to  its  normal  position,  and  the  limb  is  kept  flexed 
by  a  bandage  at  about  an  angle  of  6o°,  and  laid  on  its  outer  side 
with  an  icebag  applied.  Passive  movement  is  carefully  com- 
menced in  a  fortnight. 

5.  Longitudinal  and  Spiral  Fissures  are  met  with  in  the  femur, 
running   down   to   the  knee-joint,   but   causing    no  characteristic 
symptoms  beyond  pain  and  haemarthrosis.     Early  passive  move 
ment  is  necessary  to  prevent  impairment  of  function. 

Fractures  ef  the  Patella. 

The  patella  is  broken  in  two  distinct  ways,  viz.,  by  muscular 
force  and  by  direct  violence,  and  the  conditions  produced  are  so 
different  that  a  separate  description  is  necessary. 

1.  Fractures  hy  direct  violence  may  traverse  the  bone  in  any 
direction,  but  are  most  often  vertical  or  star-shaped,  and  possibly 
comminuted.  They  are  frequently  incomplete,  i.e.,  mere  fissures 
of  the  front  of  the  bone,  and  as  a  rule  the  fibrous  aponeurosis  or 
capsule  covering  it  is  uninjured,  thereby  preventing  any  displace- 
ment of  fragments.  There  is  a  good  deal  of  subcutaneous  bruising, 
and  perhaps  some  effusion  into  the  joint,  whilst  on  careful  palpa- 
tion the  fissure  may  be  detected.  Crepitus  can  be  obtained  if 
the  fracture  is  complete.  Treatment  consists  in  keeping  the 
limb  at  rest  on  a  back-splint,  and  perhaps  applying  evaporating 
lotions.  Passive  movements  must  be  commenced  early  where 
there  has  been  much  effusion  into  the  joint. 

2.  Fractures  due  to  muscular  force  constitute  a  very  different 
class  of  injury,  since  they  are  always  transverse,  usually  complete, 
and  also  involve  the  fibrous  aponeurosis,  so  that  considerable  dis- 
placement occurs. 

Mechanism.  —  When  the  knee  is  semi-flexed,  the  patella  is 
poised  upon  the  front  of  the  condyles  of  the  femur,  resting  upon 
the  middle  of  its  articular  surface  ;  in  this  position  any  sudden 


INJURIES  OF  BONES— FRACTURES 


483 


and  violent  contraction  of  the  quadriceps,  as  in  attempting  to 
recover  one's  equilibrium  after  having  slipped,  takes  the  hone  at 
a  disadvantage,  and  may  succeed  in  snapping  it.  Possibly  in 
some  people  there  is  a  predisposing  weakness,  as  cases  are 
not  rare  in  which  the  other  bone  yields  subsequently,  although 
perfect  functional  repair  has  been  obtained  in  that  first  broken. 
The  fragments  are  often  almost  equal  in  size  (Fig.  158),  but 
may  vary  widely  ;  and  either  of  them  may  be  again  divided 
vertically,  or  comminuted. 

The  Signs  of  this  fracture  are  very  evident,  consisting  of  loss  of 
power  in  the  limb,  pain,  distension  of  the  joint  with  blood,  and 
separation  of  the  fragments,  which  can  be  readily  felt  and  some- 
times brought  into  apposition  with  crepitus  (Figs.  158  and  159). 


Fig.  158. — Fracture  of  Patella, 
and  Separation  of  Fragments. 
(From  Gray's  '  Anatomy.') 


Fig  159  — Appearancf  of 
Knee  after  Fracture 
of  Patella. 


This  displacement,  at  first  due  to  muscular  action,  is  maintained 
by  the  effusion  of  blood,  as  also  later  by  synovial  exudation. 
Union  by  bone  is  rarely  obtained  under  ordinary  circumstances, 
a  fact  explained  partly  by  the  separation  of  the  fragments,  and 
partly  by  the  carrying  in  of  loose  tags  of  the  fibrous  aponeurosis 
or  capsule,  which  yields  at  a  different  level  to  the  bone.  Fibrous 
union  is  the  usual  result,  and  when  this  is  short  and  strong,  it 
may  be  quite  satisfactory  ;  but  more  commonly  the  bond  of  union 
yields  when  the  limb  is  used,  so  that  the  two  fragments  are  once 
again  separated,  merely  a  bridge  of  fibrous  tissue  intervening,  the 
joint  being  often  very  weak  in  consequence. 

The  Treatment  of  these   cases    has    been   a  matter  of   much 
discussion,    and    many    plans    have    been    adopted,    which    may 

31 — 2 


484  A  MANUAL  OF  SURGERY 

be  grouped  under  three  headings,  viz.,   treatment  by  retentive 
apparatus,  by  subcutaneous  operation,  or  by  the  open  method. 

1.  Simple  retentive  apparatus  may  be  employed  in  cases  where 
the  fragments  are  not  widely  separated,  and  can  be  readily 
brought  into  contact  and  maintained  in  apposition. 

Some  surgeons  depend  mainly  upon  plaster  of  Paris  to  effect 
this.  If  there  is  but  little  effusion,  the  limb  is  extended,  swathed 
in  cotton-wool  and  a  flannel  bandage,  and  over  this  the  plaster 
casing  is  applied.  As  the  apparatus  becomes  loose  from  muscular 
atrophy,  it  will  need  readjustment.  The  patient  is  kept  in  bed 
for  three  or  four  weeks,  but  the  plaster  is  retained  for  as  many 
months,  and  after  that  a  knee  support,  such  as  the  Middlesex 
splint  (vide  infra),  is  kept  on  till  twelve  months  have  elapsed. 
Where  there  is  much  effusion  after  the  accident,  the  limb  is 
placed  on  a  back-splint  and  kept  cool  by  ice  or  evaporating  lotion, 
until  the  fluid  has  been  absorbed ;  or  the  joint  may  be  aspirated 
in  order  to  hasten  matters.  The  plaster  is  then  applied,  and  the 
same  routine  followed.  The  chief  objection  to  this  plan  is  the 
enclosure  of  the  limb  in  the  plaster  case,  so  that  the  muscles  and 
joint  cannot  easily  be  got  at  for  purposes  of  massage. 

In  the  so-called  Middlesex  plan  of  treatment  a  large  piece  of 
moleskin  plaster  is  placed  over  the  front  and  sides  of  the  extensor 
surface  of  the  thigh,  reaching  halfway  up  to  the  groin,  and  terminat- 
ing below  in  two  lateral  elongated  ends  or  tags,  to  which  elastic 
traction  is  applied.  The  limb  is  put  on  a  back-splint,  with  a  foot- 
piece,  beneath  which  the  elastic  accumulator  is  firmly  tied. 
Removal  of  the  effusion  in  the  joint  may  be  hastened  by  the 
use  of  the  aspirator.  At  the  end  of  about  six  weeks  the  patient  is 
allowed  to  get  about  in  a  plaster  of  Paris  casing,  and  then,  about 
three  months  after  the  accident,  a  special  knee-splint  is  substituted, 
which  allows  of  only  a  small  amount  of  mobility  at  first,  but,  by 
filing  away  a  stop,  this  can  be  gradually  increased,  until  a  full 
range  of  movement  is  permitted.  In  this  method  of  treatment  it 
is  probable  that  only  fibrous  union  is  obtained. 

2.  To  ensure  more  accurate  apposition  and  a  firmer  union,  and 
yet  to  avoid  the  risks  necessarily  associated  with  laying  the  joint 
open,  various  subcutaneous  operations  have  been  adopted,  (a)  Barker 
recommends  antero -posterior  suture  of  the  bone  (Fig.  160).  An 
opening  is  made  with  a  tenotomy  knife  into  the  joint  just  below 
the  lower  segment,  through  which  any  effused  blood  or  synovia  can 
be  squeezed,  and  along  which  a  curved  hernia  needle  is  passed, 
traversing  the  articulation  from  below  upwards,  and  emerging 
through  the  skin  above  the  upper  fragment.  A  piece  of  sterilized 
silver  wire  is  then  carried  back  under  the  bone.  The  needle  is 
again  inserted  at  the  same  spot  below,  and  carried  in  front  of  the 
bone  under  the  skin,  emerging  at  the  same  point  above.  The 
upper  end  of  the  wire  is  threaded  through  it,  and  by  this  means 
brought  out  at  the  lower  opening.     The  bone  is  thus  encircled, 


INJURIES  OF  BONES— FRACTURES 


485 


and  by  tightening  and  twisting  the  wire  the  fragments  are  brought 
into  apposition.  The  ends  are  cut  off  and  pushed  back  under  the 
skin.  The  punctures  are  treated  antiseptically,  and  the  limb 
placed  on  a  back-splint  for  a  week  or  so,  when  passive  movement 
is  commenced,  the  patient  being  allowed  to  walk  about  at  the  end 
of  the  second  week,  and  discarding  all  apparatus  at  the  end  of 
five  weeks,  (b)  Circumferential  suture  (introduced  originally  by 
Butcher,  of  Liverpool)  is  also  practised  (Fig.  t6i),  the  wire  in  this 
case  passing  round  the  bone  from  side  to  side.  A  somewhat 
longer  period  of  after-treatment  is  needed  in  these  cases,  (c)  Mayo 
Robson,  of  Leeds,  inserts  knitting  needles  through  the  muscle 
and  tendon  above  and  below  the  fragments,  and  draws  them 
together  by  elastic  bands  passed  over  the  ends  (Fig.  162). 

Necessarily,  a  certain  element  of  risk  is  admitted  in  any  of 
these  subcutaneous  operations,  and  the  surgeon  has  to  ask  himself 
whether  he  is  doing  the  best  for  his  patient  by  utilizing  such 
proceedings,  granting  that  it  is  advisable  to  interfere  at  all. 
Personally,  we  are  of  opinion  that,  if  it  be  justifiable  to  incur  any 
risk,  it  is  best  to  proceed  by  the  open  method,  since  in  none  of 


Fig.  160. — Barker's 
Method  of  Sub- 
cutaneous Suture 
after  Fracture  of 
Patella. 


Fig.  161. — Circumferen- 
tial Suture  for  Frac- 
ture of  Patella. 


Fig.  162.  —  Mayo  Rob- 
son's  Method  of 
dealing  with  frac- 
TURED Patella. 


the  others  can  the  fragments  be  brought  into  accurate  apposition, 
owing  to  the  impossibility  of  removing  the  interposed  portion  of 
fibrous  capsule,  which  is  always  curled  in  over  one  of  the  broken 
surfaces,  whilst  the  joint  cavity  cannot  be  cleared  of  the  blood- 
clot  which  may  have  collected  within  it.  Impressed  by  the 
confidence  derived  from  a  thorough  and  efficient  application  of 
aseptic  principles,  we  cannot  but  conclude  that,  if  it  is  desirable 
to  do  more  in  a  case  of  fractured  patella  than  apply  mere  retentive 
apparatus,  the  patient's  welfare  is  best  consulted  by  adopting — 

3.  The  open  plan  of  treatment,  advocated  and  perfected  by  Lord 
Lister.  It  consists  in  freely  exposing  the  interior  of  the  articula- 
tion, clearing  the  joint  of  all  blood-clot,  removing  all  tags  of  fascia 
or  aponeurosis,  and  wiring  the  fragments  securely  together. 


486 


A   MANUAL  OF  SURGICKY 


No  surgeon  should  attempt  this  operation  unless  well  assisted 
and  thoroughly  an  fait  with  the  details  of  antiseptic  work.  At 
King's  College  Hospital  this  practice  is  now  almost  exclusively 
followed,  and  the  results,  at  any  rate  in  the  more  recent  cases,  are 
most  satisfactory,  no  instance  of  serious  mischief  from  the  opera- 
tion having  arisen  for  the  last  fifteen  years  or  more.  A  longi- 
tudinal incision  is  sometimes  adopted,  although  a  horseshoe- 
shaped  flap  is  more  frequently  dissected  up  or  down,  exposing 
the  bone.  All  blood-clot  is  removed,  and  the  fractured  surfaces 
cleared  of  all  clot  and  fibrous  shreds,  which  are  very  often 
adherent.  Tracks  for  the  wire  sutures  are  now  made  by  a 
bradawl,  extending  from  the  upper  or  lower  end  through  the 
centre  of  the  bone,  so  as  to  emerge  on  the  fractured  surface  just 
in  front  of  the  articular  cartilage  (Fig.  163);  should  the  awl 
emerge  at  different  levels  on  the  faces  of  the  fragments,  cartilage 
or  bone  must  be  chipped  away  to  make  a  channel  in  which  the 
wire  may  lie,  so  that  the  two  fragments  are  exactly  level,  with 
no  inequality  of  the  articular  cartilage.  A  sterilized  silver  wire 
of  suitable  thickness  is  then  passed  ;  the  bones  are  brought  into 
apposition,  and  the  wire  twisted  into  a  knot 
or  loop,  which  is  hammered  or  pressed  down 
into  the  periosteum,  so  as  to  keep  it  from 
projecting  under  the  skin  and  causing  irri- 
tation. A  second  wire  is  sometimes  needed 
in  order  to  prevent  rotation  of  the  fragments. 
The  wound  is  closed,  and  the  limb  kept  on 
a  Gooch's  splint  for  eight  days,  when  passive 
movement  is  commenced,  and  by  the  end  of 
a  fortnight  the  patient  is  allowed  to  walk  in 
the  simpler  cases ;  but  in  complicated  frac- 
tures and  in  elderly  people  it  is  advisable  to 
keep  the  limb  immobilized  for  a  longer  period. 
It  is  perhaps  advisable  not  to  undertake  this 
operation  immediately  after  the  accident.  The 
limb  should  be  kept  at  rest  on  a  back-splint,  and  an  icebag  applied 
for  a  week  or  ten  days,  so  as  to  allow  the  joint  to  recover  from  the 
effects  of  the  injury  it  has  sustained  ;  there  is  then  much  less  risk 
of  septic  complications. 

In  old  cases,  where  the  fibrous  union  has  stretched  and  the  utility 
of  the  limb  is  seriously  impaired,  the  open  operation  holds  out  the 
only  hope  of  helping  the  patient,  although  it  is  always  a  matter  of 
considerable  difficulty.  The  fibrous  tissue  must  be  dissected 
away,  and  the  ends  of  the  bones  freshened,  if  need  be,  with  the 
saw.  To  obtain  apposition,  the  upper  fragment  must  be  freely 
detached  from  the  femoral  condyles,  to  which  it  is  very  often 
adherent,  and  the  rectus  muscle,  which  is  secondarily  contracted, 
may  need  to  be  partially  divided.     The  limb  should  be  well  raised 


Fig.  163.  —  Position 
of  Silver  Wire  in 
Open  Operation 
for  Fractured 
Patella. 


INJURIES  OF  BONES— FRACTURES  4S7 

to  relax  the  quadriceps  and  thus  diminish  tension  on  the  bond  of 
union,  and  lowered  inch  by  inch  on  succeeding  days.  The  muscle 
is  thus  stretched  to  accommodate  itself  to  the  altered  conditions. 

If  the  fragments  cannot  be  absolutely  brought  together,  the 
same  treatment  may  be  adopted,  and  the  patient  allowed  to  get 
about  with  silver  wires  between  the  fragments  ;  the  quadriceps  is 
stretched  by  this  means,  and  a  subsequent  operation  may  prove 
successful  in  gaining  bony  union. 

Fractures  of  the  Leg. 

In  the  leg  fractures  may  be  due  to  direct  or  indirect  violence, 
and  may  involve  either  the  tibia  or  fibula  alone,  or  both  bones. 

Fractures  of  the  Tibia  alone. — Several  varieties  are  described. 
(a)  The  upper  end  is  usually  broken  as  a  result  of  direct  violence, 
the  line  of  fracture  being  transverse  ;  it  is  by  no  means  a  common 
accident.  The  characteristic  features  are  not  always  very  evident 
at  first,  since  considerable  swelling  and  ecchymosis  are  produced. 
Occasionally  as  a  result  of  falls  on  the  heel  a  T-shaped  fracture 
occurs,  the  tuberosities  being  broken  off  and  the  upper  end  of  the 
shaft  impacted  into  one  or  both  of  them.  A  few  cases  of  vertical 
separation  of  one  of  the  tuberosities  alone  are  also  on  record. 
Treatment  consists  in  placing  the  limb  upon  a  back-splint,  e.g., 
Macintyre's,  with  the  knee  bent,  and,  as  a  rule,  satisfactory  union 
ensues,  though  possibly  with  some  distortion,  (b)  Fracture  of  the 
shaft  of  the  tibia,  apart  from  the  fibula,  is  usually  caused  by  direct 
violence.  It  is  transverse  in  the  upper  part  of  the  bone,  and 
oblique  below  (Plate  X.).  The  fracture  is  diagnosed  by  feeling 
an  inequality  on  running  the  fingers  along  the  shin,  together  with 
pain  at  this  spot  on  firmly  grasping  the  bones  above  and  below. 
There  is  often  but  little  displacement,  since  the  fibula  acts  as  a 
splint,  but  the  lower  end  of  the  upper  fragment,  which  is  usually 
pointed,  is  tilted  forwards  by  the  action  of  the  quadriceps  and 
may  pierce  the  skin.  The  treatment  consists  in  the  application  of 
back  or  side  splints  (Cline's)  for  a  few  days  until  the  swelling  has 
gone  down,  and  then  the  limb  may  be  put  up  in  plaster.  If  the 
bone  has  been  comminuted,  treatment  will  be  more  protracted, 
(c)  The  internal  malleolus  is  occasionally  separated  as  the  result  of 
direct  injury,  apart  from  any  other  osseous  lesions,  constituting 
what  is  known  as  '  Wagstaffe's  fracture.'  There  is  comparatively 
little  displacement,  but  the  malleolus  is  loose,  and  crepitus  can 
usually  be  obtained  on  moving  it  backwards  and  forwards.  Union 
by  fibrous  or  osseous  tissue  ensues,  but  usually  in  a  more  or  less 
abnormal  position,  in  consequence  of  which  the  integrity  of  the 
ankle-joint  is  disturbed,  and  weakness  or  lameness  may  follow.' 
Treatment  consists  in  the  application  of  lateral  splints.  If  there 
is  any  difficulty  in  keeping  the  parts  in  apposition,  an  incision 
should  be  made,  and  the  malleolus  wired  or  pegged  to  the  tibia. 


488  A   MANUAL  OF  SURGERY 


Fractures  of  the  Fibula  alone  are  by  no  means  uncommon, 
usually  occurring  as  a  result  of  direct  violence.  There  is  no 
displacement  or  deformity,  but  the  patient  complains  of  pain 
localized  to  some  particular  spot,  and  this  can  usually  be  elicited 
by  grasping  the  bones  above  and  below,  and  compressing  them 
laterally  ('springing'  the  fibula).  Sometimes  the  diagnosis  is 
extremely  uncertain,  and  then  the  X  rays  prove  useful.  Treat- 
ment consists  in  immobilizing  the  limb  in  a  plaster  case. 

Fracture  of  both  Tibia  and  Fibula  is  a  very  common  accident, 
due  to  both  direct  and  indirect  violence ;  if  to  direct  violence  any 
part  may  be  injured,  both  bones  yielding  at  the  same  level;  but 
if  in  consequence  of  an  indirect  injury,  the  tibia  usually  gives  way 
at  its  weakest  part,  viz.,  at  the  junction  of  its  middle  and  lower 
thirds,  and  the  fibula  at  a  slightly  higher  level.  The  fractures  are 
often  oblique,  running  in  any  direction  according  to  the  character 
of  the  violence,  although  the  obliquity  is  most  frequently  directed 
downwards,  forwards,  and  inwards.  The  lower  fragment  is  gener- 
ally drawn  upwards  on  account  of  the  contraction  of  the  powerful 
calf  muscles,  and  often  rotated  outwards  from  the  weight  of  the 
foot ;  hence  there  is  well-marked  shortening,  which  can  usually 
be  overcome  by  traction.  The  ordinary  characteristics  of  a 
fracture  are  very  evident,  and  but  little  difficulty  can  ever  be 
experienced  in  making  a  diagnosis.  The  fracture  is  likely  to 
become  compound  when  due  to  indirect  violence,  owing  to  the 
sharp  end  of  the  oblique  fragment  of  the  tibia,  usually  the  upper, 
piercing  the  skin.  Skiagraphy  is  exceedingly  useful  in  enabling 
one  to  decide  as  to  the  character  of  the  lesion,  and  the  skiagrams 
should  be  taken  both  from  the  front  and  from  the  side,  as  the 
appearances  are  often  very  different  (compare  Plates  XXII.  and 
XXIII.). 

The  fracture  of  the  tibia  has  been  proved  by  skiagraphy  to  be 
frequently  of  the  bec-de-fiute  type,  and  is  then  probably  always  due 
as  much  to  forcible  torsion  of  the  limb  as  to  vertical  strain.  The 
rotation  is  a  very  important  element  in  these  cases,  and  the  lower 
end  of  the  upper  fragment  rides  prominently  forwards  (the  '  riding 
fragment  ').  The  shortening  is  sometimes  less  marked  than  in 
simple  oblique  fractures,  but  th?re  is  much  greater  difficulty  in 
getting  satisfactory  approximation  of  the  fragments,  even  after 
freeing  the  ends  of  the  tibia  by  operation.  This  difficulty  is 
probably  in  most  cases  due  to  the  broken  ends  of  the  fibula  be- 
coming engaged  in  the  fibro-muscular  tissues  around  it,  and  will 
necessitate  an  incision  over  this  bone  in  order  to  free  them. 

Treatment. — In  the  simpler  cases  reduction  is  accomplished  by 
flexing  and  fixing  the  knee,  so  as  to  relax  the  muscles  of  the  calf, 
and  then  making  traction  on  the  foot  and  manipulating  the  parts 
into  position.  The  tendo  Achillis  may,  if  necessary,  be  divided. 
It  will  usually  suffice  to  put  up  the  limb  in  a  pair  of  side-splints, 
such  as  Cline's,  the  longer  one  with  the  foot-piece  being  intended 


PLATE  XXII. 


Fracture  of  both  Bones  of  the  Leg,  seen  from  in  front. 

To  ;acc  p.  488.] 


PLATE  XXIII. 


The  same  Fracture  as  in  Plate  XXII.,  seen  from  the  inner  side. 
From  a  study  of  the  two  skiagrams  it  will  be  noticed  that  both  lower  fragments 
have  been  displaced  outwards,  with  but  little  alteration  in  their  antero- 
posterior axes. 

Tofolltnv  Plate  XXII.  ] 


INJURIES  OF  BONES— FRACTURES  489 

for  the  outer  side.  In  other  cases  it  may  be  better  to  apply  a  broad 
posterior  splint  with  a  rectangular  foot-piece,  e.g.,  Macintyre's, 
and  two  lateral  splints  ;  or  the  old-fashioned  half-box  splint  may 
be  employed.  Some  surgeons  recommend  an  anterior  wire  splint, 
extending  from  above  the  knee  to  the  foot,  the  leg  being  subse- 
quently slung  in  the  flexed  position.  This  maybe  advantageously 
modified  by  combining  it  with  an  additional  casing  of  plaster  of 
Paris.  Whatever  treatment  is  adopted,  it  is  necessary  to  see  that 
the  length  of  the  limb  is  as  far  as  possible  maintained,  and  that 
no  rotation  of  the  lower  fragment  is  present.  To  ensure  absence 
of  rotation,  all  that  is  needed  is  to  note  that  the  inner  aspect  of 
the  great  toe,  the  subcutaneous  surface  of  the  internal  malleolus, 
and  the  inner  border  of  the  patella,  are  in  the  same  line,  and 
correspond  with  the  opposite  limb.  Union  will  be  sufficiently 
advanced  in  two  or  three  weeks  at  the  latest  to  allow  of  the  limb 
being  put  up  in  plaster,  which  must  be  retained  for  at  least  another 
month,  and  even  then  a  good  deal  of  lameness  is  likely  to  persist, 
which  will  need  subsequent  massage. 

In  oblique  and  spiral  fractures  there  is  often  very  great  difficulty 
in  getting  the  fragments  together,  and  even  more  in  maintaining 
them  in  good  position.  Taking  into  consideration  the  degree  of 
permanent  depreciation  that  a  man  (especially  if  of  the  labouring 
classes)  suffers  from  vicious  union  of  these  bones,  we  have  no 
doubt  that  the  suggestion  to  cut  down  on,  and  wire,  screw,  or  peg 
the  fragments  together,  is  fully  justifiable  in  the  hands  of  skilled 
surgeons.  In  the  spiral  cases  the  operation  may  also  have  to 
include  an  incision  to  free  and  fix  the  fibula. 

Fractures  in  the  neighbourhood  of  the  Ankle-joint  are  usually 
produced  by  indirect  violence,  the  foot  slipping,  and  leading 
primarily  to  a  displacement  of  the  ankle,  the  fracture  being  a 
secondary  result.  They  would  therefore  be  better  described  as 
Fracture-dislocations  at  the  Ankle-joint. 

1.  Displacement  of  the  Foot  outwards  is  by  far  the  most  common 
variety,  constituting  what  is  known  as  Pott's  Fracture.  It  usually 
results  from  the  patient  slipping  on  the  inside  of  the  foot,  as  from 
off  a  kerbstone.  The  sudden  abduction  of  the  foot  results  in 
severe  strain  upon  the  internal  lateral  ligament,  which  gives  way, 
or  the  base  of  the  internal  malleolus  is  torn  off.  The  astragalus 
is  thereby  driven  against  the  inner  aspect  of  the  external  malleolus, 
and  tends  to  displace  that  portion  of  bone  outwards.  The  force 
is  thence  transferred  up  the  fibula,  which  bends  and  breaks  at  its 
weakest  spot — that  is,  about  3  inches  above  the  tip  of  the 
malleolus — the  upper  end  of  the  lower  fragment  being  displaced 
inwards  towards  the  tibia.  Where  the  inferior  interosseous  tibio- 
fibular ligament  remains  intact,  the  foot  itself  cannot  be  displaced 
upwards,  but  is  merely  rotated  outwards. 

The  amount  of  injury  inflicted  on  the  tissues  of  the  foot  or  on 
the  bones  of  the  leg  warrants  us  in  describing  at  least  four  dis- 


490 


A  MANUAL  OF  SURGERY 


tinct  lesions  to  which  the  term  Pott's  fracture  may  be  more 
or  less  accurately  applied,  (a)  In  the  first  degree,  the  fibula  is 
broken,  and  on  the  inner  side  merely  the  internal  lateral  ligament 
is  torn  through  (Fig.  164) ;  the  intact  malleolus  can  then  be  felt 
projecting  beneath  the  skin.  (b)  In  the  second  degree,  the 
malleolus  itself  is  torn  off,  and  a  distinct  sulcus  can  be  felt  be- 
tween it  and  the  lower  end  of  the  tibial  shaft  (Fig.  165).  (c)  The 
third  degree  is  a  much  more  serious  lesion.  The  interosseous 
tibio  fibular  ligament  yields  more  or  less  completely,  or  the  flake 
of  bone  to  which  it  is  attached  is  torn  off;  the  foot,  carrying  with 


Fig.  164. — Ordinary  Pott's  Fracture 
with  Rupture  of  internal  Lateral 
Ligament. 


Fig.  165. — Pott's  Fracture 
with  Internal  Malleolus 
torn  OFF. 


it  the  lower  portion  of  the  fibula  and  the  superficial  flake  of  the 
tibia,  which  has  been  detached,  is  displaced  firstly  outwards,  and 
so  long  as  the  upper  surface  does  not  clear  the  lower  articular 
surface  of  the  tibia,  there  is  merely  lateral  displacement  with 
marked  abduction  of  the  foot  and  increased  breadth  of  the  ankle 
(Plate  XXIV.).  Should  the  force  continue  to  act,  the  astragalus 
may  be  carried  sufficiently  outwards  to  clear  the  lower  end  of  the 
tibia,  and  then  an  upward  and  to  a  less  degree  a  backward  displace- 
ment is  added,  causing  great  eversion  of  the  foot  and  deformity  of 
the  ankle.  This  latter  type  is  sometimes  known  as  Dupiiytren  s 
Fracture .     On  the  inner  side  either  the  ligament  or  the  .malleolus 


PLATE  XX.  ' 


Dupuytren's  Fracture,  with  well-marked  Displacement  outwards  of 
the  Foot,  as  well  as  of  the  Lower  Fragment  of  the  Fibula  and 
the  Internal  Malleolus.     (Skiagram  taken  from  in  front.) 

To  face  p.  490. ) ' 


INJURIES  OF  BONES—FRACTURES 


491 


may  yield  (Fig.  166).  (d)  The  fourth  degree  consists  in  the 
usual  type  of  fracture  of  the  fibula,  associated  with  an  almost 
transverse  fracture  of  the  tibia,  just  above  the  base  of  the  inner 
malleolus  (Fig.  167).  In  this  variety,  the  lower  end  of  the  shaft 
of  the  tibia  projects  beneath  the  skin,  and  is  likely  to  be  mistaken 
for  the  tip  of  the  malleolus ;  if  this  error  is  committed,  and  the 
fracture  allowed  to  unite  without  proper  rectification,  considerable 
deformity  results.  In  rare  instances,  the  lower  end  of  the  tibia 
may  project  through  the  skin,  thus  rendering  the  fracture  com- 
pound. 

In  almost  all  of  these  varieties  the  ankle  joint  itself  is  opened, 


Fig. 


166. — Dupuvtren's 
Fracture. 


Fig.  167.— Fracture  of  Lower  End  of 
Fibula  and  Tibia  simulating  Pott's 
Fracture 


and  this,  combined  with  the  amount  of  .bleeding  that  occurs  into 
tendon  sheaths  and  muscles  around,  and  the  difficulties  often 
associated  with  fixation  of  the  fragments,  explains  why  the  results 
of  these  cases  are  frequently  so  unsatisfactory.  Should  union 
occur  with  the  foot  in  a  false  (i.e.,  everted)  position,  a  large  mass 
of  callus  develops  between  the  shaft  of  the  tibia  and  the  malleolus. 
2.  Displacement  of  the  Foot  inwards. — When  the  patient  slips  on 
the  outer  aspect  of  the  foot,  the  astragalus  is  forcibly  driven 
against  the  inner  malleolus,  which  may  be  broken  off  or  impacted 
into  it.  The  outer  malleolus  is  dragged  inwards  with  the  foot, 
and  owing  to  the  integrity  of  the  inferior  tibio-fibular  ligament, 


492 


A   MANUAL  OF  SURGERY 


which  acts  as  a  fulcrum,  the  fibula  yields  at  the  same  spot  as  in 
Pott's  fracture.  The  foot  is  displaced  inwards,  and  perhaps 
slightly  backwards. 

3.  Displacement  of  the  Foot  backwards,  by  catching  the  heel  and 
tripping  forwards,  is  usually  associated  with  fractures  of  the  tibia 
and  fibula  in  the  same  position  as  in  Pott's  fracture,  but  eversion 
of  the  foot  is  absent  (see  dislocation  of  the  ankle  backwards, 
p.  569). 

Treatment. — In  reducing  these  fractures,  traction  should  be 
made  upon  the  foot  after  the  tension  of  the  calf  muscles  has  been 
relieved  by  flexing  the  knee,  or  by  tenotomy  of  the  tendo  Achillis  ; 
the  position  of  the  internal  malleolus  must  be  accurately  defined. 
Before  applying  the  splints,  careful  attention  must  be  given  to  the 
following  points  :  (a)  The  foot  must  be  maintained  at  right  angles 
to  the  leg  ;  (b)  the  heel  must  not  project  unduly  backwards  ;  and 
(c)  the  foot  must  not  be  rotated  on  the  leg — i.e.,  the  inner  surfaces 
of  the  great  toe,  internal  malleolus,  and  patella  must  be  in  the 
same  line.  A  pair  of  Cline's  splints  is  generally  sufficient  to 
steady  the  parts.  Some  cases  are  better  treated,  however,  by  a 
Dupuytren's  splint  (Fig.  168),  which  is  really  a  Liston's  splint  on 
a  small  scale.  It  reaches  from  the  knee  to  below  the  sole  of  the 
foot,  and  is  placed  on  the  inner  side  of  the  limb,  the  patient  lying 
on  the  sound  side  during  its  application.  A  firm  pad  extends 
down  as  far  as  the  base  of  the  internal  malleolus,  and  over  this 
as  a  fulcrum  the  foot  is  drawn  inwards  by  a  handkerchief  applied 
around  the  ankle,  and  tied  to  the  notches  at  the  end  of  the  splint. 
The  foot  being  thus  fixed,  the  upper  end  of  the  splint  is  bandaged 


Fig.  168. — Dupuytren's  Splint  applied  for   Pott's  Fracture. 
(Tillmanns.) 

to  the  limb.  Any  tendency  to  backward  displacement  of  the  heel 
may  be  counteracted  by  the  use  of  a  Macintyre's  back-splint,  or 
by  the  application  of  a  Syme's  anterior  horseshoe  splint,  which 
can  be  used  in  combination  with  a  Dupuytren.  It  consists  of  a 
flat  piece  of  wood,  well  padded,  extending  from  the  knee  to  the 
ankle  along  the  crest  of  the  tibia  ;  the  lower  end  is  shaped  like  a 
horseshoe,  the  two  limbs  passing  one  on  either  side  of  the  foot. 
A  handkerchief  or  piece  of  bandage  is  applied,  with  its  centre 
over  the  point  of  the  heel ;  it  passes  up  on  either  side  between  the 
splint  and  the  foot,  winds  over  the  former  structure,  and  is  tied 


INJURIES  OF  BONES— FRACTURES  493 


behind  the  heel,  which  is  thus  lifted  forwards.  As  soon  as 
possible,  the  limb  should  be  put  up  in  water-glass  or  plaster  of 
Paris. 

In  the  simpler  forms,  early  massage  may  be  employed,  and  then 
all  the  retentive  apparatus  necessary  is  some  adhesive  plaster 
applied  so  as  to  cover  in  and  encase  the  foot  and  ankle.  In  the 
more  difficult  cases,  where  there  is  considerable  displacement  and 
much  difficulty  in  keeping  the  fragments  together,  operation  to  fix 
them  is  quite  justifiable. 

In  cases  of  vicious  union  after  Pott's  fracture,  it  is  usually 
necessary  to  re-divide  the  fibula,  and  to  excise  a  V-shnped  portion 
of  bone  from  the  tibia  extending  into  the  ankle  joint,  so  as  to 
enable  the  malleolus  to  be  brought  in  contact  with  the  shaft. 

Fracture  of  the  Os  Calcis  may  result  trom  direct  violence,  such 
as  a  blow  or  fall  on  the  heel,  or  possibly  from  muscular  action,  the 
epiphysis  being  then  separated,  or  the  shell  of  bone  into  which 
the  tendo  Achillis  is  inserted  being  torn  off.  The  fragment  thus 
separated  is  displaced  upwards  by  the  contraction  of  the  calf 
muscles,  and  the  resulting  deformity  is  very  evident.  If  the  line 
of  fracture  passes  through  the  body  of  the  bone  there  may  be 
no  displacement,  owing  to  the  attachment  of  the  interosseous  and 
lateral  ligaments  ;  but  should  the  sustentaculum  tali  be  broken, 
the  arch  of  the  foot  may  be  more  or  less  flattened.  When  due  to 
a  fall  from  a  height,  the  bone  is  often  comminuted  and  the  foot 
much  bruised  and  swollen.  Treatment  consists  in  immobilizing 
the  foot  in  a  plaster  case  if  there  is  no  displacement ;  but  where  the 
posterior  part  of  the  bone  is  drawn  upwards,  it  must  be  approxi- 
mated to  the  rest  of  the  bone  after  flexing  the  leg,  in  order  to  relax 
the  calf  muscles,  or  possibly  after  tenotomy.  A  more  satisfactory 
result  may,  however,  be  obtained  by  cutting  down,  and  wiring  or 
pegging. 

Fracture  of  the  Astragalus  is  usually  due  to  falls  on  the  foot 
from  a  height,  or  from  direct  violence  applied  to  the  foot,  as  by  a 
weight  falling  upon  it.  The  lesion  is  often  a  severe  comminuted 
one,  and  portions  of  the  bone  may  be  displaced  forwards  or  back- 
wards, making  a  marked  projection  beneath  the  skin.  In  a  case 
recently  under  our  care  at  hospital,  the  patient  had  fallen  down  a 
lift,  alighting  on  his  feet  ;  both  astragali  were  smashed,  and  this 
probably  saved  his  life.  Such  accidents  are  often  associated  with 
lesions  of  the  tibia  or  fibula,  and  possibly  even  of  the  femur. 
The  whole  region  of  the  ankle  becomes  infiltrated  with  blood, 
•  and  an  exact  diagnosis  is  sometimes  difficult.  Treatment 
consists  either  in  immobilization,  which  is  likely  to  be  followed  by 
stiffness  of  the  ankle,  or  in  bad  cases  by  excision  of  the  bone  or  of 
projecting  fragments. 

Occasionally  in  less  severe  accidents  the  bone  merely  splits 
across,  the  lesion  being  usually  situated  about  the  neck.     Such  is 


494  A   MANUAL  OF  SURGERY 


due  either  to  the  weight  of  the  body  flattening  out  the  arch  of  the 
bone  beyond  the  limits  of  elasticity,  or  if  the  foot  is  dorsi-flexed 
to  penetration  of  the  bone  by  the  anterior  edge  of  the  tibia,  im- 
paction being  even  produced  in  this  way.  Massage  and  early 
mobilization  should  be  employed  in  such  cases. 

Other  bones  of  the  tarsus  are  occasionally  fractured,  but  these 
lesions  require  no  detailed  description. 


CHAPTER  XVIII. 

DISEASES    OF    BONE. 

Inflammation  of  Bone. 

In  order  to  assist  our  readers  to  correctly  understand  the  subject 
of  inflammation  in  bone,  we  must  call  to  mind  a  few  facts  relative 
to  its  constitution  and  growth. 

Bones  are  divided  into  the  long,  the  short,  and  the  flat,  each  of 
these  consisting  of  compact  and  cancellous  tissue  in  varying 
amounts.  In  the  short  bones  there  is  but  a  thin  layer  of  compact 
tissue  surrounding  a  cancellous  central  mass,  the  meshes  of  which 
are  filled  with  medullary  fat  and  connective  tissue.  In  the  flat 
bones  the  compact  tissue  forms  two  limiting  plates,  separated  by 
a  layer  of  cancellous  tissue  of  varying  thickness  (known  in  the 
skull  as  the  diploe).  In  long  bones  the  shaft  consists  of  a  peri- 
pheral tube  of  compact  structure,  surrounding  a  space  which  is 
normally  hlled  with  medulla,  and  known  as  the  medullary  canal ; 
at  each  end  it  gradually  merges  into  a  larger  mass  of  loose 
cancellous  tissue,  the  interstices  of  which  are  similarly  packed 
with  vascular  fatty  medulla,  which  apparently  performs  the 
function  not  only  of  maintaining  the  nutrition  of  the  bone,  but 
also  of  elaborating  the  blood.  Prolongations  from  the  medulla, 
moreover,  extend  into  the  Haversian  canals,  and  are  thence  con- 
tinuous with  the  periosteum,  so  that  the  mineral  skeleton  has 
incorporated  within  it  a  vascular  fibro-cellular  mass  which 
permeates  its  whole  structure.  It  must  be  clearly  remembered 
that  there  is  normally  no  open  hollow  space,  and  therefore  no 
endosteum  or  internal  lining  membrane  (except  in  bones  con- 
taining cavities,  such  as  the  mastoid  cells  or  frontal  sinuses). 

The  vascular  supply  of  a  bone  is  derived  (a)  from  the  nutrient 
artery  which  passes  into  the  medullary  space,  and  there  breaks 
up  into  branches  which  ramify  through  the  whole  of  the  medullary 
tissue,  and  thence  extend  into  the  Haversian  canals  ;  and  (b)  from 
the  periosteum,  air  exceedingly  vascular  ensheathing  membrane, 
from  which  small  vessels  pass  perpendicularly  into  the  Haversian 
canals,  and   thus    establish  a   communication    between    the   two 


496  A   MANUAL  OF  SURGERY 

systems.  These  latter  vessels  are  especially  numerous  and  large 
close  to  the  epiphyses.  Large  veins  occur  in  the  medullary 
and  cancellous  interior,  and  are  frequently  thrombosed  in  in- 
flammatory mischief;  if  the  thrombus  becomes  infected,  and  so 
disintegrated,  pyaemia  is  very  likely  to  ensue. 

The  growth  of  bone  manifests  itself  in  three  different  ways  :  (i.)  It 
increases  in  length  from  the  shaft  side  of  the  epiphyseal  cartilage, 
the  epiphysis  itself  growing  but  little.  In  the  upper  limb  the 
chief  increase  in  length  occurs  at  the  shoulder  and  wrist,  whilst 
in  the  leg  it  is  mainly  evident  on  either  side  of  the  knee-joint,  and 
this  in  spite  of  the  fact  that  the  so-called  nutrient  arteries  are 
directed  away  from  these  points  ;  this  would  tend  to  indicate  that 
the  importance  of  these  vessels  in  supplying  nutrition  to  the  bones 
has  been  much  over-rated,  (ii.)  Increase  in  breadth  is  produced 
by  new  formation  of  bone  from  the  deeper  layer  of  the  periosteum, 
which  contains  many  yellow  elastic  fibres,  and  a  large  number  of 
angular  nucleated  cells,  or  osteoblasts,  which  are  presumably  the 
bone-forming  agents,  (iii.)  A  bone  increases  in  density  by  a  new 
deposit  of  osseous  tissue  around  the  Haversian  canals  and  cancel- 
lous spaces. 

In  considering  the  inflammatory  affections  of  bones,  it  must 
always  be  kept  in  mind  that  the  essential  pathological  phenomena 
(viz.,  hyperemia,  exudation,  and  tissue  changes,  active  or  passive) 
are  similar  to  those  manifested  in  any  other  vascular  structure, 
but  that  the  resulting  effects  are  modified  by  the  limited  space  in 
which  the  vessels  lie,  and  the  resisting  character  of  the  surround- 
ing osseous  tissue.  Hence  any  acute  inflammation,  resulting  in 
rapid  vascular  engorgement  and  considerable  exudation  quickly 
poured  out,  leads  to  necrosis  from  thrombosis,  due  to  increased 
pressure  within  the  unyielding  bony  canals.  If,  however,  the 
process  is  subacute,  so  that  the  tissue-liquefying  properties  of  the 
exudation  and  the  tissue-absorbing  activity  of  the  leucocytes  can 
come  into  play,  then  osteoporosis  or  rarefaction  of  the  bone  results,  a 
condition  sometimes  termed  caries.  On  the  other  hand,  if  the 
inflammation  is  chronic,  and  due  to  causes  other  than  tubercle  or 
the  pressure  of  tumours,  then  new  formation  occurs,  and  osteo- 
sclerosis, or  condensation,  is  most  likely  to  result.  Tubercle  in 
bones,  as  elsewhere,  causes  primarily  rarefaction  of  the  tissue 
attacked,  though  sclerosis  may  be  associated  with  or  follow  it, 
and  the  chronic  pressure  of  tumours  or  aneurisms  leads  to  rarefac- 
tion and  atrophy  locally,  although  a  certain  amount  of  sclerosis 
may  be  induced  around. 

One  more  general  fact  must  be  noted,  viz.,  that  it  is  very  rare 
for  any  inflammatory  process  to  affect  solely  one  element  of  a 
bone.  The  continuity  of  the  vascular  supply  explains  why  a 
periostitis  is  usually  or  almost  invariably  associated  with  inflam- 
mation of  the  subjacent  bone,  and  why  an  osteomyelitis  is  never 
limited  to  the  medullary  cavity. 


DISEASES  OF  BONE  497 

Terminology. — Many  different  terms  have  been  applied  to  these 
pathological  processes,  and  much  needless  confusion  introduced 
thereby  into  a  subject  at  all  times  somewhat  complicated. 
Especially  is  this  the  case  in  inflammatory  affections  of  cancellous 
or  compact  bone,  the  terms  '  osteitis  '  and  '  osteomyelitis  '  being 
used  with  very  little  precision.  All  inflammation  of  bone  occurs 
in  connection  with  the  vascular  tissue  permeating  its  structure, 
and  hence,  as  this  is  everywhere  connected  with  the  medulla, 
all  such  processes  might  be  described  as  forms  of  osteomyelitis. 
This  term  is,  however,  limited  to  the  affections  of  the  medulla 
of  long  bones,  whilst  the  term  '  osteitis '  is  applied  to  those 
occurring  in  the  compact  tissue  of  the  shaft  of  long  bones,  or  in 
the  cancellous  tissue  at  the  ends  of  long  bones,  or  in  the  interior 
of  short  bones,  and  with  such  limitations  we  shall  comply  here. 
Then,  moreover,  the  results  of  disease  have  been  often  confounded 
with  the  pathological  processes  leading  to  them,  and  the  clinical 
conditions — caries,  necrosis,  and  sclerosis — are  described  as  distinct 
diseases  ;  we  shall  endeavour  to  avoid  this  source  of  error  by  pre- 
facing our  description  of  the  diseases  with  a  few  remarks  on  each 
of  these  clinical  conditions. 

Necrosis,  or  death  of  bone,  may  occur  in  a  variety  of  forms, 
and  from  many  different  causes,  e.g.  :  (a)  From  acute  localized 
suppurative  periostitis,  the  sequestrum,  or  dead  mass,  being  then 
simply  a  superficial  plate  or  flake  of  the  compact  exterior  (Fig.  169); 
(b)  from  acute  idiopathic  infective  osteomyelitis  (acute  panostitis 
or  acute  necrosis),  the  sequestrum  then  often  involving  the  whole 
thickness  of  the  bone,  and  invading  more  or  less  of  the  length 
of    the   diaphysis,   if    the   condition  is   not    early   and    efficiently 
treated  (Figs.  171  and  172)  ;  (c)  from  acute  septic  osteomyelitis, 
usually  traumatic    in    origin,  the    sequestrum    being  annular  in 
shape,  and    involving    more  of    the    interior    of  the   bone   than 
of  the  exterior  (Fig.   173  ) ;   (d)  from  acute  or  subacute  septic 
osteitis   of  cancellous   bone,    the   sequestra   being   small    spicu- 
lated    fragments    of    the    bony     cancelli    which    have,    escaped 
absorption  by  the  granulation  tissue  always  forming  in  such  a 
process ;    (e)  from  tuberculous   disease  of  cancellous  tissue,  the 
sequestrum  being  light  and  porous,  often  infiltrated  with  curdy 
material,  and  rarely  separated  completely  from  surrounding  parts  ; 
(/)  from  syphilitic  disease  of  cancellous  or  compact  tissue,  usually 
resulting  from  excessive  sclerosis,  or  gummatous  disease  of  the 
periosteum  which  has  become  septic ;  (g)  from  the  action  of  local 
irritants,  e.g.,  mercury,  or  phosphorus  fumes  gaining  access  to  the 
interior  of  the  teeth  ;  (h)  occasionally  as  a  simple  senile  loss  of 
nutrition,  as  in  senile  gangrene  ;  and  (i)  a  variety,  described  by  Sir 
James  Paget  under  the  name  of  '  quiet  necrosis,'  occurs  as  a  result 
of  direct  injury,  the  sequestrum  separating  without  suppuration  ; 
it  is  one  of  the  causes  of  loose  bodies  in  joints,  and  especially  the 
knee,  following  a  blow  en  one  of  the  condyles. 

32 


498  A   MANUAL  OF  SURGERY 


The  separation  of  sequestra  is  always  brought  about  by  a  process 
analogous  to  that  by  means  of  which  sloughs  and  gangrenous 
materials  are  cast  off  from  the  body,  viz.,  by  complete  absorp- 
tion if  small,  aseptic,  and  surrounded  by  sufficiently  vascular 
tissue ;  by  absorption  of  as  much  as  possible,  in  larger  aseptic 
masses,  granulation  tissue  invading  and  replacing  the  dead  mass, 
and  a  line  of  separation  forming  as  a  result  of  defective  nutrition 
of  the  most  advanced  layer  ;  or,  if  septic,  an  active  rarefying 
inflammation  occurs  in  the  neighbouring  living  tissue,  which  in 
time  breaks  down,  and  so  sets  free  the  dead  mass.  (See  in  more 
detail  at  p.  69.)  From  the  eroding  action  of  the  granulation 
tissue,  the  under  surface  of  the  sequestrum  is  always  hollowed 
out,  and,  as  it  were,  worm-eaten  in  appearance.  Where  sepsis  is 
present,  the  process  is  more  active,  and  is  completed  more  rapidly, 
though  with  greater  risk  to  the  patient. 

Caries,  or,  as  it  is  sometimes  called,  osteoporosis,  or  rarefaction  of 
bone,  is  a  clinical  condition  resulting  from  inflammation,  and  con- 
sisting in  a  soft  and  spongy  state  of  the  bone,  which,  if  it  can  be 
reached,  readily  breaks  down  on  pressure  with  a  probe.  It  may 
result  from  the  following  conditions  :  (a)  A  simple  subacute  in- 
flammatory process,  e.g.,  during  the  early  stage  of  repair  in  a 
fracture  ;  (b)  from  acute  or  subacute  septic  or  infective  inflamma- 
tion of  cancellous  tissue ;  (c)  from  tuberculous  affections  of  the 
cancellous  tissue  or  periosteum  ;  (d)  from  syphilitic  disease  of  the 
medulla  or  of  the  under  surface  of  the  periosteum. 

Pathologically,  it  is  characterized  by  the  replacement  of  the 
medulla  by  granulation  tissue,  which  usually  contains  some  large 
multi-nucleated  cells,  or  osteoclasts,  and  these  seem  to  be  closely 
connected  with  the  removal  of  the  bone,  though  we  are  at  present  in 
ignorance  of  the  manner  in  which  this  is  effected.  The  cancellous 
tissue  becomes  hollowed  out  to  accommodate  these  granulations, 
and  the  osteoclasts  are  usually  found  occupying  shallow  depres- 
sions known  as  '  Howship's  lacunae.'  In  tuberculous  and  syphilitic 
lesions  the  bone  corpuscles  undergo  fatty  degeneration. 

Certain  terms  are  used  to  indicate  the  characteristics  observed 
in  particular  cases.  By  Caries  sicca  is  meant  that  the  process 
occurs  without  suppuration ;  in  C.  suppurativa  pus  is  always 
present ;  in  C.  fungosa  the  granulation  tissue  is  exceedingly  abun- 
dant, especially  in  tuberculous  disease  of  the  articular  ends  of 
bones ;  in  C.  necrotica  necrosis  is  associated  with  caries,  the 
sequestra  consisting  either  of  spiculated  fragments,  or  in  tuber- 
culous disease  of  larger  masses. 

If  caries  is  recovered  from,  a  subsequent  condition  of  sclerosis 
usually  follows,  with  loss  of  substance  and  often  deformity. 

Sclerosis  of  bone  (osteosclerosis)  is  invariably  the  result  of  some 
chronic  inflammatory  affection,  e.g.,  (a)  chronic  periostitis,  whether 
simple  or  syphilitic  ;  (b)  chronic  osteomyelitis,  simple,  tuber- 
culous, or  syphilitic  ;  or  (c)  chronic  osteitis  of  the  compact  bone, 


DISEASES  OF  BONE  49g 


which  is  always  secondary  to  one  of  the  former.  In  all  cases 
the  condition  is  due  to  a  slow  formation  of  new  bone  within  the 
Haversian  canals  or  cancellous  spaces,  thus  diminishing  their 
lumen  ;  in  syphilis  this  may  progress  to  such  an  extent  as  to  lead 
to  their  total  occlusion,  and  even  to  localized  necrosis  from  lack  of 
blood-supply,  especially  when  sepsis  has  occurred.  In  tuberculous 
bones  the  sclerosed  tissue  is  always  at  some  distance  from  the 
focus  of  mischief,  and  may  be  looked  on  as  Nature's  attempt  to 
limit  the  spread  of  the  disease ;  it  forms  also  the  final  tissue  or 
bone-scar  in  the  process  of  repair  in  those  cases  where  a  cure 
has  been  obtained  by  natural  or  surgical  means. 


Classification  of  Inflammatory  Affections  of  Bone. 

I .  Periostitis : 

(a)  Acute  localized,  with  or  without  suppuration. 

(b)  Acute  diffuse,  always  associated  with  or  secondary  to 

acute  infective  osteomyelitis. 

(c)  Chronic  simple,  or  hyperplastic. 

(d)  Chronic  tuberculous. 
(V)   Chronic  syphilitic. 

II.  Osteitis,  or  inflammation  of  compact  bone,  which  is  always 

associated  with  and  secondary  to  either  periostitis  or 
osteomyelitis,  and  so  will  not  be  described  separately. 
The  acute  form  results  in  necrosis,  the  subacute  in 
osteoporosis,  and  the  chronic  in  sclerosis,  except  in 
tuberculous  disease. 

III.  Osteomyelitis,    or   inflammation   of   the   medulla   of   long 

bones : 

(a)  Acute  septic  (traumatic). 

(b)  Acute  infective  (idiopathic  =  acute  panostitis). 

(c)  Subacute  simple  or  infective,  e.g.,  after  fractures,   or 

during  the  separation  of  sequestra,  resulting  primarily 
in  rarefaction,  but  finally  in  sclerosis. 

(d)  Chronic  simple,  tuberculous  or  syphilitic,  usually  causing 

general  enlargement  and  sclerosis  of  the  bone,  even 
if  locally  some  rarefaction  is  present. 

IV.  Inflammation    of    the    Cancellous    Tissue    (Osteitis)    may 

similarly  be  : 

(a)  Acute  septic  or  traumatic. 

(b)  Acute  infective. 

(c)  Subacute  simple  or  septic. 

(d)  Chronic  simple,  syphilitic,  or  tuberculous. 

When  limited  to  the  articular  end  of  a  bone  in  a  young  person, 
this  is  sometimes  termed  Epiphysitis. 

It  is  unnecessary  to  describe  in  detail  all  these  conditions,  since 
many  of  the  divisions  overlap,  and  hence  we  shall  group  together 


5°o 


A  MANUAL  OF  SURGERY 


the  various  acute  and  chronic  affections  in  order  to  indicate  the 
clinical  signs  and  symptoms. 

Acute  Inflammations  of  Bone. 

i.  Acute  Localized  Periostitis  usually  arises  as  a  result  of 
traumatism  applied  directly  to  the  bone,  with  or  without  an  open 
wound  ;  it  may  also  be  determined  by  general  conditions,  such  as 
rheumatism,  gout,  and  pyaemia,  or  by  an  extension  of  inflam- 
matory mischief,  as  in  an  alveolar  abscess. 

Pathologically,  the  process  consists  of  hyperemia  of  and  exuda- 
tion into  the  periosteum,  which  becomes  swollen,  turgid,  and 
thickened.  This  may  be  followed  in  due  course  by  resolution,  or 
may  leave  the  bone  thickened  and  in  a  condition  of  chronic  inflam- 
mation ;  or  suppuration  may  ensue,  and  with  it  usually  a  limited 


ffi 


Fig.  169. — Superficial  Necrosis  resulting  from  a  Localized  Periostitis 
(Diagrammatic). 

A  represents  the  necrosed  tissue  lying  in  continuity  with  the  surrounding  living 
bone  ;  the  periosteum  is  stripped  up  from  it,  and  has  an  opening  through 
which  the  pus  has  been  discharged.  B  shows  a  later  stage,  in  which  the 
sequestrum  is  being  separated  by  a  process  of  rarefying  osteitis  in  the 
immediately  contiguous  living  bone,  whilst  an  involucrum,  or  sheath  of 
new  bone,  is  formed  from  the  under  surface  of  the  periosteum  ;  a  cloacal 
aperture  remains  in  the  involucrum  for  the  escape  of  discharges.  C  shows 
the  condition  of  affairs  after  the  sequestrum  has  been  removed. 

superficial  necrosis.  In  the  last  event  pyogenic  organisms  of  no 
great  virulence  must  find  an  entrance  to  the  area  of  mischief,  and 
probably  in  cases  due  to  trauma  through  the  abraded  or  injured 
skin  ;  in  other  instances  they  may  come  from  neighbouring  foci 
of  inflammation,  or  possibly  auto-infection  may  occur.  The  in- 
flammatory process  extends  to  the  small  vessels  entering  the  bone 
from  the  under  surface  of  the  periosteum  ;  these  become  dilated, 
next  thrombosed  and  strangled  by  the  pressure  of  the  exudation 


DISEASES  OF  BONE  501 


around  them,  and  finally  pulled  out  from  the  osseous  canals  by 
the  tension  of  the  subperiosteal  effusion  and  by  the  peptonizing 
power  of  the  bacterial  products.  Consequently,  the  vitality  of  the 
superficial  layer  of  bone  is  destroyed  for  an  area  corresponding 
almost  exactly  to  that  from  which  the  periosteum  has  been 
stripped  (Fig.  169,  A). 

As  soon  as  tension  has  been  relieved  by  the  escape  of  the  pus, 
repair  commences.  Where  the  mischief  is  very  slight  and  super- 
ficial, the  involved  bone  may  entirely  recover,  or  even  small 
necrotic  portions  be  absorbed.  If  the  dead  portion  of  bone  is 
more  extensive,  it  will  be  separated  from  the  subjacent  living 
tissues  by  one  of  the  processes  already  described  (p.  498),  whilst 
from  the  under  surface  of  the  stripped-up  periosteum  a  casing  of 
new  bone  is  developed,  constituting  an  involucrum  or  sheath,  at 
first  spongy  and  cancellous  in  texture,  but  finally  hard  and 
sclerosed.  In  the  centre  of  this  new  formation  are  found  one  or 
more  openings  or  cloaca  through  which  the  discharge  passes,  and 
corresponding  in  position  to  the  openings  in  the  periosteum  and 
skin  made  by  Nature  or  the  knife  (Fig.  169,  B). 

Clinically,  the  symptoms  of  acute  localized  periostitis  consist  in 
the  ordinary  phenomena  of  acute  inflammation,  the  pain  being  of 
an  intense  aching  character,  worse  at  night,  and  increased  by 
lowering  the  limb  or  by  any  kind  of  pressure.  If  a  subcutaneous 
portion  of  bone  is  involved,  a  painful  swelling  develops,  at  first 
brawny  in  character,  but,  when  suppuration  has  occurred,  the 
centre  softens,  whilst  the  skin  over  it  becomes  red  and  cedematous. 
When  an  abscess  has  burst  or  been  opened,  bare  bone  is  felt 
beneath  the  periosteum,  and  the  greater  part  of  this  denuded 
structure  usually  dies,  and  must  then  be  either  absorbed  or 
separated  ;  in  either  case  a  sinus  remains  for  a  time,  leading  down 
through  a  cloaca  in  the  involucrum  to  the  sequestral  cavity. 
From  this  either  pus  or  serum  will  be  discharged,  according  to 
whether  the  wound  has  become  septic  or  not.  In  about  five  or 
six  weeks'  time  the  sequestrum  is  loose,  and  this  may  be  ascer- 
tained by  moving  it  with  a  probe  within  the  osseous  cavity,  which 
is  now  lined  on  the  inner  aspect  with  granulation  tissue. 

Treatment. — Rest,  elevation  of  the  limb,  leeches,  and  fomenta- 
tions are  usually  relied  on  locally  in  the  early  stages,  whilst  a 
good  purge  and  specific  anti-diathetic  remedies  may  be  used 
generally.  If,  however,  the  affection  is  not  readily  checked, 
and  suppuration  threatens,  a  free  aseptic  incision  down  to  the 
bone  is  the  best  means  of  preventing  necrosis.  Should  an  abscess 
form,  it  must  be  opened  early,  and  possibly  by  this  means  death 
of  the  bone  may  be  obviated  or  limited.  When  necrosis  has 
occurred,  the  parts  must  be  carefully  dressed  and  kept  aseptic, 
until  the  sequestrum  is  detached.  An  incision  is  then  made  over 
the  involucrum,  the  periosteum  stripped  from  it,  one  of  the  cloacae 
enlarged,  and  the  dead  bone  removed.    The  cavity  will  now  rapidly 


502  A  MANUAL  OF  SURGERY 

fill  up  with  granulations,  and  heal  completely.  In  many  cases 
recovery  may  be  expedited  by  chiselling  away  those  portions  of 
dead  bone  which  must  ultimately  be  separated  without  waiting 
for  the  tardy  process  of  Nature  ;  this  should  not  be  undertaken 
until  the  destructive  changes  have  ceased,  and  then  only  to  a 
limited  extent.  The  dead  bone  is  recognised  from  the  living  by 
its  white  appearance  and  by  not  bleeding  when  cut. 

2.  Acute  Infective  Osteomyelitis  (Syn.  :  Acute  Necrosis,  Acute 
Diffuse  or  Infective  Periostitis,  Acute  Diaphysitis,  Acute  Panostitis). 
—  This  disease  usually  occurs  in  children,  often  of  a  tuberculous 
inheritance,  and  not  unfrequently  follows  one  of  the  exanthemata 
(e.g.,  measles  or  scarlet  fever).  It  generally  commences  before 
the  age  of  puberty,  and  is  an  affection  of  the  gravest  import ;  the 
multiplicity  of  names  attached  to  it  suggest  quite  accurately  that 
its  manifestations  may  be  very  diverse  in  character. 

Pathology. — The  patients  are  always  in  a  state  of  depressed 
general  health,  so  that  their  germicidal  powers  are  considerably 
diminished.  Moreover,  spots  of  localized  ulceration  are  often 
present  in  the  throat,  mouth,  or  intestines,  which  give  a  ready 
entrance  for  micro-organisms  into  the  system.  Evidently  some 
of  these  must  be  circulating  within  the  blood,  ready  to  attack  any 
area  of  diminished  tissue  resistance.  A  slight  injury  in  the  shape 
of  a  strain  or  a  wrench,  which  is  often  entirely  overlooked  or  for- 
gotten, may  suffice  to  determine  the  commencement  of  an  in- 
flammatory process  which  rapidly  spreads  by  continuity  of  tissue, 
until  perhaps  the  whole  structure  of  the  bone  may  be  affected. 

The  majority  of  the  ligaments  and  not  a  few  tendons  are 
inserted  into  the  epiphysis,  and  it  is  not  difficult  to  appreciate 
the  fact  that  articular  strain  must  be  mainly  felt  in  the  juxta- 
epiphyseal  region,  i.e.,  immediately  beyond  these  insertions.  It 
has  been  already  mentioned  that  the  traumatic  separation  of 
epiphyses  is  liable  to  be  followed  by  suppuration,  even  in  healthy 
children,  and  it  is  easy  to  understand  that  in  an  unhealthy  child 
a  very  slight  injury  in  the  epiphyseal  region  may  determine  a 
similar  process. 

The  disease  almost  always  starts  in  the  soft  vascular  tissue  on 
the  shaft  side  of  the  epiphyseal  cartilage,  but  occasionally  it  com- 
mences in  the  epiphysis  itself  at  the  margin  of  the  ossifying  centre, 
and  in  a  few  instances  (mainly  amongst  young  adults)  it  may  be 
preceded  by  a  patch  of  localized  periostitis,  suggesting  that  an 
acute  infection  ha^  supervened  upon  a  subacute  periosteal  focus. 
The  bacteria,  once  admitted,  grow  and  multiply  rapidly,  and  give 
rise  to  inflammatory  phenomena,  the  nature  and  extent  of  which 
depend  largely  on  the  exact  situation  of  the  infective  focus,  the 
amount  of  resistance  offered  by  surrounding  tissues,  and  the 
virulence  of  the  organisms.  As  in  any  other  part  of  the  body,  the 
trouble  is  most  likely  to  travel  along  the  line  of  least  resistance, 
i.  If  the  process  commences  in  the  periphery  of  the  juxta- 


DISEASES  OF  BONE 


So.? 


epiphyseal  region  close  to  the  periosteum,  the  line  of  least  resist- 
ance will  be  towards  that  structure,  and  hence  a  sub -periosteal 
abscess  may  form,  whilst  the  central  portions  of  the  bone  may 
escape  almost  entirely.  The  extent  of  this  abscess  depends 
mainly  upon  the  virulence  of  the 
bacteria,  but  considerable  portions  of 
the  diaphysismaybe  denuded,  resulting 
in  extensive  necrosis,  which,  however, 
involves  the  superficial  rather  than  the 
deeper  parts.  It  rarely  extends  to  the 
neighbouring  joint  owing  to  the  close 
bond  of  union  which  exists  between 
the  diaphyseal  periosteum  and  the 
epiphyseal  cartilage.  In  this  variety 
an  early  incision  to  let  out  the  pus 
may  suffice  to  prevent  necrosis,  or,  at 
any  rate,  to  limit  it.  The  constitu- 
tional symptoms  will  be  less  severe 
than  in  other  varieties  ;  there  is  less 
likelihood  of  the  development  of 
pyaemia,  and  the  toxic  fever  soon  dis- 
appears after  the  removal  of  the  pus. 
Subsequently  the  same  course  of 
events  occurs  as  in  the  localized 
variety  of  acute  periostitis — viz.,  an 
involucrum  forms,  perforated  by  one 
or  more  cloacae,  and  the  sequestrum 
in  time  separates.  FlG-      170. —Acute      Osteo- 

A  good  illustration   of  this  type  is     pyelitis     of    the    Lower 
,   &  ,  .     .       ;1  ■      .-,-         End    of    the    Femur    in    a 

to    be   found    in   the   acute    periostitis      Child     of     Nine     Weeks. 
which  affects  the  lower  end  of  the  femur.      (After  Lexer.) 
It    almost    always    starts    posteriorly,  IC  internal  condyle  ;  K,  centre 
stripping  the  thin  periosteum  off  the      of  ossification  in  epiphysis; 
back  of  the  bone  as  far  as  the  bifurca-     A,  abscess  cavity  in  epiphyseal 

tion  of  the  linea  aspera.     Its  prefer-     linf ;   S'  sequestrum;  I,  in- 

r        .  .       .  .    r  .  .  ,      ,  f     j  volucrum. 

ence  tor  this  situation  is  evidently  due 

to  the  fact  that  strains  upon  the  knee-joint  are  mainly  experienced 

when  the  limb  is  hyper-extended,  and  that  such  strain  is  directed 

to  the  posterior  ligaments,  and  hence  the  posterior  portion  of  the 

epiphyseal  line  is  likely  to  suffer.    An  abscess  forms,  and  inasmuch 

as  it  lies  deeply  and  its  origin  is  not  easily  recognised,  it  is  allowed 

to  progress  for  some  time,  one  result  being  that  the  osteogenetic 

powers  of  the  periosteum  are  destroyed,  so  that  an  involucrum 

rarely  forms  in  this  particular  example  of  necrosis.     Removal  of 

the  sequestrum  is  also  difficult  from  anatomical  reasons,  and  hence 

amputation  is  sometimes  required. 

2.   Should  the  process  start  in  the  centre  of  the  juxta-epiphyseal 


504  A  MANUAL  OF  SURGERY 


region,  it  may  spread  in  several  directions,  and  the  results  vary 
considerably. 

(a)  The  process  may  reach  the  periosteum  first  and  then  the 
phenomena  of  a  diffuse  sub-periosteal  abscess,  as  indicated  above, 
with  the  addition  of  the  symptoms  due  to  its  deeper  origin,  will 
manifest  themselves.  This  is,  perhaps,  the  most  usual  course  for 
the  disease  to  take. 

(b)  Less  frequently  the  infection  extends  along  the  medullary 
cavity  and  gives  rise  to  the  most  typical  form  of  osteomyelitis 
(Fig.  170).  The  medulla  becomes  intensely  hypersemic ;  the 
veins  are  thrombosed  ;  localized  foci  of  suppuration  and  gangrene 
appear ;  and  in  consequence  of  the  increased  pressure  infective 
emboli  are  likely  to  be  detached  and  pyaemia  to  follow.  Even  if 
the  latter  does  not  occur,  the  general  condition  is  profoundly 
affected  by  the  absorption  of  toxins.  Suppuration  also  occurs 
beneath  the  periosteum,  although  the  amount  of  pus  may  not  be 
great  at  first;  but  the  membrane  is  stripped  up  from  the  diaphysis, 
perhaps  to  such  an  extent  as  to  involve  the  whole  length  and 
circumference  of  the  shaft.  Unless  prompt  measures  are  taken  to 
limit  the  progress  of  the  disease,  necrosis  is  certain  to  follow, 
usually  implicating  the  whole  thickness  of  the  diaphysis,  and 
sometimes  extending  along  its  whole  length.  In  fact,  the  whole 
diaphysis  is  occasionally  found  lying  loose  in  an  abscess  cavity, 
the  two  epiphyses  having  been  previously  separated. 

(c)  It  has  been  already  mentioned  that,  owing  to  the  intimate 
connection  between  the  periosteum  of  the  diaphysis  and  the 
epiphyseal  cartilage,  the  neighbouring  joint  usually  escapes  infec- 
tion. Should,  however,  the  epiphyseal  line  be  within  the  joint,  as 
in  the  hip,  it  must  perforce  become  the  seat  of  an  acute  infective 
arthritis  as  soon  as  the  bacteria  reach  its  periphery.  The  elbow- 
joint  is  similarly  liable  to  suffer  when  bacteria  attack  the  upper 
end  of  the  ulna,  since  the  epiphysis  is  a  mere  flake  of  bone  and  the 
greater  part  of  the  olecranon  is  derived  from  the  shaft.  Sometimes 
the  junction  cartilage  is  softened  and  destroyed  by  the  organisms, 
so  that  the  inflammation  spreads  through  the  epiphysis  to  the 
articular  cartilage,  which  is  eroded,  and  the  joint  opened.  Occa- 
sionally the  pus  burrows  along  the  soft  tissues  outside  the  bone, 
as  along  the  biceps  groove  into  the  shoulder-joint. 

In  infants,  where  there  is  little  or  no  bone,  the  cartilage  may  be 
rapidly  destroyed,  and  an  opening  made  through  it  into  the  joint, 
giving  rise  to  what  was  described  by  Sir  Thomas  Smith  as  the 
acute  arthritis  of  infants. 

(</)  When  the  infecting  organisms  are  of  a  mild  type  and  the 
patient's  health  not  much  depreciated,  the  process  may  not  spread 
far  from  the  spot  first  involved,  but  may  give  rise  to  a  chronic 
abscess  in  the  bone  in  that  situation.  Naturally  this  is  not  likely 
to  occur,  except  in  regions  where  large  masses  of  cancellous  tissue 
exist,  as,  for  instance,  the  head  of  the  tibia.     It  must  not  be  for- 


DISEASES  OF  BONE 


5°5 


gotten,  however,  that  certain  epiphyses  occur  away  from  joints, 
and  chronic  abscesses  in  such  situations  as  the  great  trochanter 
may  be  explained  on  these  grounds.  A  similar  condition  is  some- 
times due  to  tubercle  (p.  519),  but  of  course  the  organisms  found 
in  the  pus  are  different,  whilst  the  tuberculous  variety  is  probably 
more  chronic  ;  otherwise  the  results  of  the  process,  clinical  and 
pathological,  are  alike. 

The   organism  generally  found  in  this  disease  is   the   Staphy- 
lococcus pyogenes   aureus,  but   occasionally  others    are  responsible 


Fig.  171. — Diagram  of  Massive   Necrosis   after  Acute  Osteomyelitis. 

(Billroth.) 

In  A  (early)  the  necrosed  tissue,  though  continuous  above  and  below  with  the 
healthy  bone,  is  surrounded  by  a  cavity  formed  by  the  stripping  up  of 
the  periosteum,  and  from  it  two  sinuses  pass  to  the  exterior  ;  in  B  (late) 
the  sequestrum  is  supposed  to  have  been  loosened  and  removed,  and  the 
cavity  remaining  is  lined  by  granulation  tissue,  and  surrounded  by  a  thick 
involucrum  of  new  bone,  in  which  two  cloacae  exist. 

for  it,  and  the  symptoms  vary  somewhat  with  the  causative 
microbe.  Thus,  if  due  to  the  Staph,  pyog.  albus,  the  process  is 
less  acute  ;  a  good  deal  of  brawny  infiltration  of  the  periosteum 
ensues,  and  necrosis  is  more  easily  prevented  by  early  treatment ; 
this  variety  is  sometimes  termed  '  periostitis  albuminosa.'  The 
Streptococcus  pyogenes,  if  present  at  all,  is  only  found  in  young 
children,  and  the  resulting  necrosis  is  often  less  extensive.     The 


506  A   MANUAL  OF  SURGERY 

Pneumococciis  has  also  been  discovered  in  this  disease,  as  well 
as  the  Bac.  coli  communis,  which  latter  only  occurs  in  association 
with  other  organisms ;  the  resulting  pus  is  very  foul. 

Clinical  History. — The  disease  usually  commences  abruptly 
with  a  rigor,  followed  by  high  fever  and  severe  pain  in  the  limb, 
which  soon  becomes  swollen,  brawny  and  congested.  It  may  at 
first  be  mistaken  for  an  acute  attack  of  rheumatism,  although  the 
fact  that  the  inte^articular  portion  is  affected,  and  not  the  articula- 
tion, should  readily  prevent  this  error.  The  pain  is  of  an  extremely 
severe  nature,  so  that  the  child  screams  whenever  the  limb  or  even 
the  bed  is  touched. 

Should  the  trouble  be  mainly  limited  to  the  periosteum, 
evidences  of  its  being  stripped  off  the  bone,  and  of  the  accumu- 
lation of  pus  beneath  it,  soon  show  themselves.  An  abscess 
forms  which  may  quickly  transgress  its  periosteal  boundary  and 
burrow  under  fascial  or  muscular  planes  ;  its  limitation  to  the 
diaphysis  has  been  already  explained  ;  but,  although  the  neigh- 
bouring joints  may  escape  infection,  they  are  very  likely  to  suffer 
from  a  serous  exudation,  and  subsequently  some  limitation  of 
movements  may  be  observed.  Sooner  or  later  the  abscess  bursts 
or  is  opened,  giving  exit  to  a  larger  or  smaller  amount  of  pus,  and 
the  subjacent  bone  is  found  bare  and  apparently  dead.  Possibly 
the  relief  of  tension  may  suffice  in  such  cases  to  limit  the  mischief, 
the  periosteum  again  becoming  adherent  to  the  bone,  and  a  cure 
being  established  without  extensive  necrosis.  More  frequently  a 
considerable  portion  of  the  shaft  loses  its  vitality,  and  has  to  be 
separated  in  the  manner  already  described,  whilst  an  involucrum 
forms  around  it  from  the  periosteum  (Figs.  171  and  172).  If  no 
septic  organisms  have  been  admitted,  no  fever  or  bad  constitutional 
symptoms  need  be  expected  during  this  later  stage.  Sometimes 
the  process  is  so  acute  as  to  cause  actual  sloughing  or  disintegra- 
tion of  the  periosteum,  so  that  its  osteogenetic  powers  are  destroyed, 
and  subsequent  repair  becomes  difficult  or  impossible. 

When  the  medulla  itself  is  more  especially  involved,  the  symp- 
toms of  pyaemia  or  of  severe  toxaemia  become  very  prominent, 
and  the  child  may  die  from  this  cause  before  the  local  mischief  has 
been  able  to  advance  very  considerably.  The  pain  will  continue 
to  be  of  a  severe  character,  although  the  patient's  perceptions  may 
be  so  blunted  by  the  toxic  condition  that  it  lies  more  or  less  un- 
conscious. The  swelling  of  the  limb  is  not  so  great  as  in  the 
former  type,  but  the  mischief  may  be  very  extensive,  and  although 
there  is  no  great  collection  of  pus  beneath  the  periosteum,  yet 
it  may  be  stripped  up  along  the  whole  length  of  the  shaft,  and  even 
detached  from  the  epiphyses  at  each  end.  Should  the  child  not 
die  of  toxaemia,  extensive  destruction  of  bone  is  certain  to  result. 

When  the  epiphysis  is  attacked,  the  symptoms  commence  in 
the  same  way,  but  are  likely  to  be  followed  by  those  of  an 
acute  suppurative  arthritis  (p.  578).      This  affection  is  sometimes 


DISEASES  OF  BONE 


507 


termed  acute  epiphysitis.  It  is  almost  limited  to  infants  and  very 
young  children,  and  is  said  to  occur  most  frequently  in  the  sub- 
jects of  inherited  syphilis.  The  head  of 
the  humerus  and  the  upper  and  lower 
ends  of  the  femur  are  the  parts  most 
commonly  involved.  In  some  of  these 
cases  the  ligaments  are  so  seriously 
weakened  and  relaxed  that  a  loose  flail- 
joint  results. 

In  the  milder  types  of  osteomyelitis, 
the  patients  complain  of  severe  pain  at  the 
end  of  some  bone  (one  type  of  growing 
pain),  and  this  may  be  attended  by  some 
degree  of  fever  and  of  local  disability. 
The  symptoms  may  quiet  down  after  a 
time  and  no  harm  result,  but  in  some 
cases  the  growth  of  the  bone  will  be 
checked  or  entirely  stopped.  In  other 
patients  a  subacute  or  chronic  abscess  may 
form  and  perhaps  come  to  the  surface, 
and  on  opening  it  a  sinus  is  found  leading 
to  the  interior  of  the  bone,  in  which  a 
sequestrum  of  cancellous  tissue  is  found. 

The  Prognosis  of  the  acute  form  is 
always  somewhat  grave.  Life  may  be 
threatened  by  pyaemia  or  toxaemia  in  the 
early  stages,  whilst  later  on  hectic,  amyloid 
disease  of  the  viscera,  and  exhaustion,  may 
terminate  the  case  if  sepsis  has  been  ad- 
mitted. 

The  utility  of  the  limb  may  be  unim- 
paired if  the  disease  has  not  been  too  ex- 
tensive, and  if  prompt  treatment  has  been  Fi(.  _Necrosis  fol. 
adopted  ;  but  if  neighbouring  joints  are  LOWING  acute  Osteo- 
affected  by  a  suppurative  arthritis,  or  if  myelitis.  (From  Speci- 
the  osteogenetic  powers  of  the.  periosteum  MEN  jn  College  of 
have  been  destroyed  by  the  acuteness  of  Surgeons'  Museum.) 
the  process,  amputation  may  be  required.  The  irregular  new  bone  of 
In  cases  which  have  recovered,  excessive  ^™S,  J  j£ 
growth  of  the  bones  sometimes  follows,  tions  of  the  sequestrum, 
owing  to  the  long-standing  hyperaemia  of 

the  part ;  but  if  the  epiphyseal  cartilage  has  been  much  affected 
the  limb  may  be  stunted  in  its  subsequent  development. 

Treatment.— Prompt  surgical  interference  must  be  adopted  in 
order,  if  possible,  to  cut  short  the  malady.  As  soon  as  the  local 
pain  and  high  fever  give  evidence  that  this  affection  is  present, 
a  free  incision  should  be  made  in  the  long  axis  of  the  limb 
through  the  periosteum,  whether  pus  can  be  detected  or  not.     The 


508  A   MANUAL  OF  SURGERY 

surgeon  will  then  proceed  to  carefully  investigate  the  condition 
of  the  bones  by  inspection  and  the  use  of  the  finger  and  probe, 
and  his  further  proceedings  will  to  a  large  extent  depend  upon 
what  is  thus  found. 

If  the  suspicions  as  to  the  existence  of  osteomyelitis  are  thereby 
confirmed,  the  most  vigorous  surgical  treatment  is  demanded,  for 
if  the  teachings  of  pathology  are  to  be  depended  on,  it  is  certain 
that  no  good  can  follow  any  half  measures  which  stop  short  of 
the  medullary  canal.  As  a  rule,  the  surgeon  will  find  himself  in 
the  neighbourhood  of  the  epiphyseal  cartilage,  and  if  the  case  has 
been  taken  in  hand  early,  it  is  possible  that  the  mischief  will  be 
quite  limited  ;  all  that  is  then  required  is  to  scrape  or  gouge 
away  the  softened  and  hyperaemic  bone  at  the  end  of  the  diaphysis, 
together  with  any  necrotic  tissue  which  may  be  present,  taking  the 
greatest  care  not  to  encroach  on  the  epiphyseal  cartilage.  The 
cavity  thus  formed  is  thoroughly  washed  with,  an  antiseptic, 
and  perhaps  swabbed  out  with  pure  carbolic  acid ;  a  drain-tube 
is  inserted,  and  in  all  probability  recovery  will  rapidly  ensue. 

If  the  case  has  gone  further,  the  periosteum  will  be  found 
stripped  from  the  bone  for  a  varying  distance,  and  possibly  the 
epiphysis  partially  or  completely  separated.  Under  these  circum- 
stances it  is  always  necessary  to  open  up  the  medullary  canal 
by  removal  of  part  of  the  compact  bone,  so  as  to  allow  the 
hyperaemic  and  gangrenous  fatty  tissue  contained  therein  to  be 
scraped  out,  and  this  proceeding  may  involve  a  considerable 
portion  of  the  shaft.  When  grave  constitutional  phenomena  are 
present,  associated  with  loosening  of  the  epiphysis,  it  will  often 
be  found  expedient  to  amputate  in  order  to  prevent  death  from 
toxaemia. 

If  the  periosteum  has  been  more  extensively  involved,  and  a 
large  amount  of  bone,  possibly  the  whole  diaphysis,  denuded, 
two  courses  are  open  to  the  surgeon :  either  to  remove  the 
whole  necrosed  area  at  once,  or  simply  to  relieve  tension  and 
wait  for  an  involucrum  to  form  before  taking  away  the  sequestrum. 
The  great  advantage  of  the  former  plan  consists  in  the  immediate 
extirpation  of  the  infective  focus,  thereby  diminishing  the  risks 
of  pyaemia  or  toxaemia,  and  preventing  the  necessity  for  further 
operative  proceedings.  On  the  other  hand,  it  is  claimed  that  the 
continued  presence  of  the  sequestrum  is  beneficial,  in  that  it 
stimulates  the  periosteum  to  new  formation  of  bone,  and  hence  it 
should  not  be  removed  until  a  sufficient  involucrum  has  formed. 
The  practice  usually  adopted  is.  as  follows  :  For  the  femur  and 
humerus  sequestrotomy  should  be  delayed ;  immediate  removal 
would  lead  to  hopeless  shortening  and  crippling  of  the  limb.  For 
the  bones  of  the  forearm  or  leg,  immediate  removal  is  perfectly 
justifiable,  since  there  is  always  a  second  bone  present  to  main- 
tain the  length  of  the  limb.  Some  surgeons  have  recommended 
that  a  bone-graft  or  suitable  rod  of  celluloid  or  ivory  should  be 


DISEASES  OF  BONE  509 


inserted  to  take  the  place  of  the  resected  diaphysis  and  stimulate 
the  osteogenetic  powers  of  the  periosteum  ;  there  is  no  objection 
to  such  an  attempt  being  made,  provided  that  asepsis  is  main- 
tained, but  it  is  very  questionable  whether  much  good  will  follow. 

When  there  is  any  doubt  as  to  the  actual  condition  of  the  bone, 
and  the  symptoms  indicate  that  the  medulla  is  not  much  involved, 
its  immediate  removal  is  undesirable  ;  the  pus  is  allowed  to 
escape  through  a  free  incision,  the  cavity  is  well  irrigated,  and 
the  stripped-up  periosteum  allowed  to  fall  back  upon  the  bone, 
and  regain  adhesions  to  it,  if  possible.  Drainage  is  provided  for, 
strict  asepsis  maintained,  and  the  discharge  soon  becomes  merely 
serous.  A  portion  of  the  bone  dies,  and  during  its  separation 
from  neighbouring  parts  becomes  incased  in  a  newly  formed 
involucrum.  When  the  sequestrum  is  free — that  is,  in  about  five 
or  six  weeks — sequestrotomy  will  be  required  ;  it  consists  in  reflect- 
•  ing  the  periosteum  from  the  new  casing,  and  in  enlarging  or 
uniting  one  or  more  of  the  cloacae,  so  as  to  allow  the  sequestrum 
to  be  withdrawn  ;  it  sometimes  expedites  matters  to  divide  the 
sequestrum  into  two  portions,  and  then  to  deal  with  each 
separately.  The  cavity  thus  left  is  well  irrigated,  and  either 
drained  or  packed  with  gauze,  so  as  to  allow  it  to  heal  from  the 
bottom  by  granulation.  Occasionally  the  operation  for  removal 
of  the  sequestrum  is  exceedingly  difficult  and  dangerous,  owing 
to  the  situation  of  the  sinuses,  and  in  some  places,  e.g.,  the 
posterior  aspect  of  the  lower  end  of  the  femur,  it  is  almost  im- 
practicable to  reach  it ;  under  such  circumstances  amputation  may 
be  preferable.  This  summary  proceeding  may  also  be  needed 
in  the  course  of  this  disease  on  account  of  pyaemia,  defective 
repair,  exhaustion  from  chronic  sepsis,  or  suppuration  in  a  neigh- 
bouring joint. 

3.  Acute  Septic  Osteomyelitis  arises  as  a  result  of  infection 
from  without,  e.g.,  in  cases  of  compound  fracture,  and  after 
amputation,  excision,  or  even  osteotomy.  The  organisms  present 
are  usually  staphylo-  or  strepto- cocci,  together  with  various 
non-pathogenic  forms.  The  clinical  history  of  a  case  involving 
the  shaft  of  a  long  bone  is  as  follows :  The  patient  during  an 
attack  of  septic  traumatic  fever  due  to  an  injury  or  operation 
has  one  or  more  rigors,  which  suggest  the  existence  of  pyaemia, 
and  is  suddenly  seized  with  severe  pain  in  the  limb,  which 
becomes  intensely  sensitive.  On  examining  the  wound,  the  soft 
parts  are  found  to  be  unhealthy  and  infiltrated,  the  lower  end  of 
the  bone  is  bare  and  yellow,  and  from  the  interior  projects  a 
stinking  mass  of  gangrenous  medullary  tissue.  Should  early  and 
efficient  treatment  not  be  undertaken,  the  patient  runs  a  consider- 
able risk  of  succumbing  to  pyaemia  or  septic  intoxication,  whiist 
a  varying  amount  of  the  interior  of  the  bone  dies  (central  or 
tubular  necrosis),  and  a  small  segment  of  its  whole  thickness  below, 
so  that  the  sequestrum  which  ultimately  separates  is  annular  and 


S'o 


A   MANUAL  OF  SURGERY 


m 


pi 


conical  (Fig.  173).  Should  the  patient  survive,  the  necrotic  tissue 
gradually  separates,  and  during  this  process  a  mass  of  new  bone  is 
formed  from  the  under  surface  of  the  periosteum,  so  that  the  shaft 
becomes  much  thickened  externally.  Hectic 
fever  may  supervene  whilst  this  is  occurring. 
The  Treatment  of  this  condition  has  been 
somewhat  modified  of  late  years.  Formerly, 
the  only  plan  adopted  was  amputation  of 
the  limb  through  the  next  joint.  At  the 
present  time  one  would  freely  open  up  the 
wound  as  early  as  possible,  flush  it  out,  and 
then  thoroughly  scrape  away  the  sloughing 
medullary  tissue  from  the  interior  of  the 
bone,  subsequently  disinfecting  the  cavity 
with  pure  carbolic  acid,  and  placing  a  drain- 
tube  or  gauze  wick  in  it  for  a  few  days.  A 
certain  amount  of  necrosis  follows,  but  with- 
out high  fever  or  toxaemia.  Should  this 
treatment  fail,  amputation  may  still  be 
resorted  to. 

A  similar  process  may  also  invade  the  short 
bones,  and  the  cancellous  extremities  of  long 
bones,  being  often  secondary  to  septic  ar- 
thritis, or  to  a  compound  fracture  involving 
such  parts.  The  local  and  general  pheno- 
mena are  very  similar  to  those  detailed 
above,  except  that  no  large  sequestra  are 
formed,  the  dead  bone  coming  away  in  small 
spicules  (one  form  of  caries  necrotica),  whilst 
the  pain  and  fever  are  less  severe,  and  there 
is  less  likelihood  of  the  development  of 
pyaemia.  Treatment  consists  in  free  drainage, 
removal  of  the  septic  tissue  and  efficient 
purification  of  the  wound. 

We  have  also  seen  one  or  two  cases  of  subacute  septic  osteomyelitis, 
involving  the  shaft  of  long  bones  after  operation,  in  which  the 
medulla  became  profoundly  altered  in  texture,  being  transformed 
into  granulation  tissue,  with  rarefaction  of  the  bony  cancelli ;  the 
process  was  associated  with  considerable  pain  and  some  amount 
of  constitutional  disturbance.  No  necrosis  followed,  but  amputa- 
tion was  necessary  on  account  of  the  extent  of  the  disease  and  the 
pain. 

Typhoid  Osteitis. 

Affections  of  the  osseous  system  are  not  uncommon  in  typhoid  fever,  and 
usually  come  on  about  the  third  week  or  during  the  early  stages  of  con- 
valescence. The  tibia  and  ribs  are  most  often  affected,  and  in  a  large  percentage 
of  cases  typhoid  bacilli,  with  or  without  pyogenic  cocci,  will  be  found.  It  is 
curious  to  note  how  long  the  organisms  may  lie  latent  in  the  tissues  before 
causing  an  abscess — in  one  case  for  seven  years.     The  trouble  commences 


'**\V 


V\ 


Fig.  173. — Tubular  or 
Conical  Seques- 
trum from  Septic 
Osteomyelitis 
after  Amputation. 


DISEASES  OE  BONE 


5" 


either  as  a  periostitis  or  osteomyelitis,  subacute  in  character,  and  tending  to 
improve  for  a  time,  and  then  relapse.  It  may  easily  develop  an  abscess,  and 
then  some  amount  of  necrosis  or  caries  may  follow  ;  thus  in  a  case  recently 
operated  on  by  one  of  us  a  considerable  sequestrum 
was  removed  from  the  upper  third  of  the  femur, 
whilst  in  the  opposite  leg  there  had  been  an  abscess 
in  a  similar  position,  but  without  death  of  bone. 
The  abscess  is  always  subacute,  often  chronic, 
and  the  affected  bone  may  be  carious  rather  than 
necrotic.  On  its  first  appearance  the  affected 
limb  should  be  elevated  and  fomented,  and  fre- 
quently the  more  acute  symptoms  will  yield  ;  but 
the  part  often  remains  enlarged,  swollen  and  tender, 
and  exacerbations  of  pain  are  not  unlikely  to  occur 
from  time  to  time,  sooner  or  later  leading  up  to  the 
formation  of  an  abscess.  When  suppuration  has 
occurred,  the  parts  must  be  freely  incised,  diseased 
bone  removed,  granulation  tissue  scraped  away,  and 
the  parts  disinfected  with  liquefied  carbolic  acid. 
The  wounds  are  usually  found  to  be  extremely 
chronic  and  indolent,  and  may  require  scraping 
several  times. 


Chronic  Inflammation  of  Bone. 

Chronic  Osteoperiostitis. — By  this  disease 
is  meant  a  chronic  inflammatory  condition 
of  the  bone,  which  results  in  overgrowth, 
thickening,  and  condensation. 

Varieties. — (a)  It  may  arise  as  a  localized 
chronic  periostitis,  traumatic,  rheumatic,  or 
syphilitic  in  origin,  or  due  to  the  close 
proximity  of  a  chronic  ulcer ;  it  is  char- 
acterized by  a  formation  of  new  bone 
beneath  the  periosteum,  the  so-called  node 
(Fig.  174).  The  cancelli  are  arranged  at 
right  angles  to  the  surface,  in  consequence 
of  the  new  tissue  forming  around  the  small 
vessels,  which  enter  the  bone  from  the 
under  surface  of  the  periosteum.  At  first 
this  new  material  is  soft  and  spongy,  but  it 
rapidly  becomes  hard  and  sclerosed,  and  a 
similar  condition  affects  the  subjacer.t 
compact  structure,  which  is  thickened  and 
indurated  by  a  new  formation  around  the 
Haversian  canals.  If  the  irritation  persists, 
as  in  the  case  of  a  chronic  ulcer,  this  condi- 
tion may  run  on  into  the  following  variety. 

(b)    The  diffuse    form    of   chronic   osteo- 
periostitis usually  originates  in  some  deep- 
seated  or  central  affection,  tuberculous  or 
syphilitic  in  nature,  and  tends  to  involve  the 
it  is  sometimes  limited  to  one  or  other  end. 


Fig.  174.  —  Chronic 
osteo  -  periostitis 
of  Tibia,  showing 
the  Fusiform 
Swelling  on  the 
Front  of  the 
Bone,  consisting 
of  Dense  Osseous 
Tissue,  and  the 
Medullary  Cavity 
encroached  upon. 
(Museum  of  Royal 
College  of  Sur- 
geons.) 

whole  bone,  although 
If  tuberculous,  there 


5i2  A  MANUAL  OF  SURGERY 

may  be  a  small  abscess  or  some  central  necrosis,  and  around  this 
focus  of  prolonged  irritation  the  bone  becomes  thick  and  indurated. 
In  the  later  stages  a  considerable  new  formation  may  occur 
beneath  the  periosteum,  and  even  the  medullary  canal  become 
entirely  obliterated.  If  syphilitic  in  origin,  it  may  be  due  to  a 
central  gumma,  or  a  general  condition  of  sclerosis  may  supervene 
without  any  special  focus. 

The  Symptoms  consist  of  deep  aching  pain  in  the  limb,  worse  at 
night,  with  perhaps  tenderness  over  some  particular  spot.  This 
latter  condition  is  especially  evident  in  cases  where  a  localized 
abscess  exists  in  the  head  of  a  bone,  such  as  the  tibia.  On 
examination  the  bone  is  felt  to  be  thickened,  and  its  surface  more 
or  less  nodulated.  If  the  disease  is  localized  and  superficial,  a 
distinct  node  may  be  felt,  consisting  of  a  hard,  fusiform,  and  tender 
swelling.  Where  the  enlargement  is  more  general,  there  is  less 
tenderness,  though  the  pain  is  constant. 

The  Diagnosis  of  such  cases  is  not  always  easy,  the  enlarge- 
ment of  the  bone  being  sometimes  mistaken  for  the  early  stage 
of  a  malignant  tumour.  The  rate  of  growth  will  be  of  little 
assistance,  since  it  is  very  variable  ;  but  a  tumour  may  have  more 
defined  limits,  and  its  tension  is  often  not  the  same  throughout. 
Skiagraphy  is  valuable  in  this  direction,  since  in  simple  chronic 
periostitis  the  bone  is  solid  and  throws  a  continuous  and  well- 
defined  shadow,  while  in  malignant  diseases  a  certain  amount  of 
soft  tissue  is  sure  to  be  present,  either  centrally  or  peripherally, 
easily  penetrated  by  the  rays,  and  hence  leaving  gaps  in  the 
shadow.  If,  in  spite  of  such  assistance,  the  case  is  still  doubtful, 
an  exploratory  incision  will  be  required. 

The  Treatment  at  first  consists  in  resting  the  limb,  applying 
counter-irritation  (e.g.,  iodine  paint  or  the  actual  cautery),  and 
giving  iodide  of  potassium  internally.  If  relief  is  not  thereby 
obtained,  an  operation  will  be  necessary.  An  incision  is  made  over 
the  whole  length  of  the  thickened  bone,  right  through  the  peri- 
osteum. This  membrane  is  now  stripped  aside  with  periosteal 
detachers,  raspatories,  etc.,  and  if  merely  a  nodular  enlargement 
is  present,  the  new  formation  is  chiselled  away.  When  the  whole 
thickness  of  the  bone  is  involved,  a  gutter  or  trench  must  be  made 
by  gouge  and  mallet,  extending  into  the  medullary  cavity,  and  its 
length  corresponding  to  the  enlargement.  The  soft  parts  are 
then  partially  drawn  together  and  the  wound  dressed.  It  is 
advisable  to  cover  it  with  protective,  so  that  the  hollow  may  fill 
with  blood-clot,  and  this  is  then  allowed  to  organize  (p.  213  ). 
If  the  wound  remains  aseptic,  and  enough  bone  is  removed,  most 
satisfactory  results  follow.  In  some  aggravated  conditions,  how- 
ever, which  have  lasted  for  many  years,  amputation  is  required. 


DISEASES  OF  BONE 


Tuberculous  Diseases  of  Bone. 

Bone  may  be  affected  in  two  ways  by  tubercle,  either  the 
periosteum  or  the  cancellous  tissue  being  primarily  involved. 

i.  In  Tuberculous  Periostitis  a  specific  infiltration  of  the 
periosteum  is  met  with,  consisting  of  a  deposit,  partly  in  that 
membrane  and  partly  under  it,  of  pulpy  granulation  tissue  con- 
taining the  characteristic  miliary  tubercles,  which  are  chiefly 
developed  around  the  vessels  passing  from  the  periosteum  into 
the  bone.  As  in  tuberculous  disease  elsewhere,  caseation  and 
suppuration  are  likely  to  follow,  leading  to  the  formation  of 
abscesses  which  are  primarily  subperiosteal,  and  filled  with  curdy 
pus ;  these  in  time  find  their  way  to  the  surface,  either  directly 
or  by  more  or  less  tortuous  channels,  and  leave  sinuses,  extending 
down  to  the  bone.  The  final  effect  of  such  a  condition  depends 
largely  on  whether  the  subjacent  bone  consists  of  thick  or  thin 
compact  tissue.  If  the  compact  bone  is  thick,  the  disease  is 
usually  localized  to  the  part  first  affected,  the  surface  of  the  bone 
escaping  entirely,  except  some  slight  superficial  erosion.  Occa- 
sionally, however,  the  disease  may  spread  along  the  periosteum 
for  some  distance,  and  even  involve  a  neighbouring  epiphysis 
or  joint.  If  the  compact  bone  is  thin,  as  in  the  bodies  of  the 
vertebrae,  the  underlying  cancellous  tissue  is  almost  certain  to  be 
secondarily  affected,  and  the  changes  to  be  immediately  described 
are  produced. 

Clinical  History. — In  the  early  stages  a  somewhat  diffuse  elastic 
or  pulpy  swelling  forms  over  the  bone,  which  is  tender  and  asso- 
ciated with  characteristic  bone  pain,  worse  at  night.  It  takes 
some  weeks  or  months  to  develop,  and  on  skiagraphy  the  under- 
lying osseous  tissue  may  appear  quite  normal  in  texture.  In  the 
latter  stages,  when  caseation  or  suppuration  is  present,  the  swelling 
often  becomes  more  defined  and  its  surface  nodulated  ;  it  then 
somewhat  resembles  an  ordinary  node,  but  is  usually  more 
irregular  in  shape,  of  somewhat  unequal  consistency,  and  on  firm 
pressure  small  portions  may  be  felt  to  give  way.  If  an  abscess 
forms,  the  pain  becomes  greater,  but  it  diminishes  as  soon  as 
tension  is  relieved  by  discharge  of  the  pus.  The  admission  of 
sepsis,  however,  increases  the  trouble.  It  is  probably  seen  in  its 
most  typical  form  in  connection  with  the  ribs. 

Treatment. — In  the  early  stages,  constitutional  treatment  may 
suffice,  together  with  rest  and  carefully  adjusted  pressure,  as 
by  strapping  with  Scott's  dressing.  The  condition,  however, 
demands  incision  if  a  neighbouring  joint  is  threatened,  or  when 
suppuration  has  occurred.  Free  removal  of  all  the  granulation 
tissue  and  softened  bone  with  a  Volkmann's  spoon  is  required, 
disinfection  of  the  cavity  with  undiluted  carbolic  acid,  and 
stuffing  it   with  gauze  soaked  in  an  emulsion   of  glycerine   and 

33 


5M 


A   MANUAL  OF  SURGERY 


purified    iodoform   (10   per   cenl.),   ihe   wound    being  allowed   to 
granulate  from  the  bottom. 

2.  Tuberculous  Osteitis  always  arises  in  cancellous  tissue,  and 
it  affects  the  short  bones,  or  the  shafts  or  ends  of  long  ones. 

(a)  The  short  bones  of  the  hands  and  feet  are  very  liable  to  this 
condition.  It  occurs  in  weakly  children  with  a  tuberculous  in- 
heritance, or  in  those  whose  general 
health  has  been  depressed  by  one 
of  the  exanthemata,  or  sometimes 
in  those  otherwise  healthy.  Some 
slight  injury  may  determine  the 
onset  of  the  attack,  which  fre- 
quently involves  several  bones 
simultaneously.  When  the  pha- 
langes are  involved,  the  disease  is 
known  as  Tuberculous  Dactylitis. 

Clinical  History. — The  affected 
bone  becomes  slowly  enlarged, 
expanded,  and  painful,  the  pain 
being,  however,  slight  in  amount, 
though  generally  worse  at  night 
This  continues  for  some  time,  until 
finally  one  spot  rapidly  increases 
in  size,  becoming  red  and  tender, 
and  finally  an  abscess  forms,  which 
bursts  or  is  opened,  leaving  a 
sinus,  down  which  a  probe  can  be 
passed  into  the  carious  interior  of 
the  bone.  Occasionally  contiguous 
joints  are  involved  in  this  process, 
whilst  the  tendon  sheaths  are  also 
liable  to  be  affected  ;  a  large  por- 
tion of  the  swelling  is  due  to 
periosteal  infiltration  (Fig.  175). 

Pathology. — A  deposit  of  tubercle 
bacilli  occurs  in  or  around  the 
bloodvessels  in  the  interior  of 
the  bone,  which  may  have  been 
previously  rendered  somewhat 
hyperaemic  as  the  result  of  an 
injury.  The  organisms  produce 
their  usual  effect,  viz.,  transformation  of  the  normal  medullary 
tissue  into  pulpy  granulation  tissue  containing  tubercles,  the  bony 
cancelli  becoming  meanwhile  eroded  and  rarefied,  and  the  bone 
corpuscles  undergoing  fatty  degeneration  (vide  Caries,  p.  498). 
Sequestra  occasionally  form,  but  more  often  in  adults  than  in 
children,  owing  to  the  greater  density  of  the  bone  in  the  former. 
They  are  due  to  a  cutting-off  of  the  blood-supply  of  a  definite 


Fig.  175.  —  Tuberculous  Dac- 
tylitis.    (Royal  College  of 

Surgeons'  Museum.) 

This  disease  started  in  the  proxi- 
mal phalanx,  and  has  perforated 
it  anteriorly,  the  tubercu'ous 
material  having  involved  the 
periosteum  and  tendon  sheath, 
whilst  the  first  inter-phalangeal 
joint  is  becoming  invaded. 
There  is  also  a  considerable 
formation  of  granulation  tissue 
on  the  dorsal  aspect. 


PLATE  XXV 


Tuberculous  Disease  of  Radius. 
The  patient  was  a  lady  over  fifty  years  of  age,  who  had  suffered  for  some  months 
from  pain  and  swelling  of  this  bone.     The  site  and  extent  of  the  disease  is 
indicated  by  the  light  area  in  the  shadow  of  the  bone.     Eventually  amputa- 
tion was  required. 

To  face  p.  514.] 


DISEASES  OE  BONE 


5'5 


portion  of  the  bony  tissue,  either  as  a  result  of  tuberculous 
endarteritis,  or  from  early  caseation  within  the  cancel li  of  the 
whole  of  the  granulation  tissue.  The  sequestra  are  usually 
yellowish  white  in  colour  from  the  presence  of  the  caseating 
tissue  in  their  substance,  and  are  seldom  completely  separated 
from  the  surrounding  bone ;  thus,  they  are  often  quite  clear 
superficially  and  laterally,  but  adherent  on  the  deeper  side. 
When  the  tuberculous  disease  does  not  involve  the  whole  bone, 
the  nearest  healthy  'tissue  may  become  sclerosed,  and  thus  one 
not  unfrequently  finds  a  central  sequestrum  surrounded  by 
rarefied  bone  which  merges  into  an  area  of  sderosed  tissue. 
When  a  tuberculous  focus  becomes  septic,  the  destructive  process 
increases  in  rapidity,  and  minute  spiculated  sequestra  often  come 
away  in  the  discharge.  The  term  expansion  of  bone  used  above  is 
perhaps  scarcely  correct,  inasmuch  as  the  enlargement  is  due  to 
absorption  on  the  inner  aspect,  whilst  there  is  a  new  formation  of 
bone  under  the  periosteum.  Skiagraphy  is  a  useful  adjunct  in 
estimating  the  amount  of  disease  present,  since  the  affected  bone 
is  less  dense,  and  consequently  light  areas  appear  in  the  midst  of 
the  dark  shadow  cast  by  the  bone  (see  Plate  XXV.). 

The  Treatment  of  tuberculous  dactylitis  in  the  early  stages 
consists  in  attention  to  the  general  health,  together  with  rest 
locally,  and  perhaps  strapping  the  parts  with  Scott's  dressing. 
Should  the  disease  progress  in  spite  of  such  measures  operation 
must  not  be  unduly  delayed,  since  neighbouring  joints  and  tendon 
sheaths  are  very  likely  to  be  attacked.  An  incision  is  made  down 
to  the  bone  at  some  suitable  spot  where  tendons  or  other  im- 
portant structures  will  not  be  injured  ;  the  periosteum  is  divided, 
and  the  outer  layer  of  compact  bone  removed  by  gouge  or 
trephine,  so  as  to  allow  the  diseased  medulla  to  be,  scraped  away 
with  a  Volkmann's  spoon.  When  all  the  tuberculous  tissue  has 
been  eliminated,  the  cavity  thus  produced  is  swabbed  out  with 
liquefied  carbolic  acid,  and  stuffed  with  gauze  soaked  in  an 
iodoform  emulsion,  in  order  to  ensure  healing  by  granulation. 
Unless  this  scraping  is  thorough,  recurrence  is  very  likely  to 
ensue,  but  the  integrity  of  epiphyses  and  of  articular  cartilages 
must  be  respected.  When  an  abscess  or  a  sii  us  exists,  the  same 
measures  must  also  be  adopted.  Not  unfrequently  the  growth  of 
the  bone  is  very  considerably  hindered  either  by  the  disease  or 
by  the  treatment  requisite  in  order  to  eradicate  it,  and  the  part 
becomes  stunted  or  deformed  in  consequence. 

(b)  Any  of  the  bones  of  the  tarsus  may  be  involved  in  exactly  the 
same  manner,  the  clinical  history  and  treatment  being  identical, 
although  possibly  articular  lesions  are  somewhat  more  common 
than  when  the  disease  is  limited  to  the  phalanges.  The  affected 
portion  of  the  foot  becomes  swollen,  shiny,  and  pulpy,  since  the 
overlying  periosteum  is  often  involved  in  the  process  ;  and  it  is 
sometimes  difficult  to  determine  whether  the  lesion  is  limited  to 

33—2 


5"> 


A    MANUAL  OF  SURGERY 


the  bones  or  also  involves  the  joints.  In  the  early  stages  one 
part  of  the  foot  may  he  more  swollen  than  another,  according  to 
the  location  of  the  trouble.  The  os  calcis  is  most  often  affected, 
and  afterwards,  in  order  of  frequency,  come  the  first  metatarsal, 
astragalus  (the  head),  and  scaphoid.  When  it  starts  in  the 
astragalus,  the  swelling  occurs  below  the  level  of  the  ankle-joint 
in  front  of  or  behind  the  malleoli,  whilst  pressure  over  the  head 
of  the  bone  gives  rise  to  pain.  The  foot  is  usually  in  a  position 
of  equinus,  but  not  to  such  a  marked  degree  as  when  the  ankle- 
joint  itself  is  affected  ;  the  subastragaloid  movements  (inversion 
and  eversion,  abduction  and  adduction)  are  also  considerably 
limited,  or  may' be  absent.  An  examination  of  the  accompanying 
illustration  (Fig   176)  will  explain  the  fact  that  tuberculous  disease 


Fig.  176. — Arrangement  of  Synovial  Membranes  of  Foot. 

1,  Posterior  calcaneo-astragaloid,  behind  the  interosseous  ligament ;  2,  anterior 
calcaneo-astragaloid  and  astragalo-scaphoid  ;  3,  calcaneo-cuboid  ;  4,  cubo- 
metatarsal ;  5,  the  large  common  sac  between  scaphoid  and  cuneiform, 
between  the  cuneiform,  and  between  the  cuneiform  and  second  and  third 
metatarsals  ;  6,  between  the  internal  cuneiform  and  first  metatarsal 

starting  in  the  astragalus  is  very  likely  to  involve  the  ankle-joint, 
or  to  spread  to  the  os  calcis  or  scaphoid.  Disease  of  the  os  calcis 
leads  to  more  limited  swelling  of  the  back  of  the  foot  on  one  or 
both  sides  of  the  heel ;  the  movements  of  the  ankle  will  not  be 
impaired,  although  walking  is  painful,  and  hence  the  patient 
limps,  treading  only  on  the  toes.  Further  forwards  tuberculous 
disease  is  most  likely  to  start  in  or  around  the  scaphoid,  the 
bulbous  swelling  of  the  foot  being  then  shifted  anteriorly,  and 
the  movements  of  the  ankle  remaining  unimpaired.  The  prognosis 
is  much  worse  when  the  disease  attacks  the  inner  half  of  the  foot, 
comprising  the  astragalus,  scaphoid,  cuneiform,  and  three  inner 
metatarsal  bones,  owing  to  the  arrangement  of  the  synovial 
membranes,  than  when  it  affects  the  outer  segment  consisting  of 
the  cuboid  and  two  outer  metatarsals,  which  are  excluded  from 


DISEASES  OF  BONE 


5'7 


the  general  synovial  membrane,  and  are  thus  more  amenable  to 
treatment. 

Sooner  or  later  suppuration  occurs  with  increased  pain,  and, 
should  the  sinus  which  results  from  opening  the  abscess  become 
septic,  the  trouble  is  sure  to  spread  much  more  rapidly,  and  the 
prognosis  becomes  increasingly  grave. 

Treatment  is  conducted  according  to  the  rules  which  always 
guide  us  in  that  of  tuberculous  disease.  In  the  early  stages  the 
foot  and  ankle  arc  immobilized,  and  preferably  in  plaster  of  Paris 
or  water-glass.  The  child  is  sent  to  the  seaside,  and  plenty  of 
good  food  administered,  and  it  is  not  allowed  to  walk  until  all 
pain  has  ceased;  even  then  the  plasler  case  must  be  retained  until 


Fig.  177. 


-Chronic  Abscess  in  the  Lower  End  of  the  Tibia. 
(Kings'  College  Museum.) 


the  swelling  has  entirely  disappeared.     It  is  wise  to  remove  the 
plaster  every  month  or  two  for  inspection  and  readjustment. 

Should  the  disease  persist  in  spite  of  such  treatment,  or  should 
suppuration  occur,  removal  of  the  tuberculous  tissue  by  operation 
may  be  required.  If  the  os  calcis  alone  is  involved,  it  will  usually 
suffice  to  open  well  into  it  either  from  one  or  both  sides,  to  scrape 
out  its  interior  and  then  pack  it  with  iodoform  and  gauze  after 
disinfecting  it  with  liquefied  carbolic  acid.  Decalcified  bone  chips 
mixed  with  iodoform  have  been  packed  into  the  cavity  in  order 
to  hasten  bony  consolidation,  but  not  with  much  success ;  in  any 
case  the  interior  of  the  bone  becomes  occupied  by  fibrous  tissue, 
with    perhaps    a   few   bony  spicules,  and    a    marked    permanent 


5«8 


A  MANUAL  OF  SURGERY 


depression  always  remains  at  the  site  of  operation.  Excision  of  the 
os  calcis  was  formerly  practised,  but  is  not  to  be  recommended, 
since  even  if  performed  subperiosteally,  the  power  of  repair 
that  remains  is  very  slight.  If  the  disease  mainly  affects  the 
astragalus,  it  may  suffice  to  remove  it  entirely,  neighbouring 
articulations  being  curetted,  if  need  be ;  but  probably  the  disease 
will  have  spread  so  far  that  amputation  will  be  required,  and  then 
Syme's  operation  is  better  than  methods  such  as  Pirogoff's,  which 
retain  any  portion  of  the  tarsus.  Disease  of  the  cuboid  and  outer 
half  of  the  foot  in  front  of  the  os  calcis  can  often  be  dealt  with 


B 


^f7 


p£$fcu  ^ 


Fig.  178. — Lower   End  of  Tibia   affected   with  Tuberculous  Disease. 
(From  King's  College  Museum.) 

In  A,  a  subperiosteal  deposit  of  new  bone  is  seen  surrounding  an  opening 
(cl),  which  leads  into  the  interior  of  the  bone  ;  in  B,  the  interior  of  the 
same  bone  is  seen,  and  shows  a  sequestrum  (S)  just  above  the  epiphyseal 
line.     The  ankle  joint  is  healthy. 

efficiently  by  scraping,  but  when  the  common  synovial  membrane 
on  the  inner  side  is  involved,  amputation  will  probably  be  required, 
failing  success  by  conservative  measures. 

(c)  If  the  tuberculous  disease  affects  the  ends  of  long  bones,  it  most 
commonly  starts  in  the  epiphysis,  or  under  the  articular  cartilage, 
though  sometimes  on  the  shaft  side  of  the  epiphyseal  cartilage. 
The  changes  already  described  take  place,  and  lead  to  early 
destruction  of  the  latter  cartilage,  so  that  the  adjacent  parts 
of   both  epiphysis   and    diaphysis   become  involved  (tuberculous 


DISEASES  OF  BONE 


5'9 


epiphysitis).  The  general  signs  are  similar  to  those  present 
when  the  smaller  bones  are  affected,  but  the  results  produced 
may  vary  considerably,  (i.)  In  the  slighter  forms,  where  efficient 
treatment  is  adopted,  the  tuberculous  tissue  may  be  totally  ab- 
sorbed, and  the  process  thus  comes  to  an  end,  though  the  affec- 
tion of  the  epiphyseal  cartilage  may  lead  to  subsequent  impair- 
ment of  growth,  (ii.)  In  others  it  may  be  circumscribeel  by  the 
bone  becoming  sclerosed  around  a  caseating  focus,  and  then,  if 
suppuration  ensues,  a  deep  abscess  in  the  cud  of  the  bone  may  be 
produced  (Fig.  177).  Such  is  rarely  of  large  size,  containing 
at  most  1  or  2  drachms  of  curdy  pus,  and  is  lined  by  a  definite 
pyogenic      membrane      of 

the  usual  tuberculous  type.  -    -  ~^' .     % 

The   effects   produced    by 
this   condition  are   similar 

to  those  of  chronic  osteo-  *         '& 

periostitis,  viz.,  a  deep 
aching  or  boring  pain  in 
the  bone,  worse  at  night, 
together  with  enlargement 
of  the  affected  part,  whilst 
one  spot  is  often  very 
tender  on  palpation.  If  it 
has  existed  for  any  length, 
of  time,  the  whole  shaft 
may  become  enlarged  as  a 
result  of  chronic  osteo-peri- 
ostitis  (p.  511).  (iii.)  The 
disease  may  burrow  along 
the  epiphyseal  line,  and 
find  its  way  into  the  neigh- 
bouring joint,  if  the  epi- 
physis is  intra -articular, 
as  in  the  hip  ;  but  if  the 
epiphyseal  cartilage  is 
placed  beyond  the  limits  of 
the  capsule,  a  subperiosteal 
extra-articular  abscess  will 
result  (Fig.  178).  Should  the  disease  spread  equally  in  all 
directions,  the  epiphysis  may  actually  be  separated,  (iv.)  A 
more  common  result  is  for  the  whole  or  part  of  the  cancellous 
tissue  of  the  epiphysis  to  become  involved,  and  the  joint  to  be 
secondarily  affected  with  tuberculous  arthritis,  either  by  perfora- 
tion, erosion,  or  necrosis  of  the  articular  cartilage,  or  by  extension 
to  the  synovial  membrane  around  its  margins,  (v.)  The  process 
may  sometimes  extend  upwards  along  the  medulla  into  the  shaft, 
causing  a  diffuse  osteo-periostitis  with  or  without  a  medullary 
abscess  (Fig.  179). 


Fig.  179. — Localized  Abscess  in  the  Lower 
End  of  the  Femur,  extending  from 
the  Epiphyseal  Line  upwards  into  the 
Medulla.  (From  Specimen  in  the 
College  of  Surgeons'  Museum.) 


520  A   MANUAL  OF  SURGERY 


The  Treatment  of  tuberculous  epiphysitis  is  conducted  in  the 
first  place  by  absolute  immobilization  and  hygienic  measures  ;  but 
the  surgeon  must  not  be  tempted  to  trust  too  long  to  such  a 
regime,  for  fear  of  the  joint  becoming  also  affected.  As  soon  as 
possible,  an  opening  should  be  made  into  the  interior  of  the 
epiphysis,  and  all  the  pulpy  granulation  tissue,  caseous  debris,  or 
diseased  bone  removed  with  a  sharp  spoon,  the  cavity  being  sub- 
sequently disinfected,  and  stuffed  with  gauze  infiltrated  with 
iodoform.  Of  course,  the  utmost  care  must  be  taken  not  to  open 
the  joint  by  scraping  through  the  articular  cartilage.  Where  a 
chronic  abscess  exists  in  the  end  of  a  bone,  a  trephine  should  be 
applied  over  the  tender  spot,  and,  if  the  cavity  is  not  at  first 
opened,  the  bone  may  be  drilled  in  different  directions  to  ascertain 
whether  or  not  pus  exists. 

(d)  The  medullary  canal  of  the  shaft  of  a  long  bone  sometimes 
becomes  the  seat  of  tuberculous  disease ;  this,  as  also  the  abscess 
of  bone  described  above,  is  more  common  in  adults  than  in 
children.  The  part  thus  affected  becomes  carious,  with  or  with- 
out the  formation  of  sequestra  or  pus;  but  the  most  marked 
feature  of  this  deep-seated  central  trouble  is  that  the  whole  bone 
passes  into  a  state  of  chronic  inflammation,  which  we  have 
described,  as  well  as  the  treatment  necessary  for  it,  under  the 
title  of  chronic  diffuse  osteo-periostitis  (p.  511). 

Syphilitic  Diseases  of  Bone. 

The  osseous  tissues  may  be  involved  in  acquired  syphilis  in 
either  the  secondary  or  the  tertiary  periods. 

In  the  Secondary  Stage  flying  pains  about  the  bones  (sometimes 
termed  osteocopic)  are  often  complained  of ;  they  are,  however, 
of  but  little  importance,  and  disappear  rapidly  as  the  patient  gets 
under  the  influence  of  mercury.  In  the  late  secondary  or  early 
tertiary  periods,  a  periosteal  node  is  often  met  with,  as  a  result 
of  chronic  periostitis.  It  usually  affects  only  one  bone,  and  most 
commonly  the  tibia,  and  consists  of  an  infiltration  and  thickening 
of  the  periosteum,  which  may  entirely  disappear,  but  later  on  is 
accompanied  by  a  formation  of  new  bone.  This  is  at  first  spongy 
and  soft  in  character,  but  after  a  while  becomes  hard  and 
sclerosed ;  the  Haversian  canals  are  always  placed  at  right  angles 
to  the  subjacent  osseous  tissues.  When  such  has  once  occurred, 
absorption  of  the  newly  formed  bone  does  not  readily  follow, 
even  under  treatment,  the  part  perhaps  remaining  permanently 
thickened.  It  is  recognised  clinically  as  a  fusiform  swelling, 
a  little  tender  on  pressure,  and  the  seat  of  deep  aching  pain, 
usually  worse  at  night.  It  must  be  understood  that  the  pain 
is  not  so  much  associated  with  the  onset  of  night  as  with  the 
increased  warmth  of  the  limbs  when  in  bed  ;  indeed,  patients  with 
syphilitic  tibia?  frequently  sleep  with  their  legs  exposed.     Night- 


DISEASES  OF  BONE 


521 


watchmen  and  others,  on  the  contrary,  complain  of  pain  during 
the  day,  when  they  take  their  rest.  Suppuration  does  not  often 
occur,  and  constitutional  rather  than  local  treatment  is  required. 

In  the  Tertiary  Period  the  bones  may  participate  in  the  changes 
which  involve  any  and  every  tissue  of  the  body.  These  consist 
in  an  infiltration  and  overgrowth  of  the  connective  tissues,  which 
if  diffused  through  an  organ  produce  sclerosis,  if  localized  to  one 
spot  lead  to  the  formation  of  a  gumma.  Hence  the  following 
lesions  are  met  with  : 

(a)  The  formation  of  subperiosteal  gummata,  either  localized  or 
diffuse,  probably  resulting  in  caries  of  the  subjacent  bone  ;  if  the 
affection  is  limited,  only  a  small  portion  may  be  thus  involved;  but 


HG.    iSo. 


-Diffuse  Gummatous  Disease  and  Caries  of  the  Skull. 
(From  King's  College  Museum.) 


where  it  is  widely  diffused,  an  extensive  surface  of  the  bone  may 
become  eroded  and  irregular.  This  process  is  sometimes  accom- 
panied by  a  development  of  new  bone  under  the  adjacent  peri- 
osteum, and  is  very  often  complicated  by  sclerosis  and  necrosis. 
The  calvarium  is  the  part  most  frequently  involved  in  this  change, 
but,  owing  to  the  osteogenetic  powers  of  the  pericranium  being 
small,  there  is  rarely  any  new  formation  of  bone  in  the  neigh- 
bourhood, and  thus  the  skull  may  present  a  curious  worm-eaten 
appearance  (Fig.  180).  Frequently  the  gummata  break  down  and 
destroy  the  superficial  scalp  tissues,  leaving  deep  and  extensive 
wounds,  discharging  an  abundance  of  foul  pus,  at  the  bottom  of 
which  bare  and  even  dead  bone  may  be  felt. 


522 


A   MANUAL  OF  SURGERY 


(b)  At  the  same  time  a  condition  of  sclerosis  may  be  produced 
in  the  underlying  or  surrounding  parts,  and  this  may  progress  to 
such  a  degree  as  to  seriously  compress  and  constrict  the  vessels 
in  the  Haversian  canals.  Moreover,  an  obliterative  endarteritis 
is  almost  always  present,  and  these  factors,  combined  with  the 
separation  of  the  periosteum  by  the  above-mentioned  gummatous 
changes,  so  interfere  with  the  vitality  of  the  bone,  that  should 
sepsis  occur  in  the  broken-down  gummata,  necrosis  is  almost 
certain  to  ensue,  especially  in  the  skull. 

The  effects  produced  vary  considerably  in  different  cases,  and 
especially  with  the  situation.     When  the  calvarimn  is  attacked, 

septic  phenomena  are  com- 
monly present,  and  necrosis 
is  a  usual  accompaniment 
of  the  gummatous  changes. 
The  process  in  such  a  case, 
as  is  represented  in  Fig.  181, 
would  probably  be  as 
follows  :  The  pericranium 
corresponding  to  the  necrotic 
area  became  gummatous, 
and  at  the  same  time  the 
subjacent  bone  underwent 
sclerosis.  Sooner  or  later 
the  gummata  burst  or  were 
opened;  septic  changes 
supervened,  and  the  scalp 
tissues  were  stripped  off  the 
calvarium  to  the  limits  of 
the  disease,  necrosis  result- 
ing in  the  sclerosed  area  of 
bone.  A  line  of  rarefaction 
subsequently  formed  around 
the  sequestrum  in  conse- 
quence of  Nature's  attempts  to  separate  it.  The  disease  is  marked 
by  its  extreme  chronicity,  the  sequestrum  lying  bare  in  the  wound 
perhaps  for  years  without  being  separated,  owing  to  the  slight 
degree  of  vascularity  and  the  extreme  condensation  of  the  sur- 
rounding parts.  Moreover,  as  explained  above,  there  is  an  entire 
absence  of  an  involucrum.  In  the  shafts  of  long  bones,  where  the 
compact  tissue  is  thick  and  resistant,  there  may  be  extensive 
periosteal  disease,  with  but  little  affection  of  the  underlying 
parts ;  but  if  this  compact  layer  is  thin,  and  especially  when  the 
cancellous  ends  are  involved,  a  considerable  amount  of  destruction 
from  caries  may  result,  though  if  sepsis  is  not  admitted  there  will 
be  an  entire  absence  of  necrosis. 

In  the  Treatment  constitutional  remedies,  in  the  form  of  iodide 


FiG.  181. — Syphilitic  Necrosis  of  the 
Skull 

The  sequestrum  is  becoming  separated,  and 
a  ring  of  caries  is  forming  around  it 


DISEASES  OF  BONE  523 


of  potassium  and  mercury,  should,  if  possible,  be  depended  on. 
Gummata  should  never  be  opened  without  the  strictest  attention 
to  asepsis.  If  sepsis  has  occurred,  the  wounds  may  be  treated  by 
applying  iodoform  and  dressing  with  lint  steeped  in  lotio  nigra, 
or  covered  with  mercurial  ointment.  Counter-openings  are  often 
required  for  purposes  of  drainage,  especially  in  the  scalp.  Necrosed 
portions,  when  separated,  are  to  be  removed,  carious  tissue  may 
be  scraped  away  with  a  sharp  spoon,  and  the  surface  powdered 
with  iodoform  and  dressed  antiseptically.  In  the  calvarium  no 
attempt  must  be  made  to  chisel  away  the  dead  bone. 

(c)  Occasionally  a  gummatous  osteomyelitis  is  met  with,  in  which 
a  gumma  forms  in  the  interior  of  a  bone.  It  results  in  the 
so-called  expansion  of  bone  and  secondary  thickening  and  enlarge- 
ment of  its  whole  structure,  i.e.,  a  diffuse  osteo-periostitis.  The 
symptoms  are  the  same  as  those  described  for  the  latter  affection, 
and  if  it  resists  the  administration  of  anti-syphilitic  remedies,  it 
must  be  treated  in  the  same  way,  viz.,  by  separation  of  the 
periosteum,  freely  opening  the  medullary  cavity,  and  removing  all 
diseased  tissue.  These  cases  when  affecting  the  long  bones  have 
often  been  mistaken  for  malignant  growths  ;  necessarily,  it  is  a 
matter  of  the  most  vital  importance  to  come  to  a  right  conclusion 
as  to  their  nature.  The  greater  rapidity  of  growth  in  the  syphilitic 
cases,  and  the  evidences  of  syphilis  elsewhere,  or  of  a  syphilitic 
history,  will  often  guide  the  surgeon  to  a  right  conclusion  ;  but  if 
there  is  any  doubt  an  exploratory  incision  should  always  be  under- 
taken before  amputation  is  resorted  to. 

In  Inherited  Syphilis  any  of  the  above  manifestations  may  be 
seen,  but  with  more  or  less  special  features  added,  and,  in  addition 
to  these,  certain  forms  which  do  not  occur  in  the  acquired  type  of 
the  disease  have  been  described. 

1.  A  new  formation  of  bone  beneath  the  periosteum  is  perhaps 
the  most  frequent  result,  and  this  occurs  with  but  little  pain. 
Perhaps  the  most  common  situation  of  this  lesion  in  infants  is  the 
calvarium,  where  bony  masses  known  as  Parrot's  nodes  form  around 
the  anterior  fontanelle,  causing  the  top  of  the  skull  to  resemble  a 
'  hot  cross  bun  '  in  shape.  In  the  early  stages  the  bone  is  soft  and 
spongy,  and  on  post-mortem  examination  is  dark  red  or  maroon 
in  colour.  If  the  process  is  not  checked  by  suitable  anti-syphilitic 
treatment,  the  newly-formed  osseous  tissue  becomes  dense  and 
sclerosed,  and  the  deformity  may  then  persist  through  life 
(Fig.  18,  p.  138).  Any  part  of  the  calvarium  may,  however,  be 
affected,  and  the  change  is  not  necessarily  limited  to  the  first 
years  of  life. 

2.  A  similar  condition  is  met  with  in  the  shafts  of  long  bones, 
due  to  the  deposition  of  alternating  lamellae  of  soft  and  hard  bone, 
outside  the  ordinary  compact  tissue. 

3.  Syphilitic   epiphysitis    (or,    as    it    is    termed,    syphilitic   osteo- 


524  A   MANUAL  OF  SURGERY 


■  hondntis)  is  a  lesion  characterized  by  enlargement  of  the  ends 
of  the  bones,  met  with  in  infants,  and  somewhat  resembling 
rickets,  but  coming  on  at  an  earlier  date.  The  enlargement  is 
mainly  situated  in  the  epiphysis,  but  not  uncommonly  extends 
some  way  along  the  shaft,  thus  contrasting  forcibly  with  rickets. 
Occasionally  only  one  side  of  the  epiphysis  is  affected.  The 
change  commences  in  the  zone  of  calcified  cartilage  nearest  the 
diaphysis,  which  becomes  friable,  opaque,  and  irregular,  and  as 
the  condition  progresses  it  may  be  transformed  into  granulation 
tissue,  so  that  separation  of  the  epiphysis  follows.  This  in  turn 
sometimes  results  in  suppuration  and  acute  arthritis,  or  the  limb 
hangs  powerless  in  a  condition  known  as  syphilitic  pseudo-paralysis. 
The  disease  is  usually  symmetrical,  and  often  multiple,  and  situated 
in  much  the  same  positions  as  rachitic  affections,  the  knees,  elbows, 
and  wrists  being  perhaps  most  often  affected. 

4.  A  symmetrical  overgrowth  of  the  tibiae,  perhaps  combined 
with  an  anterior  curvature,  also  occurs  in  syphilitic  children, 
resulting  in  permanent  elongation  of  the  legs  (p.  400). 

5.  Craniotabes  consists  of  a  localised  absorption  of  the  osseous 
tissue  of  the  cranium,  leaving  small  areas  where  the  bone  is  thinned 
or  absent,  so  that  on  pressure  a  sensation  of  crackling,  like  that  of 
parchment,  is  imparted  to  the  finger.  It  occurs  most  frequently 
in  the  parietal  bone  (in  60  per  cent,  alone ;  in  95  per  cent,  witli 
other  bones — Carpenter'-''),  and  in  the  majority  of  cases  within  the 
first  six  months  of  life,  a  fact  that  throws  considerable  doubt  on 
the  idea  that  it  is  due  to  rickets. 

The  Treatment  of  syphilitic  lesions  in  children  must  be  earned 
out  in  acccordance  with  general  principles,  and  mainly  by  the 
administration  of  suitable  drugs. 

Rickets. 

Rickets  is  a  general  disease  of  malnutrition,  occurring  in 
children,  and  manifesting  itself  mainly  in  lesions  connected  with 
the  bones.  It  usually  commences  within  the  first  three  years  of 
life,  but  sometimes  appears  later. 

Causes. — Any  and  every  fault  in  the  hygienic  and  dietetic  treat- 
ment of  a  child  seems  capable  of  inducing  rickets ;  but  the  most 
important  factor  in  its  aetiology  is  insufficient  or  improper  food, 
especially  the  too  early  administration  of  starchy  materials, 
whilst  uncleanliness  and  want  of  air  and  light  also  predispose  to 
it.  Prolonged  lactation  is  not  necessarily  a  cause,  if  the  mother 
is  healthy  and  capable  of  feeding  the  child  ;  but  amongst  poor 
patients  this  habit  is  frequently  responsible  for  its  appearance, 
although   in   Japan,   where   the  children  are  suckled   for  two  or 

*  Carpenter.  '  Syphilis  of  Children  in  Every-day  Practice.'  Bailliere, 
Tindall  and  Cox.      1901. 


DISEASES  OF  BONE  525 


three  years,  the  disease  is  unknown.  Rickets  is  common  in 
the  poorer  classes,  who  are  herded  together  in  small  and  badiy 
ventilated  rooms,  and  is  so  peculiarly  frequent  in  this  country 
as  to  be  known  in  Germany  as  the  '  English  disease  '  (Englischt 
kvankheit). 

The  Symptoms  may  be  divided  into  the  early  or  general,  and  the 
later  or  osseous.  The  general  symptoms  are  mainly  referable  to  a 
state  of  irritability  of  the  gastro-intestinal  mucous  membrane.  The 
child  may  be  fat  and  flabby,  or  thin  and  emaciated  ;  the  mucous 
membranes  are  pale,  and  vomiting  and  diarrhoea  are  constantly 
present,  the  motions  being  often  green,  slimy,  and  very  offensive. 
The  spleen  is  enlarged,  the  abdomen  tumid,  and  profuse  sweating 
of  the  head  is  very  characteristic. 

The  commencement  of  the  osseous  changes  is  usually  indicated  by 
increasing  irritability  and  restlessness,  the  child  tossing  off  his 
bed-clothes  at  night,  and  crying  out  when  handled  or  touched. 
The  articular  ends  of  the  long  bones  become  enlarged,  as  also  the 
junction  of  the  costal  cartilages  with  the  ribs.  Sooner  or  later 
the  shafts  of  the  long  bones  soften,  and  may  bend  in  various 
directions,  and  thus  many  deformities  may  be  produced. 

The  head  usually  becomes  flattened  antero-posteriorly,  so  that 
the  forehead  appears  square  in  shape  and  enlarged,  whilst  frontal 
bosses  may  develop  on  either  side,  due  to  new  formation  of  bone 
under  the  periosteum  ;  it  is  a  question,  however,  whether  these  are 
not  syphilitic  rather  than  rachitic  in  origin.  The  fontanelles  remain 
open  much  longer  than  usual,  and  craniotabes  is  said  to  occur. 
The  teeth  do  not  erupt  till  late,  and  are  stunted,  defective  in 
enamel,  and  easily  eroded,  so  that  the  ends  of  the  incisors  are 
often  concave  ;  they  must  not  be  mistaken  for  syphilitic  teeth, 
since  the  concavity  is  a  small  arc  of  a  large  circle,  whilst  the 
typical  notch  of  syphilis  is  a  large  segment  of  a  small  circle. 

The  spine  may  be  affected  by  kyphosis  (p.  386),  or  less  frequently 
by  scoliosis  (p.  381)  ;  the  kyphotic  curve  results  when  the  patient 
is  allowed  to  lie  too  much  in  bed  with  the  head  on  a  high  pillow, 
or  if  it  is  carried  about  with  a  curved  back ;  scoliosis  more  often 
occurs  when  the  patient  is  able  to  walk.  Occasionally  the  two 
conditions  are  associated  in  the  same  child,  a  kypho-scoliosis 
resulting,  which  is  usually  due  to  its  being  carried  about  sitting 
on  a  nurse's  arm  with  the  pelvis  tilted. 

Changes  in  the  thorax  are  produced  by  enlargement  of  the 
costo-chondral  junctions  (beaded  ribs),  which,  when  present  on 
either  side  of  the  sternum,  produce  what  is  known  as  the  rickety 
rosary.  If  there  is  any  obstruction  to  the  entrance  of  air  into  the 
lungs,  as  from  a  tracheitis  or  bronchitis,  the  atmospheric  pressure 
may  cause  the  softened  bone  and  cartilage  to  sink  inwards,  and 
as  a  result  of  this  the  sternum  may  be  pushed  forwards  {pigeon 
breast),  whilst  the  curvature  of  the  ribs  at  the  angle  is  increased. 
A  very  characteristic  feature  of  the  rickety  change  consists  in  the 


526 


A  MANUAL  OF  SURGERY 


lateral  groove  thus  produced  on  each  side  of  the  sternum,  which 
may  meet  with  a  transverse  depression  below,  caused  by  the 
projection  of  the  lower  ribs  by  the  tumid  abdomen. 

The  pelvis  is  flattened  antero- 
posterior^, or  more  rarely  tri- 
radiate,  the  former  condition 
being  produced  when  the  patient 
lies  habitually  on  his  back,  the 
latter  only  occurring  when  he  is 
allowed  to  walk  about,  the  ace- 
tabula  being  thus  pressed  in- 
wards and  backwards  by  the 
heads  of  the  femora. 

The  deformity  of  the  long  bones 
(Fig.  182)  usually  consists  in  an 
increase  in  their  natural  curves, 
especially  at  points  where  power- 
ful muscles  are  attached.  The 
femora  are  curved  antero-pos- 
teriorly,  and  the  tibiaein  a  similar 
direction,  although  there  is  often 
some  lateral  displacement  super 
added.  Genu  valgum  or  varum 
may  also  result  from  the  epiphy- 
seal changes. 

When  the  acute  stage  of 
rickets  has  passed  away,  any 
deformities  present  become  fixed 
by  the  complete  ossification  of 
the  softened  bony  tissues.  As 
a  rule,  the  density  of  such  de- 
formed bones  is  increased,  whilst 
their  natural  shape  is  altered  by 
deposits  of  new  subperiosteal 
bone  or  struts  in  the  concavities, 
so  that  on  section  they  are 
usually  more  or  less  flattened 
from  side  to  side.  Growth  is 
often  checked  by  this  disease, 
so  that  the  individual  becomes 
stunted  and  dwarf-like. 
Pathologically,  the  chief  changes  in  rickets  are  found  in  the 
neighbourhood  of  the  epiphyses.  Ordinarily,  the  epiphyseal 
cartilage  is  a  lamella  about  a  line  in  thickness,  bounded  on  either 
side  by  a  zone  of  calcified  tissue,  containing  regular  alveolar 
spaces  filled  with  vascular  medulla,  and  lined  by  osteoblasts, 
shelving  gradually  into  normal  cancellous  bone.  In  rickets  the 
epiphyseal  cartilage  is  not  only  circumferentially  enlarged,  but  also 


Fig.  i32. — Pelvis  and  Leg-bones 
in  Rickets.  (From  College  of 
Surgeons'  Museum.) 


DISEASES  OF  BONE 


527 


thickened  and  irregular  (Fig.  183),  outgrowths  of  cartilage  project- 
ing on  either  side  into  the  calcified  tissue,  which  is  more  abundant 
and  more  open  in  texture  than  usual,  whilst  it  passes  irregularly 
into  the  cancellous  bone.  Thus,  there  is  an  increase  in  the 
material  which  Nature  prepares  for  the  formation  of  bone,  but  the 
ossifying  process  is  inefficiently  carried  out.  In  addition  to  this, 
the  Haversian  canal  systems  and  the  medullary  spaces  in  the 


Fig.  184. — Transverse  Section  through 
the  Shaft  of  the  Ulna  from  a 
Rickety  Child  of  Thirteen  Months 
(  x  10),  showing  Spongy  Tissue  beneath 
the  Periosteum  instead  of  the  Com- 
pact Tissue  of  Normal  Bone. 


Fig.  183. — Section  through 
Lower  End  of  Rickety 
Radius,  showing  Exagger- 
ated Depth  and  Irregular 
Borders  of  the  Prolifer- 
ating Epiphyseal  Carti- 
lage. 

(From  Ashby  and  Wright'c  '  Diseases  of  Children.') 

diaphyses  are  enlarged,  so  that  the  bones  become  weaker  and 
less  rigid  from  the  insufficient  amount  of  lime  salts  present,  and 
thus  readily  bend  under  the  weight  of  the  body  or  from  muscular 
action.  Less  frequently  the  subperiosteal  compact  bone  becomes 
similarly  rarefied  (Fig.  184). 

In  the  Treatment  of  rickets  the  most  essential  feature  in  the 
early  stages  is  the  correction  of  all  errors  in  the  personal  hygiene. 
The  diet  should  consist  of  good  cow's  milk,  diluted  if  need  be, 
and  with  lime-water  added  ;  whilst  the  juice  expressed  from  raw 
beef,  or   one    of   the    many  meat  juices   now  sold,   may  also  be 


528  A   MANUAL  OF  SURGERY 


administered.  The  condition  of  the  bowels  must  be  attended  to, 
and  the  child  placed  in  as  good  surroundings  as  possible.  Parrish's 
food  (syr.  ferri  phos.  co.)  may  be  given  by  itself,  but  if  the  infant  is 
thin  and  emaciated,  cod-liver  oil  should  be  added.  Deformities 
must,  if  possible,  be  prevented  by  keeping  the  child  in  the  re- 
cumbent posture,  and  not  allowing  it  to  crawd  or  run  about.  The 
early  stages  of  deformity  can  often  be  corrected  by  daily  manipu- 
lation of  the  affected  bones,  and  in  the  later  stages  they  may  be 
improved  by  suitable  apparatus  for  immobilizing  the  limb,  com- 
bined with  pressure.  Osteotomy,  or  even  resection  of  portions 
of  bone,  is  required  in  the  severer  cases  where  the  deformity 
persists  (see  p.  400). 

Scurvy  Rickets  (Svu.  :  Acute  Rickets,  Hemorrhagic  Rickets). — Attention  has 
been  directed  of  recent  years,  notably  by  Sir  Thomas  Barlow,  to  a  curious 
condition  met  with  in  children,  which  seems  to  combine  some  of  the  most 
marked  features  of  rickets  and  scurvy,  but  in  which  either  one  or  the  other  set 
of  phenomena  may  predominate.  It  is  usually  seen  in  the  children  of  well-to- 
do  people,  and  apparently  arises  from  defective  nutrition,  especially  from  the 
prolonged  administration  of  peptonized  or  prepared  foods,  together  with  an 
absence  of  fresh  meat  and  vegetables.  In  the  slighter  cases  there  may  be  but 
little  evidence  of  the  scorbutic  condition,  beyond  the  fact  that  in  a  rickety 
child  there  is  some  tendency  for  the  gums  to  bleed,  or  a  little  hematuria  ;  but 
in  those  that  are  more  marked  the  rickety  signs  are  of  little  importance 
compared  with  those  due  to  hemorrhagic  extravasations.  The  disease  often 
comes  on  suddenly  with  some  amount  of  pyrexia,  rarely  exceeding  1020  F.,  but 
the  child  is  evidently  ill,  and  perhaps  complains  of  tenderness  of  the  limbs, 
which  may  be  kept  so  quiet  as  to  suggest  that  they  are  paralyzed.  This  is 
followed  by  the  appearance  of  swellings  of  some  size,  due  to  subperiosteal 
extravasations,  the  skin  over  the  affected  parts  being  at  first  shiny  and 
o^dematous,  but  subsequently  becoming  stained  by  the  blood  pigment.  The 
femur  and  tibia  are  most  often  affected  in  this  way,  and  the  epiphyses  may 
occasionally  become  detached,  or  even  spontaneous  fractures  occur.  Bleeding 
may  also  take  place  beneath  the  conjunctiva  or  into  the  orbit,  leading  to 
protrusion  of  the  eyeball,  whilst  there  may  be  blood-stained  diarrhoea, 
hematuria,  or  epistaxis. 

The  disease,  when  recognised,  is  readily  amenable  to  treatment,  but  should 
its  nature  be  overlooked,  the  child  is  likely  to  become  emaciated  and  die. 
Attention  to  the  diet  is  the  main  point  to  be  attended  to,  for  when  fresh  milk, 
lime-juice,  or  vegetables  are  given,  the  symptoms  soon  disappear.  The  affected 
limbs  must  be  kept  at  rest,  and  cooling  lotions  applied,  whilst  splints  are 
employed  for  separated  epiphyses  or  fractures. 

Achondroplasia  is  the  name  given  to  a  rare  and  curious  congenital  condition, 
somewhat  resembling  rickets,  in  which  the  growth  of  osseous  tissue  on  the 
shaft  side  of  the  epiphyses  of  the  long  bones  of  both  arms  and  legs  is  defec- 
tive, so  that  the  limbs  are  short  and  stunted,  and  the  stature  correspondingly 
diminished,  although  the  epiphyses  are  normal.  The  bones  generally  are  not 
bent  or  curved  abnormally,  though  there  is  probably  some  change  of  the  neck 
or  shaft  of  the  femur,  resulting  in  lordosis,  which  is  very  marked  when  the 
patient  stands.  The  fingers  taper  to  their  tips,  and  are  separated  one  from 
another  in  '  spoke-like  '  fashion.  The  bones  at  the  base  of  the  skull,  being  of 
cartilaginous  origin,  undergo  premature  synostosis,  whilst  the  upper  half  of 
the  skull,  being  derived  from  membrane,  and  therefore  developing  naturally, 
looks  unusually  large  ;  the  face  is  small  and  the  bridge  of  the  nose  depressed 
as  in  congenital  syphilis.     The  children,  if  they  live,  are  usually  efficient  in 


DISEASES  OF  BONE 


529 


their  mental  development,  and  the  thyroid  body  normal.    No  known  treatment 
is  of  any  value. 

Simple  Atrophy  of  Bone. 

This  results  from  a  variety  of  conditions  quite  independent  of  rarefying 
inflammation,  in  which  it  is  always  a  marked  feature,  (a)  It  maybe  congenital, 
perhaps  involving  bones  and  soft  tissues  alike,  (b)  It  may  result  from  inter- 
ference with  the  epiphyses,  as  in  rickets,  or  after  injuries,  or  as  a  sequela  to 
tuberculous  or  other  inflammations  involving  the  junction  cartilage,  (c)  It 
may  be  due  to  injury  or  disease  of  the  central  nervous  system  or  of  peripheral 
nerves,  as  in  tabes  dorsalis,  syringomyelia,  leprosy,  etc.  (d)  It  maybe  caused 
by  want  of  use,  as  in  a  paralysed  or  ankylosed  limb,  (e)  Local  pressure,  as  of 
a  tumour  growing  within  or  outside  the  bone,  or  of  an  aneurism,  may  deter- 
mine its  existence,  and  possibly  to  such  a  degree  as  to  result  in  spontaneous 
fracture.  (/)  It  may  be  a  senile  change,  as  seen  in  the  lower  jaw,  cervix 
femoris,  or  cranium. 

The  type  of  atrophy  varies  with  the  cause.  Sometimes  it  merely  consists 
in  an  arrest  of  longitudinal  development  ;  at  others  the  bones  are  not 
only  short,  but  smaller  in  all  directions,  and  in  leprosy  may  undergo  almost 
total  absorption.  If  the  cause  is  localized,  and  acts  from  without,  the  compact 
bone  is  more  or  less  cleanly  eroded  ;  whilst  if  the  cause  is  general,  absorption 
may  occur  either  from  within,  the  medullary  canal  becoming  enlarged  and  the 
compact  tissue  thinned,  or  from  without,  the  cross-section  of  the  bone  gradually 
dwindling. 

The  possible  presence  of  atrophy  must  always  be  kept  in  mind  when 
dealing  with  ankylosed  or  paralysed  limbs,  since  very  little  force  may  suffice 
to  produce  a  fracture. 

Mollities  Ossium  (Syn.  :  Osteo-malacia). 

This  disease  is  one  of  somewhat  unusual  occurrence,  characterized  by  the 
absorption  of  the  osseous  substance  of  the  bones,  as  a  result  of  which  soften- 
ing and  rarefaction  are  produced,  followed  by  bending  or  spontaneous  fracture. 

The  complaint  is  almost  limited  to  the  female  sex  (only  S  per  cent,  of  the 
cases  reported  are  in  males),  and  usually  commences  during  pregnancy  ;  it  is 
said  to  be  sometimes  connected  with  a  rheumatic  tendency.  Any  part  of  the 
skeleton  may  be  affected  ;  in  females  the  change  usually  attacks  the  pelvis, 
spinal  column,  and  ribs  first,  and  the  limbs  later  ;  in  men  the  process  starts  in 
the  long  bones. 

Pathologically,  the  change  consists  in  a  replacement  of  the  medullary 
substance  by  a  soft  fibro-cellular  tissue,  which  is  exceedingly  vascular,  and 
into  which  haemorrhage  often  occurs  ;  the  resulting  material  looks  in  the  fresh 
state  something  like  splenic  pulp.  The  bony  cancelli  are  absorbed,  as  also  the 
greater  part  of  the  compact  tissue,  with  the  exception  of  a  thin  layer  situated 
beneath  the  periosteum  ;  in  a  well-marked  case  the  mineral  salts  may  be 
diminished  to  about  one-sixth  of  their  normal  amount,  but  the  relative  propor- 
tion of  phosphate  of  lime  to  the  carbonate  is  not  changed.  Part  of  the  bone 
substance  remains  for  a  time  in  a  decalcified  state,  with  the  corpuscles  evident, 
but  in  a  condition  of  fatty  degeneration.  Probably  some  acid,  e.g.,  lactic  acid, 
is  the  active  agent  in  dissolving  the  earthy  salts,  which  escape  partly  in  the 
urine,  partly  in  the  faeces.  It  is  possible  that  the  process  is  connected  with 
the  absorption  of  some  internal  secretion,  normal  or  vitiated,  particularly  that 
from  the  ovary,  an  idea  suggested  by  the  fact  that  the  removal  of  the  uterine 
appendages  has  in  a  few  cases  stayed  the  disease. 

Clinically,  the  onset  is  usually  somewhat  indefinite,  the  only  complaint 
being  of  pain  in  various  parts  of  the  body,  whilst  the  patient  becomes 
emaciated  and  exhausted.  Sooner  or  later  skeletal  changes  ensue  and 
demonstrate  the  character  of  the  disease.  The  limbs  may  either  bend  or 
break  ;  in  the  latter  case  there  is  often  no  attempt  at  repair.  The  pelvis 
becomes  tri-radiate  in  shape  owing  to  the  acetabula  being  pressed  inwards 
and  backwards  by  the  weight  of  the  body,  and  in  p.egnant  women  this  may 

34 


53Q  A  MANUAL  OF  SURGERY 


cause  so  much  deformity  as  to  necessitate  Caesarian  section  or  Porro's  opera- 
tion. Death  may  result  from  exhaustion,  or  from  obstruction  to  parturition, 
or  the  patient  may  live  more  or  less  bedridden  for  years,  the  limbs  becoming 
useless,  shortened,  and  perhaps  contorted  in  a  strange  and  abnormal  fashion. 
Treatment  is  unsatisfactory.  Opiates  may  be  administered  to  relieve  pain, 
which  is  often  very  severe,  and  various  drugs,  such  as  alum,  and  phosphate 
or  hypophosphite  of  lime,  have  been  recommended.  In  cases  not  associated 
with  parturition  or  pregnancy,  oophorectomy  is  said  to  have  been  employed 
with  benefit.  The  induction  of  premature  labour  is  considered  by  some  to  be 
beneficial,  not  only  for  the  sake  of  obviating  the  necessity  for  such  operations 
as  Caesarian  section,  but  also  on  the  chance  of  checking  the  disease. 

Hypertrophy  of  Bone. 

It  is  always  a  matter  of  difficulty  to  draw  a  definite  line  between  a  true 
hypertrophy  and  inflammatory  or  other  overgrowths,  and  especially  is  this  the 
case  in  connection  with  bones  where  chronic  inflammation  is  always  associated 
with  new  bone  formation.  Two  or  three  conditions  to  which  the  term 
hypertrophy  is  perhaps  more  correctly  attached  may,  however,  be  mentioned, 
(d)  It  is  sometimes  congenital  ;  if  involving  a  whole  limb  or  any  large  portion 
of  the  body,  it  is  known  as  Gigantism ;  if  merely  affecting  the  fingers  or  toes, 
it  is  termed  macrodactyly  (p.  390).  (b)  It  may  follow  inflammatory  affections 
of  bones,  which  are  thereby  left  with  an  increased  blood  supply,  e.g. ,  after 
acute  osteomyelitis,  which  has  not  destroyed  the  epiphyseal  cartilages ;  in 
such  cases  the  overgrowth  is  mainly  longitudinal,  (c)  Increased  growth  of 
bones  is  associated  with  several  diseases  to  be  described  immediately,  viz., 
osteitis  deformans,  acromegaly,  etc.,  and  in  these  it  is  possibly  due  to  the 
effect  of  some  internal  secretion. 

Osteitis  Deformans. 

Osteitis  deformans  is  an  inflammatory  disease  of  the  osseous  skeleton,  first 
described  by  Sir  James  Paget  in  1876.  The  onset  is  insidious,  and  the  progress 
very  slow.  It  is  characterized  by  a  painful  overgrowth  of  the  long  bones, 
spine,  cranium,  and  pelvis,  which  are  also  softened,  so  that  those  which  bear 
the  weight  of  the  body  become  curved.  It  may  commence  in  one  bone  alone, 
and  then  usually  the  tibia  or  femur,  but  more  often  many  bones  are  affected 
at  the  same  time.  Attention  may  be  drawn  to  the  condition,  either  by  the 
pain,  which  the  patient  at  first  considers  to  be  rheumatic,  or  by  the  general 
enlargement  and  bending  of  the  bones,  or  by  the  increased  size  of  the  head, 
necessitating  the  use  of  larger  hats.  The  cranial  overgrowth  is  eccentric  in 
character,  and  the  calvarium  may  become  very  thick ;  the  facial  skeleton, 
however,  is  not  much  affected.  The  spine  becomes  markedly  kyphotic 
(Fig.  185),  the  dorsal  curve  being  increased,  and  the  lumbar  concavity 
obliterated  ;  it  is  nearly  rigid  from  ankylosis  of  the  vertebrae,  and  may  be 
very  painful.  The  head  is  carried  forwards  by  the  bend  of  the  spine,  the 
height  is  diminished,  the  shoulders  are  round,  and  the  chest  sunken  towards 
the  pelvis :  the  gait  is  slow  and  awkward  The  disease  usually  attacks 
middle-aged  men  ;  its  progress  is  exceedingly  slow,  the  patient  often  living  to 
an  advanced  age,  or  dying  from  some  intercurrent  malady.  Some  cases  have 
terminated  in  multiple  sarcomata  of  the  bones.  The  structure  of  the  osseous 
tissue  is  suggestive  of  inflammatory  rather  than  degenerative  changes.  It 
is  softer  and  more  uniform  in  structure  than  usual,  the  difference  between 
the  cancellous  and  compact  tissue  being  less  defined  ;  the  Haversian  canals 
are  large,  and  arranged  irregularly,  whilst  the  bony  substance  is  chalky- 
looking. 

Differential  Diagnosis. — From  arthritis  deformans,  which  it  resembles  by  the 
attitude  and  gait  of  the  patient,  it  is  known  by  the  absence  of  articular  lesions, 
especially  in  the  fingers,  and  the  enlargement  of  the  bones,  notably  of  the 


DISEASES  OF  BONE 


53» 


cranium.     From  acromegaly  it  is  distinguished  by  the  absence  of  enlargement 
of  the  hands,  feet,  and  lower  jaw. 

Treatment  is  most  unsatisfactory,  no  remedy  at  present  known  having  any 
control  over  the  disease. 

Acromegaly. 

Acromegaly  is  a  rare  condition  the  characteristics  of  which  were  first 
described  by  Dr.  Pierre  Marie  in  18S5.  It  is  a  general  affection  involving 
mainly  the  osseous  system,  commencing  usually  in  young  adults,  and,  after 


Fig.  185.— Osteitis  Deformans.     (Bryant.) 


lasting  for  a  long  time,  killing  the  patient  by  syncope  or  cerebral  compression, 
if  some  intercurrent  malady  does  not  destroy  him. 

It  is  characterized  by  a  very  definite  enlargement  of  the  hands  and  feet, 
which  are,  however,  not  lengthened,  so  that  the  hands  have  been  compared 
to  battledores,  and  the  fingers  to  sausages.  The  bones  themselves  are 
enlarged,  and  the  soft  structures  on  the  palmar  aspects  project  as  pads.  The 
nails  and  skin  are  unchanged,  whilst  the  other  segments,  both  of  the  upper 
and  lower  limbs,  are  usually  unaffected,  though  sometimes  considerable  over- 
growth in  length  occurs ;  in  fact,  many  of  the  so-called  giants  who  have  been 
exhibited  are  typical  illustrations  of  acromegaly.  Both  the  upper  and  lower 
jaws  are  thickened  and  prominent,  whilst  the  lower  lip  is  enlarged  and  over- 
hanging. The  orbital  ridges  project,  and  the  forehead  is  usually  low  ;  the 
nose  and  tip  of  the  tongue  are  also  more  or  less  enlarged  The  spine  is 
kyphotic  in  the  dorsal  region,  with  a  slight  lumbar  lordosis.  The  ribs  and 
sternum  project  anteriorly. 

The  patient  usually  suffers  from  headache,  lassitude,  and  great  fatigue, 
wandering  pains  about  the  body,  and  excessive  appetite  and  thirst ; 
amenorrhcea  is  a  marked  symptom  in  women,  whilst  men  suffer  from  a  loss 
of  virile  power.  The  urine  is  abundant,  but  cf  a  low  specific  gravity.  Vision 
is  usually  diminished,  and  optic  neuritis  has  been  observed  in  some  cases. 

Morbid  Anatomy. — But  little  is  known  as  to  the  cause  or  pathological 
changes  occurring  in  this  disease,  beyond  the  fact  that  the  anterior  glandular 


532 


A   MANUAL  OF  SURGERY 


half  of  the  pituitary  body  is  hyper trophied,  and  the  sella  turcica  expanded. 
The. changes  in  the  bones  are  merely  those  of  overgrowth. 

Diagnosis. — The  disease  has  been  mistaken  for  myxasdema,  but  there  is  not 
much  difficulty  in  distinguishing  the  two  if  it  be  remembered  that,  in  the 
latter  condition,  the  skin  is  not  mobile  over  the  thickened  subcutaneous  tissue, 
that  the  face  is  broad,  pasty,  and  puffy,  and  that  masses  of  gelatinous  tissue 
are  found  above  the  clavicle,  whilst  in  acromegaly  the  face  is  elongated,  and 
the  skin  and  subcutaneous  tissues  normal.  The  mental  condition  and  speech 
of  a  patient  suffering  from  myxoedema  are  widely  different  from  those  in 
acromegaly ;  whilst  in  the  former  the  thyroid  body  is  either  absent  or 
diseased,  and  in  the  latter  skeletal  changes  are  present.  From  chronic  osteo- 
arthritis affecting  the  hands,  the  diagnosis  is  easy,  in  that  there  are  usually  no 
signs  of  articular  disease,  and  much  less  pain.  From  osteitis  deformans,  the 
distinguishing  features  have  already  been  indicated. 

Treatment  is  merely  symptomatic,  antipyrine  being  useful  in  relieving  the 
headache,  as  also  valerianate  of  caffeine.  Possibly  thyroid  extract  may  be  of 
some  use  in  combating  the  functional  phenomena,  though  it  will  not  influence 
the  skeletal  changes. 


Fig.   i85. 


-Head  of  Woman  with  Acromegaly, 

AND    FROM    THE    SlDE.* 


Seen  from  the  Front 


Another  curious  affection  which  has  been  recently  described  is  that  known 
by  the  formidable  title  of  Hypertrophic  Pulmonary  Osteo-arthropathy.  It 
has  been  long  known  that  clubbing  of  the  terminal  phalanges  was  a  common 
accompaniment  of  chronic  pulmonary  disease  ;  but  this  new  affection  is  more 
extensive.  The  terminal  phalanges  of  the  fingers  and  toes  are  enlarged  and 
bulbous,  with  the  nails  curved  over  them  towards  the  palm  or  sole ;  there  is 
also  a  considerable  swelling  of  the  bones  just  above  the  wrists  and  ankles,  and 
possibly  a  similar  condition  around  other  joints.  The  spine  is  kyphotic  in  the 
upper  dorsal  region,  but  with  well-marked  lordosis  below.  It  is  thus  seen 
that  the  changes  are  somewhat  like  those  of  acromegaly,  from  which  they  are 
distinguished  by  (a)  the  implication  only  of  the  terminal  phalanges  ;  (b)  the 
swellings  above  the  wrists  and  ankles  ;  and  (c)  the  absence  of  the  characteristic 
deformities  in  the  skull  and  head.  These  phenomena  probably  result  from 
a  chronic  osteitis,  due  to  toxic  absorption,  since  the  condition  arises  in  such 


*  Reproduced  from  the  Edinburgh  Medical  Journal,  by  kind  permission  of 
Dr   G.  A.  Gibson. 


DISEASES  OF  BONE 


532 


diseases  as  chronic  bronchitis,  bronchiectasis,  and  chronic  empyema,  where 
suppuration  has  existed  for  some  time.  Little  can  be  done  in  the  way  of 
treatment,  except  to  remove  the  cause. 

Tumours  of  Bone. 

Many  different  types  of  tumours  grow  from  bone.  The 
characters  of  the  osteomata,  chondromata,  and  fibromata  have 
been  described  in  Chapter  VII.,  and  various  solid  and  cystic 
tumours  connected  with  the  teeth  are  dealt  with  elsewhere. 

Sarcoma  is  the  most  important  primary  tumour  of  bones,  and 
almost  any  form  may  occur.  The  microscopical  characters  have 
been  detailed  in  the  chapter  on  tumours,  and  we  shall  here  only 


Fig.   T.87. — Endosteal  Sarcoma.     (King's  College  Hospital  Museum.) 

refer  to  their  clinical  characteristics.    They  may  be  divided  into  two 
main  groups — the  endosteal  or  central,  and  the  periosteal. 

Endosteal  or  Central  Sarcoma  (Fig.  187)  of  bone  commences  in 
the  medullary  cavity  or  cancellous  tissue,  and  results  in  the  so- 
called  '  expansion  of  bone,'  which  consists  in  absorption  of  the 
bone  from  within,  whilst  at  the  same  time  new  osseous  tissue  is 
being  deposited  from  the  under  side  of  the  periosteum,  though  in 
these  cases  only  to  a  limited  degree.  The  Symptoms  at  first 
resemble  those  of  chronic  osteo-periostitis,  although  in  most  cases 
of  tumour  there  is  rather  less  pain.  The  growth  usually  com- 
mences near  the  end  of  a  long  bone  ;  it  seldom  encroaches  on  the 
articular  cartilage,  so  that  the  joint  escapes,  although  it  may 
contain  an  excess  of  serous  fluid  ;  occasionally,  however,  the 
growth  may  extend  laterally  beyond  the  level  of  the  cartilage,  and 
thus  invade  the  articular  cavity.  Spontaneous  fracture  is  not  an 
unfrequent  complication,  and  owing  to  the  expansion  of  the  bony 


5 


A   MANUAL  OF  SURGERY 


framework  '  eggshell  crackling '  is  sometimes  met  with.  After  a 
while,  the  growth  may  extend  beyond  the  osseous  limits  into  the 
soft  parts,  and  then  the  chances  of  general  dissemination  are  con- 
siderably increased.  The  chief  varieties  of  sarcoma  growing  from 
the  interior  of  long  bones  are  the  round  or  spindle-celled,  and  the 
myeloid.  The  two  former  early  diffuse  themselves  throughout 
the  medullary  cavity,  and  infect  neighbouring  tissues  and  the 
system  generally.  Not  unfrequently  cartilaginous  nodules  may 
be  found  scattered  through  the  mass.  Myeloid  tumours  are  almost 
benign  in  character,  never  giving  rise  to  secondary  deposits,  either 
in  lymphatic  glands  or  viscera,  and  their  growth  within  the  bone 


Fig.  188. — Periosteal  Sarcoma.      (Bryant.) 

is  limited  to  the  region  from  which  they  originated  ;  sometimes  a 
layer  of  condensed  bone  forms  a  definite  barrier  to  check  any 
advance  along  the  medullary  canal.  The  sites  of  election  for 
myeloid  tumours  are  the  lower  ends  of  the  femur  and  radius,  and 
the  upper  ends  of  the  tibia  and  humerus — that  is,  where  the 
growth  of  the  limbs  is  greatest ;  they  also  grow  within  the  hori- 
zontal ramus  of  the  lower  jaw  and  the  diploe.  Not  uncommonly 
a  fibro-sarcomatous  epulis  is  myeloid  in  nature. 

In  considering  the  nature  of  an  endosteal  sarcoma,  it  should  be 
remembered  that  myeloid  tumours  grow  more  slowly  than  the 
round-  or  spindle-celled,  and  are  more  likely  to  develop  cysts 
owing  to  haemorrhage  into  their  substance.  In  all  of  them  a 
certain  amount  of  bony  skeleton  may  pervade  the  growth. 


DISEASES  OF  BONE  535 


The  Periosteal  Sarcomata  (Fig.  188)  are  round-  or  spindle- 
celled  in  nature.  They  often  grow  very  rapidly,  without  giving 
rise  to  much  pain,  unless  causing  erosion  of  the  bone.  They 
usually  start  on  one  side  of  the  bone,  but  later  on  may  surround 
its  whole  circumference.  They  spread  rapidly  along  its  exterior, 
and  are  highly  malignant  in  nature,  giving  rise  to  secondary 
growths  in  the  neighbouring  lymphatic  glands  or  in  the  viscera. 
They  frequently  become  ossified,  with  or  without  the  development 
of  cartilage,  and  in  such  cases  the  subjacent  bone  becomes  sclerosed 
and  thick.  The  bony  skeleton  of  such  a  growth  is  very  character- 
istic, consisting  of  fine  spiculated  trabecular,  radiating  more  or 
less  regularly  from  the  surface,  and  looking  in  the  dried  state 
somewhat  like  asbestos.  When  a  periosteal  sarcoma  does  not 
become  ossified,  the  growth  usually  erodes  the  underlying  bone, 
and  may  lead  to  spontaneous  fracture  ;  the  tumour  in  such  cases 
is  softer  and  more  elastic  than  in  the  former  variety.  All  osseous 
sarcomata  are  exceedingly  vascular,  and  may  even  pulsate,  whilst 
the  superficial  veins  are  obviously  dilated  beneath  the  stretched 
integument,  giving  rise  to  a  blue  network. 

The  Diagnosis  of  osteo- sarcoma  in  the  early  stages  is  often  a 
matter  of  the  greatest  difficulty.  The  endosteal  form  may  easily 
be  mistaken  for  chronic  osteo-periostitis,  medullary  gumma,  or  a 
deep  abscess  of  the  bone,  and  can  sometimes  only  be  distinguished 
from  them  by  an  exploratory  incision,  which  should  always  be 
undertaken  in  doubtful  cases  prior  to  radical  operations,  such  as 
amputation.  In  the  later  stages,  the  presence  of  '  eggshell 
crackling '  or  cystic  change  will  help  to  make  evident  the  nature 
of  the  disease.  The  periosteal  form  may  at  first  be  looked  upon 
as  a  periosteal  node,  or  a  deeply  placed  abscess.  The  rounded 
and  definite  edge  of  the  growth,  its  irregular  consistency,  and  the 
history  of  the  case,  will  assist  in  the  determination  of  its  nature  ; 
but  in  the  early  stages  an  exploratory  operation  is  not  unfrequently 
necessary.  For  the  diagnosis  of  a  pulsating  sarcoma  from  an 
aneurism,  see  p.  261.  When  either  form  involves  the  articular 
end  of  a  bone,  especially  the  lower  end  of  the  femur,  it  may 
simulate  tuberculous  disease  of  the  adjacent  joint.  It  will,  how- 
ever, be  noted  that  the  centre  of  the  swelling  corresponds  to  a 
point  well  above  or  below  the  joint,  that  a  certain  amount  of 
movement  is  possible,  and  even  without  pain,  whilst  the  starting 
pains  at  night  characteristic  of  joint  mischief  are  absent.  The 
age  of  the  patient,  and  the  presence  or  not  of  cachexy,  are  also 
important  features  which  have  to  be  taken  into  consideration. 
Skiagraphy  serves  in  some  cases  as  an  important  diagnostic 
adjuvant. 

The  Treatment  of  osteo-sarcoma  must  always  be  of  a  radical 
nature,  and,  remembering  the  highly  malignant  character  of  many 
of  these  growths,  we  would  strongly  urge  the  importance  of  an 
early    exploratory   operation    in   doubtful    cases ;    if    undertaken. 


536  ./   MANUAL  OF  SURGERY 


with  antiseptic  precautions  no  harm  can  ensue,  and  a  definite 
diagnosis  is  thereby  possible.  If  the  case  is  left  until  increased 
growth  reveals  the  true  state  of  affairs,  it  is  more  than  likely  that, 
except  in  the  myeloid  variety  it  will  be  too  late  for  successful 
operative  interference.  In  every  form  of  the  disease  except  the 
myeloid,  the  affected  limb  should  be  removed  high  above  the 
tumour.  Thus,  if  growing  from  the  lower  end  of  the  tibia,  dis- 
articulation at  the  knee-joint  should  be  performed ;  if  at  the  upper 
end  of  the  tibia,  amputation  through  the  middle  or  lower  third  of 
the  thigh  ;  if  from  the  lower  end  of  the  femur,  amputation  through 
the  upper  third  of  the  bone,  if  not  at  the  hip-joint.  For  sarcoma 
of  the  head  of  the  humerus,  disarticulation  through  the  shoulder- 
joint  may  suffice,  but  it  is  often  wiser  to  remove  the  scapula  and 
greater  part  of  the  clavicle  as  well  (interscapulo-thoracic  amputa- 
tion). The  results  of  the  latter  proceeding,  as  regards  final  cure, 
have  been  much  more  satisfactory  than  those  of  the  former. 
When  muscular  bellies  have  been  invaded,  it  is  desirable,  though 
not  always  practicable,  to  include  the  whole  of  them  in  the  scope 
of  the  operation. 

Myeloid  sarcomata  being  practically  non-malignant,  except 
locally,  are  dealt  with  in  a  much  more  conservative  manner, 
amputation  through  healthy  tissue  just  above  the  growth  being 
all  that  is  necessary.  It  is  advisable  that  the  medulla  at  the 
point  of  section  of  the  bone  should  be  examined  microscopically 
before  the  wound  is  closed,  to  make  certain  that  it  has  not  been 
invaded.  When  affecting  the  lower  end  of  the  radius,  an  attempt 
may  be  made  to  save  the  limb  by  excising  the  diseased  portion  of 
bone  ;  if  a  portion  of  the  ulna  is  also  taken  away  at  the  same  time, 
there  is  less  chance  of  the  hand  being  drawn  up  and  abducted, 
and  hence  it  is  more  likely  to  become  useful.  A  leather  gauntlet 
to  steady  the  part  subsequently  will  almost  certainly  be  required. 
Central  sarcoma  of  the  lower  jaw,  if  myeloid  in  nature,  may  be 
treated  by  making  a  free  opening  in  the  bone,  scraping  the 
diseased  tissue  away,  and  swabbing  out  the  cavity  with  pure 
carbolic  acid.  The  continuity  of  the  jaw  may  thus  be  maintained, 
even  if  the  teeth  are  lost.  Several  successful  cases  treated  ac- 
cording to  this  plan  have  been  recorded. 

Secondary  Sarcoma  of  bone  is  by  no  means  uncommon.  It  is 
usually  endosteal  in  character,  and,  except  in  the  most  unusual 
circumstances,  will  not  demand  treatment,  owing  to  the  general 
infection  of  the  system.  Possibly  where  it  has  led  to  spontaneous 
fracture,  and  there  is  much  pain  owing  to  the  difficulty  of  fixation, 
it  would  be  justifiable  to  remove  the  limb. 

Carcinoma  of  bone  is  always  secondary  in  nature,  although  it 
may  be  involved  by  direct  extension  in  a  primary  growth.  It  may 
occasionally  lead  to  spontaneous  fracture,  but  the  bone  may 
consolidate  again  satisfactorily. 


DISEASES  OF  BONE  557 


A  rare  form  of  secondary  carcinoma  of  bone  is  that  known  as 
Thyroid  Cancer.  The  primary  growth  is  in  the  thyroid  body, 
whilst  the  secondary  deposits  in  the  bone  are  exactly  similar  in 
structure  to  it,  and  usually  pulsate  strongly. 

Pulsating  Tumours  of  Bone,  or  Osteo-ar.eurism. — Not  a  few  cases 
of  sarcoma  of  bone,  whether  central  or  peripheral  in  character, 
have  an  evident  pulsation,  owing  to  their  extreme  vascularity, 
the  thin-walled  vessels  in  their  substance  being  even  dilated  and 
aneurismal.  Apart  from  these,  two  other  conditions  are  met  with, 
the  nature  of  which  cannot  be  considered  as  yet  settled,  in  which 
distinct  pulsation  is  also  noticeable. 

In  the  first  of  these  the  medullary  cavity  is  occupied  by  a 
non-malignant  vascular  tissue,  practically  identical  with  what  we 
have  already  described  as  an  aneurism  by  anastomosis.  A  large 
number  of  small  arterioles  open  into  spaces  without  the  interven- 
tion of  capillaries,  so  that  an  erectile  tissue  similar  in  nature  to 
the  corpus  cavernosum  penis  results.  Such  tumours  are  situated 
most  frequently  in  the  cranial  bones,  and  may  be  multiple,  the 
medullary  tissue  being  in  consequence  atrophied,  and  the  compact 
tissue  thinned,  so  that  '  eggshell  crackling  '  may  be  obtained. 

The  second  form  is  found  most  commonly  in  the  upper  end  of 
the  tibia,  or  some  such  cancellous  mass.  It  consists  of  a  hollow 
cavity  formed  in  the  cancellated  tissue,  and  filled  with  blood. 
Several  distinct  arterial  twigs  may  open  into  it,  and  the  overlying 
bone  is  thinned  and  absorbed.  It  is  probable  that  the  majority  of 
such  cases  are  in  reality  due  to  the  breaking  down  of  sarcomata 
of  extreme  tenuity. 

The  Diagnosis  of  these  conditions  from  an  ordinary  aneurism  is 
alluded  to  elsewhere  (p.  261) ;  but  it  is  often  impossible  to  distin- 
guish one  form  of  pulsating  tumour  of  bone  from  another  without 
an  exploratory  incision. 

The  Treatment  of  these  cases  necessarily  varies  with  the  con- 
dition found  after  the  preliminary  incision  into  its  substance, 
which  should  always  be  made  after  rendering  the  limb  bloodless. 
Where  it  seems  probable  that  the  condition  is  not  associated  with 
malignant  disease,  or  is  merely  due  to  a  myeloid  tumour,  the 
cavity  should  be  well  scraped,  swabbed  out  with  pure  carbolic 
acid,  and  then  firmly  stuffed  with  gauze,  so  as  to  obtain  healing 
by  granulation  from  the  bottom.  In  other  cases  amputation  is 
the  only  treatment. 

Hydatid  Disease  of  Bone. — The  cancellous  tissue  of  bones  occa- 
sionally becomes  the  site  of  hydatid  development,  any  part  either 
of  the  medullary  cavity  or  of  the  ends  being  involved.  The  bone 
becomes  expanded,  with  all  the  symptoms  of  an  endosteal  growth. 
Considerable  deformity  may  occur,  and  when  the  compact  layer 
has  become  sufficiently  absorbed,  spontaneous  fracture  may  follow. 


538  A  MANUAL  OF  SURGERY 

A  peculiar  characteristic  of  this  affection  is  that  there  is  no 
limiting  cyst  wall,  the  small  daughter  cysts  being  diffused  widely 
throughout  the  affected  area.  A  diagnosis  is  little  likely  to  be 
made  (at  any  rate,  in  this  country,  where  hydatid  disease  is  so 
rare)  prior  to  an  exploratory  incision.  Treatment. — If  all  the 
cysts  can  be  removed  without  interfering  with  the  integrity  of  the 
shaft,  a  recovery,  with  good  subsequent  utility  of  the  limb,  should 
follow.  Where,  however,  the  disease  has  encroached  widely  on 
the  bony  tissue,  whether  spontaneous  fracture  has  occurred  or 
not,  amputation  holds  out  the  only  prospect  of  cure. 


CHAPTER  XIX. 

INJURIES  OF  JOINTS— DISLOCATIONS. 

Sprains  and  Strains. — -When  some  of  the  ligamentous  fibres 
around  a  joint  are  ruptured  or  stretched,  as  the  result  of  sudden 
violence,  the  joint  is  said  to  be  sprained  or  strained.  The  acci- 
dent itself  is  associated  with  severe  pain,  and  is  immediately 
followed  by  more  or  less  haemorrhage  into  the  surrounding 
tissues,  or  into  the  articular  cavity.  An  attack  of  synovitis, 
varying  in  severity,  generally  ensues,  and  may  lead  to  persistent 
weakness  and  pain  in  the  joint,  either  from  the  formation  of 
adhesions,  or  from  imperfect  repair  of  the  ligaments.  If  this  con- 
dition is  neglected,  it  may  originate  tuberculous  disease  in  those 
who  are  so  predisposed,  whilst  osteo-arthritis  is  a  by  no  means 
uncommon  sequela.  If  the  patient  is  in  a  bad  state  of  health  at 
the  time  of  the  injury,  it  is  possible  that  an  attack  of  acute 
infective  arthritis  may  be  lighted  up.  Treatment. — The  joint 
should  be  firmly  supported  by  a  bandage  as  soon  after  the 
accident  as  possible,  and  cold  or  evaporating  lotions  applied.  In 
the  slighter  cases,  all  that  is  needed  is  to  strap  the  joint  or  use 
elastic  pressure,  the  patient  being  allowed  to  use  the  limb  at  the 
end  of  a  day  or  two  ;  but  in  severe  sprains  it  is  better  to  keep  the 
part  absolutely  at  rest  for  some  days,  since  neglect  in  the  early 
stages  may  give  rise  to  as  much,  if  not  more,  trouble  than  if  the 
limb  had  been  fractured.  Friction  with  stimulating  liniments^ 
massage,  and  douching  the  joint  alternately  with  hot  and  cold 
water,  are  subsequently  useful  in  restoring  the  limb  to  full  func- 
tional activity.  When  synovitis  supervenes,  the  treatment  suit- 
able for  that  condition  must  be  adopted. 

Penetrating  Wounds  of  Joints  are  often  accompanied  by  an 
escape  of  synovia,  which  is  recognised  as  a  glairy,  oily  fluid, 
floating  perhaps  on  the  surface  of  the  blood  ;  if,  however,  the 
aperture  is  small,  this  may  not  occur.  It  is  always  followed  by  a 
certain  amount  of  inflammation,  the  severity  and  extent  of  which 
depend  on  whether  the  joint  is  infected  and  the  character  of  that 
infection.      If  no  infection  has  taken  place,  and  the  joint  is  main- 


540  A  MANUAL  OF  SURGERY 

tained  in  an  aseptic  condition,  a  simple  synovitis  ensues,  and  soon 
passes  off;  if,  however,  micro-organisms  have  entered,  acute 
arthritis  probably  supervenes,  leading  to  destruction  and  dis- 
integration of  the  joint.  (For  symptoms  and  treatment,  see 
Chapter  XX.)  A  penetrating  wound,  even  if  untreated,  does 
not  necessarily  become  septic  ;  thus,  if  the  lesion  is  produced  by 
a  small  clean  instrument,  and  especially  if  this  is  inserted  in  a 
slanting  direction,  so  that  the  wound  is  valvular,  or  if  the  incision 
is  a  large  one,  allowing  free  vent  to  all  discharges,  recovery  with- 
out septic  inflammation  is  possible. 

Considerable  difference  of  opinion  has  been  expressed  as  to  the 
necessity  for  accurately  determining  whether  or  not  the  synovial 
membrane  has  been  involved.  Speaking  generally,  one  would 
recommend  that  if  the  wound  is  small,  and  the  surgeon  has 
reason  to  believe  that  the  instrument  inflicting  it  has  been  aseptic, 
the  external  skin  should  be  thoroughly  purified,  and  an  antiseptic 
dressing  applied.  A  careful  watch  must  be  kept  upon  the  con- 
dition of  the  joint,  and  upon  the  temperature  of  the  patient ;  as 
soon  as  any  signs  of  acute  arthritis  manifest  themselves,  free 
incisions  are  made  into  the  joint,  so  as  to  relieve  tension  and  allow 
the  cavity  to  be  irrigated.  If,  however,  the  wound  is  inflicted  by 
a  dirty  instrument,  and  there  is  but  little  doubt  that  the  joint 
has  been  penetrated,  it  is  most  important  to  make  certain  of 
this  fact.  For  this  purpose  the  wound  should  be  enlarged,  so 
that  its  depths  may  be  purified,  and  then  carefully  examined. 
If  it  is  found  that  the  cavity  has  been  opened,  the  aperture 
should  be  increased  in  size  so  as  to  allow  it  to  be  washed  out  and 
a  drainage-tube  inserted ;  if  acute  arthritis  supervenes,  it  must 
be  treated  in  the  usual  way. 

Dislocations. 

Although  the  term  '  dislocation  '  is  most  commonly  applied  to  a 
forcible  displacement  of  one  of  the  bones  entering  into  an  articula- 
tion, as  the  result  of  an  injury,  it  must  not  be  forgotten  that  con- 
genital and  pathological  displacements  also  exist. 

Congenital  Dislocation. — This  term  is  applied  generally  to  any 
defect  of  a  joint  present  at  birth,  but  is  really  a  misnomer,  since 
the  condition  is  almost  always  due  to  an  error  of  development,  as 
a  result  of  which  a  normal  location  of  the  bony  constituents  has 
never  been  present,  and  hence  a  dislocation  cannot  have  taken 
place.  The  hip-joint  is  most  frequently  affected  ;  but  similar 
malformations  have  occurred  in  the  shoulder,  wrist,  and  jaw, 
whilst  the  patella  may  be  congenitally  absent  or  displaced. 

Congenital  Dislocation  of  the  Hip  is  by  no  means  rare,  although 
its  causation  is  still  quite  uncertain  ;  probably  it  is  due  in  some 
cases  to  malposition  of  the  foetus  in  the  uterus  or  to  some  irregu- 
larity in  the  shape  of  the  uterine  wall,  e.g.,  such  as  results  from 


INJURIES  OF  JOINTS— DISLOCATIONS 


54i 


the  presence  of  fibroids.  The  malformation  is  frequently  bilateral, 
more  commonly  unilateral.  It  often  passes  unnoticed  until  the 
child  begins  to  walk,  and  then  the  characteristic  signs  become 
evident.  The  limb  is  shortened  and  flexed  on  the  pelvis,  owing 
to  the  traction  of  the  ilio-psoas  muscle,  necessitating  a  consider- 
able amount  of  lordosis  to  maintain  the  body  in  a  vertical  position 
(Fig.  191),  whilst  scoliosis  is  well  marked  in  one-sided  cases. 
Since  the  head  of  the  femur  is  displaced  from  the  middle  line,  a 


Figs.  189,  190. — Congenital    Dislocation  of    Both    Hips   in  a    Girl   of 
Fifteen  Years,  seen  from  the  Front  and  Back.    (From  Photographs 

KINDLY  LENT  BY  Mr.  J.  JACKSON  CLARKE.) 

gap  is  usually  noticed  between  the  thighs  close  to  the  perineum. 
Considerable  adduction  of  the  lower  end  of  the  femur  (Figs.  189 
and  190)  may  result  from  muscular  contraction  (adductors),  and  in 
bilateral  cases  a  scissor-leg  deformity  may  ensue.  The  patient's 
gait  is  of  a  curious  waddling  character,  which  becomes  very 
marked  if  one  side  alone  is  affected.  Since  the  head  of  the  bone 
is  only  maintained  in  position  by  its  ligamentous  and  muscular 
attachments,  it  can  often  be  drawn  down  at  first,  and  the  leg  thus 
lengthened  to  the  extent  of  an  inch  or  two  ;  moreover,  it  is  often 


542 


A   MANUAL  OF  SURGERY 


easy  to  rtduce  the  displacement  and  put  the  head  of  the  bone  in 
the  acetabulum  in  children  that  have  not  walked  much.  It  is 
sometimes  necessary  to  invert,  sometimes  to  evert,  the  limb,  as 
well  as  make  traction,  in  order  to  accomplish  this,  the  head  of  the 
bone  not  being  always  in  the  same  place.     At  a  subsequent  date 

strains  to  the  limb  are  almost  entirely 
borne  by  the  ligamentous  tissues,  and 
hence  attacks  of  synovitis  are  common. 
The  Pathological  Anatomy  varies  con- 
siderably according  to  whether  or  not 
the  child  has  walked.  At  bivth  the  head 
and  neck  are  sometimes  nearly  normal, 
although  the  head  is  often  rather  small 
and  perhaps  flattened  at  the  spot  where 
it  rests  against  the  innominate  bone,  and 
the  neck  is  short  and  stunted.  The  liga- 
mentum  teres  is  long,  thin  and  usually 
somewhat  flattened.  The  acetabulum 
is  smaller  and  more  shallow  than  usual, 
but  can  usually  receive  the  head  of  the 
bone,  though  it  cannot  retain  it  :  this  is 
stated  by  Lock  wood  to  be  due  to  the 
absence  of  the  cartilaginous  rim,  but 
this  explanation  is  certainly  not  true 
in  all  cases.  The  capsule  is  large  and 
roomy.  After  the  child  has  walked,  sundry 
modifications  make  themselves  evident. 
The  head  of  the  bone  becomes  more  and 
more  displaced,  so  that  it  may  finally  lie 
well  above  the  acetabulum  on  the  dorsum 
ilii  (Plate  XXVI.).  The  capsule  becomes 
stretched  over  the  displaced  head,  and 
much  thicker  than  usual ;  the  ligamen- 
tum  teres  is  flat  and  band-like.  The 
head  of  the  bone  is  considerably  altered 
in  shape ;  the  defective  development  of 
the  acetabulum  is  more  obvious,  since  it  becomes  triangular  in 
shape,  owing  chiefly  to  want  of  growth  of  the  iliac  portion,  whilst 
the  muscles  are  necessarily  modified  as  to  their  length.  A  new, 
but  very  imperfect,  acetabulum  forms  on  the  spot  where  the  head 
of  the  bone  usually  rests. 

Treatment. — Should  a  diagnosis  be  made  before  the  child  has 
commenced  to  walk,  there  is  no  reason  why  treatment  should  not 
be  instituted  at  once.  The  head  of  the  bone  can  usually  be  placed 
in  its  socket,  and  is  kept  there  by  fixing  the  limb  in  a  position  of 
abduction,  whilst  inward  pressure  is  made  over  the  trochanter 
with  a  screw  apparatus.  Schede  has  by  this  means  converted 
the  unstable  articulation  into  a  stable  one.     Such  treatment  will 


Fig.  191. — Side  View  of 
Same  Patient  to  show 
the  Extreme  Lordosis. 


PLATE  XXVI. 


INJURIES  OF  JOINTS—DISLOCATIONS  545 

last  from  six  to  twelve  months.  Others  have  effected  the  same 
result  by  prolonged  traction. 

At  a  later  age  (up  to  five  or  six  years)  Lorenz's  bloodless 
method  of  treatment  may  be  employed  with  good  hopes  of  a 
successful  issue  in  unilateral  cases.  (1)  The  head  of  the  bone  is 
first  drawn  down  to  the  level  of  the  acetabulum.  Some  surgeons 
recommend  this  to  be  effected  by  gradual  extension  ;  others  do  it 
at  one  sitting  under  an  anaesthetic.  The  adductor  muscles  are 
the  chief  hindrance,  and  will  require  a  good  deal  of  kneading, 
or  even  possibly  section  with  a  tenotome.  (2)  The  head  of  the 
bone  is  to  be  replaced  in  the  acetabulum,  and  as  this  cavity  is 
small  and  chink-like,  and  sometimes  covered  in  by  the  front  of 
the  capsule,  a  good  deal  of  difficulty  may  be  here  experienced. 
The  limb  is  fully  flexed  and  then  forcibly  abducted,  extended 
and  everted,  no  undue  violence  being  permissible,  or  the  bone 
may  be  fractured.  The  head  of  the  bone  can  sometimes  be  felt 
to  slip  into  the  acetabulum,  and  the  manoeuvre  should  be  repeated 
several  times,  as  it  were,  grinding  the  head  of  the  femur  into  the 
acetabulum.  (3)  The  limb  is  then  put  up  in  plaster  of  Paris  from 
the  pelvis  to  the  knee  in  a  position  of  abduction  and  slight  eversion, 
and  with  the  leg  flexed.  It  is  maintained  in  this  position  for 
ten  or  twelve  weeks,  and  it  is  well  to  ascertain  by  skiagraphy 
that  the  bone  has  not  slipped.  At  the  end  of  that  period  it  will 
probably  be  found  that  a  less  degree  of  abduction  will  suffice  in 
order  to  keep  the  bone  in  place,  and  a  fresh  case  of  plaster  is 
applied  with  the  limb  in  this  new  position,  the  extension  and  out- 
ward rotation  being  maintained.  As  soon  as  possible  the  child  is 
encouraged  to  walk  on  the  limb  in  this  position  of  abduction,  so 
as  to  force  the  head  of  the  bone  still  deeper  into  the  acetabulum  ; 
crutches  are  required  at  first,  but  he  will  soon  do  without  them. 
The  plaster  casing  is  usually  needed  for  six  months. 

In  older  children  (from  five  to  ten  years)  operative  treatment 
can  be  undertaken  with  some  prospect  of  success.  Hoffa  and 
Lorenz  have  been  the  great  exponents  of  this  proceeding,  though 
for  children  under  five  years  they  both  admit  the  value  of  the 
bloodless  method.  Their  operations  consist  in  opening  the  joint 
from  the  back  and  front  respectively,  shaping  up  the  head  of  the 
bone,  enlarging  the  acetabulum  so  that  the  head  can  be  replaced 
in  it,  and  dividing  any  tense  structures  which  prevent  reduction. 
The  limb  is  subsequently  immobilized  in  a  position  of  eversion 
and  abduction,  but  for  as  short  a  time  as  possible.  Even  if  anky- 
losis results,  the  patient's  gait  is  considerably  improved. 

Pathological  Dislocations  are  produced  as  the  result  of  some 
intra-articular  affection,  e.g.,  tuberculous  disease,  osteo-arthritis, 
Charcot's  disease,  etc.     It  is  unnecessary  to  describe  them  here. 


544  A  MANUAL  OF  SURGERY 


Traumatic  Dislocations. 

Causes. — These  are  divided  into  the  predisposing  and  exciting. 
Under  the  former  head  may  be  included  some  anatomical  pecu- 
liarity of  the  joint,  such  as  the  shallow  socket  of  the  glenoid  cavity, 
or  some  weakness  of  the  muscles  or  ligaments  which  control  the 
movements  of  the  articulation.  Dislocations  are  rare  in  children, 
since  any  violence  directed  to  a  joint  or  its  neighbourhood  is  more 
likely  to  lead  to  an  epiphyseal  separation.  Moreover,  in  old 
people  the  bones  become  brittle,  and  thus  fractures,  rather  than 
dislocations,  are  produced ;  hence  the  later  lesions  are  almost 
limited  to  adults,  and,  owing  to  their  greater  exposure  to  injury, 
occur  in  men  rather  than  in  women. 

The  Exciting  Causes  are  the  application  of  external  violence  and 
muscular  force,  acting  alone  or  in  combination.  The  former  may 
be  direct,  but  is  more  commonly  indirect,  the  force  being  applied 
at  a  distance  from  the  joint.  Muscular  action  by  itself  can  only 
produce  dislocation  in  certain  joints,  which  by  their  peculiar  con- 
formation are  predisposed  to  it ;  the  head  of  the  humerus,  the 
patella  and  condyle  of  the  jaw  are  the  bones  most  often  affected 
in  this  way.  If,  however,  the  ligaments  of  a  joint  have  been 
stretched  by  previous  disease  or  displacement,  recurrent  disloca- 
tions, the  result  of  muscular  action,  are  not  unusual. 

The  term  complete  dislocation,  or  luxation,  is  applied  to  that  con- 
dition in  which  the  articular  surfaces  of  the  bones  are  completely 
separated  from  one  another.  An  incomplete  dislocation,  or  subluxa- 
tion, is  one  in  which  the  surfaces  are  only  partially  separated. 

A  compound  dislocation  is  one  in  which  the  skin  has  been  ruptured 
and  a  communication  established  with  the  external  air.  A  com- 
plicated dislocation  is  one  in  which  there  has  been  some  associated 
injury  of  vessels,  nerves,  or  viscera.  The  term  fracture-dislocation 
is  one  applied  to  a  condition  in  which  a  dislocation  is  complicated 
by  fracture  of  one  or  both  bones  involved. 

The  Signs  of  a  dislocation  are  as  follows  :  (i)  The  evidences  of 
a  local  trauma,  e.g.,  pain,  bruising,  and  swelling  of  the  soft 
tissues,  due  to  their  laceration  and  the  effusion  of  blood  into 
them  ;  the  amount  of  this  varies  in  different  cases  :  (2)  deformity 
of  the  limb  due  to  the  articular  end  of  the  displaced  bone  being  in 
some  abnormal  position,  where  it  can  often  be  felt  and  sometimes 
seen  :  and  (3)  restricted  mobility  of  the  affected  joint,  and  hence 
impairment  of  function  of  the  limb.  The  degree  to  which  this 
obtains  is  necessarily  variable,  but,  as  a  rule,  it  is  very  marked  ; 
if,  however,  fracture  is  also  present,  passive  movements  may  be 
possible,  though  associated  with  pain  and  crepitus. 

The  Effects  produced  by  a  dislocation  extend  to  all  the  struc- 
tures entering  into  and  surrounding  the  site  of  injury.  The  liga- 
ments are  partially  or  completely  torn  ;  the  bony  surfaces  are  not 
unfrcquently  fractured,  especially  in   closely-fitting  hinge  joints, 


INJURIES  OF  JOINTS— DISLOCATIONS 


54  5 


such  as  the  elbow  and  ankle  ;  the  cartilages  may  be  bruised, 
or  portions  of  them  detached,  and  neighbouring  muscles  and 
tendons  lacerated  and  displaced  ;  adjacent  vessels  and  nerves  are 
often  contused  or  compressed.  Considerable  effusion  of  blood  is 
always  present,  infiltrating  the  whole  area  involved. 

The  character  of  the  injury  explains  the  difficulties  that  are 
met  with  in  its  reduction.  These  arise  from  two  main  causes  : 
(a)  The  anatomical  structure  of  the  joint  and  its  ligaments,  re- 
sulting in  the  hitching  of  bony  prominences  against  one  another, 
whilst  the  head  of  the  bone  does  not  always  lie  opposite  the  hole 
in  the  capsule  through  which  it  originally  passed.     In  a  few  cases 


A  B 

Fig.  192. — Old-standing  Suecoracoid  Dislocation  of  the  Shoulder,  show- 
ing Atrophy  of  True  Glenoid  Cavity,  together  -with  Formation  of 
New  Joint  and  Alteration  in  Shape  of  Head  of  Bone.  A,  View  from 
the  Front  ;  B,  from  the  Outer  Side.  (From  College  of  Surgeons' 
Museum.) 

the  end  of  the  bone  may  be  grasped  by  neighbouring  ligaments 
and  muscles  in  such  a  way  as  to  render  its  replacement  a  matter 
of  the  greatest  difficulty.  (b)  Muscular  contraction  also  con- 
stitutes an  obstacle,  which,  though  formerly  difficult  to  counter- 
act, is  now  readily  overcome  by  the  use  of  anaesthetics.  Not 
only  does  the  patient  maintain  the  limb  in  a  condition  of  rest 
by  a  voluntary  tonic  contraction,  but  it  becomes  fixed  by  the 
involuntary  passive  tension  of  the  displaced  muscles.  Moreover, 
clonic  spasms  may  arise  from  the  direct  or  reflex  irritation  of 
nerves,  and  these  the  patient  is  quite  incapable  of  controlling. 
When  once  reduced,  Nature  soon  restores  tiie  part,  so  that  in  many 

35 


546  A   MANUAL  OF  SURGERY 

cases  no  permanent  lesion  remains,  although  in  some  the  rent  in 
the  capsule  does  not  heal  firmly,  leaving  the  joint  weak  and 
liable  to  a  recurrence  of  the  displacement,  while  intra-articular 
adhesions,  or  the  cicatricial  contraction  of  the  injured  ligaments 
and  muscles,  may  cause  some  loss  of  mobility. 

If  a  dislocation  is  allowed  to  remain  unreduced,  the  true  articular 
cavity  becomes  shallow  and  partly  filled  up  by  a  transformation 
of  its  cartilage  into  fibrous  tissue,  whilst  the  displaced  head  of 
the  bone  becomes  adherent  to  the  structures  amongst  which  it 
lies ;  as  the  result  of  a  plastic  inflammation,  either  dense  fibrous 
adhesions  are  formed,  or  a  new  false  joint  (psetidarthrosis).  The 
articular  cartilage  is  eroded,  and  the  exposed  bone  eburnated  and 
sclerosed,  whilst,  owing  to  chronic  periostitis,  the  end  of  the  shaft 
may  be  considerably  deformed.  The  portion  of  bone  upon  which 
the  displaced  head  rests  undergoes  changes,  partly  atrophic  (from 
pressure),  partly  hypertrophic  (as  a  result  of  chronic  periostitis), 
whereby  a  new  socket  is  produced  (Fig.  192).  Neighbouring 
muscles  are  secondarily  shortened,  and  accommodate  themselves 
to  the  abnormal  position  of  the  limb,  and  tendons  which  have 
been  torn  gain  fresh  attachments.  These  changes  necessarily 
interfere  more  or  less  seriously  with  the  power  of  the  limb  and 
the  movements  of  the  joint. 

Treatment. — The  treatment  of  dislocations  consists  in  the  re- 
duction of  the  displaced  bone  with  as  little  delay  as  possible. 
There  are  two  chief  methods  of  gaining  this  end,  viz.,  manipula- 
tion and  extension. 

Manipulation  is  always  the  best  means  to  employ  where 
practicable,  less  injury  being  sustained  by  the  surrounding  tissues. 
It  consists  in  moving  the  limb  in  such  directions  as  shall  cause 
the  displaced  end  to  retrace  the  course  that  it  has  already  taken, 
through  the  rent  in  the  capsule  to  its  normal  position.  The 
shoulder  and  hip  joints  are  more  amenable  to  this  method  of  treat- 
ment than  hinge  joints.  Anaesthesia  will  be  required  in  difficult 
cases.  The  special  manipulations  needed  in  any  particular 
instance  are  detailed  under  the  various  joints. 

Extension  is  employed  to  overcome  muscular  and  other  forms  of 
resistance,  so  as  to  draw  the  bone  back  into  its  original  position. 
In  order  to  make  this  effectual,  the  parts  above  the  dislocation 
are  steadied  by  some  counter-extending  force  applied  either  by  the 
hands  of  an  assistant,  or  by  a  belt  or  towel,  or  by  the  knee  or  foot 
of  the  surgeon.  Extension  may  be  made  by  the  hands,  or  a 
firmer  grip  may  be  maintained,  and  greater  force  used,  by  apply- 
ing a  bandage  or  a  jack-towel  to  the  limb  by  means  of  a  clove- 
hitch.  In  a  few  cases,  the  force  may  be  exerted  through  some 
form  of  multiplying  pulley,  fixed  at  one  end  to  a  hook  or  staple, 
and  at  the  other  end  to  the  loop  of  a  towel  or  bandage  attached 
to  the  limb.  When  any  such  contrivance  is  employed,  precau- 
tions must  be  taken  to  prevent  the  soft  tissues  from  being  injured. 


INJURIES  OF  JOINTS— DISLOCATIONS  547 

A  useful  plan  consists  in  applying  a  damp  bandage  at  the  point 
from  which  traction  is  to  be  made,  and  over  this  a  thick  skein  of 
worsted  in  the  form  of  a  clove-hitch,  the  loop  being  attached  to 
the  hook  of  the  pulley.  The  extension  must  be  made  continu- 
ously ;  no  jolting  or  jerking  action  is  allowable,  or  considerable 
mischief  may  ensue.  Since  the  introduction  of  anaesthetics,  how- 
ever, pulleys  have  been  very  rarely  required,  except  in  dealing 
with  old-standing  cases. 

Reduction,  however  produced,  is  usually  accompanied  by  a 
sudden  and  distinct  snap  or  suction  sound,  due  to  the  contraction 
of  muscles,  unless  the  patient  is  deeply  under  an  anaesthetic,  and 
the  muscles  are  absolutely  relaxed.  The  limb  is  subsequently 
kept  at  rest  for  some  days,  to  allow  the  rent  in  the  capsule  to  heal. 
Cooling  lotions  are  applied  to  reduce  the  swelling,  and  at  the  end 
of  ten  days  or  a  fortnight  passive  movements  commence,  together 
with  friction  and  massage  of  the  soft  parts. 

The  treatment  of  unreduced  dislocations  is  often  a  matter  of  con- 
siderable difficulty.  Attempts  to  reduce  them  may  be  undertaken 
up  to  two  or  three  months,  but  no  undue  violence  is  permissible, 
owing  to  the  fact  that  adhesions  to  neighbouring  parts  may  thereby 
be  ruptured,  and  the  main  vessels  or  nerves  endangered.  The 
use  of  pulleys  has  been  sometimes  recommended,  but  so  many 
accidents  have  been  reported,  varying  in  severity  from  laceration 
of  the  skin  to  actual  avulsion  of  the  limb,  that  it  is  better  to  dis- 
continue such  treatment  if  it  has  failed  on  its  first  application. 

The  amount  of  mobility  possible  in  an  unreduced  dislocation 
varies  a  good  deal  in  different  cases,  and  the  character  of  the 
treatment  is  mainly  governed  by  this.  If  movement  is  tolerably 
free,  and  not  particularly  painful,  massage  and  manipulation  may 
be  undertaken,  and  a  very  useful  limb  result.  Where,  however, 
movement  is  both  painful  and  limited,  operative  treatment  should 
be  undertaken  ;  subcutaneous  section  of  muscles  and  tendons  has 
been  practised,  but  without  much  success,  and  the  risk,  owing  to 
the  fact  that  the  peri-articular  structures  are  displaced  and  dis- 
torted, is  so  great  as  to  render  such  a  procedure  unadvisable. 
Two  chief  methods  of  operative  treatment  are  applicable  :  (i.)  Re- 
duction by  an  open  operation.  The  head  of  the  bone  is  cut  down  on, 
and  freed  from  its  adhesions  to  surrounding  structures,  the  capsule 
of  the  joint  being  also  opened,  and  the  cavity  cleared;  reduction 
may  then  be  possible  by  means  of  manipulation  or  extension. 
A  few  cases  of  successful  treatment  of  old-standing  dislocations 
of  the  shoulder  by  this  means  have  been  recorded  ;  but,  as  a  rule, 
the  gain  derived  thereby  is  not  commensurate  with  the  risks  and 
difficulties  of  the  operation,  especially  if  a  considerable  interval 
has  elapsed  since  the  accident,  (ii.)  Excision  of  the  displaced  head 
of  the  bone  will  give  the  best  result  in  most  cases.  In  the  elbow- 
joint  it  is  often  the  only  practicable  treatment,  and  in  the  shoulder 
and  hip  it  is  usually  better  than  attempting  open  reduction. 


548 


A  MANUAL  OF  SURGERY 


Compound  dislocations  are  almost  always  serious  lesions,  for  not 
only  is  the  skin  lacerated,  and  the  joint  exposed  to  the  risk  of 
septic  contamination,  but  adjacent  vessels  and  nerves  are  liable 
to  injury.  Unless  efficient  treatment  is  adopted,  suppurative 
arthritis  ensues,  leading  to  disorganization  of  the  articulation  with 
subsequent  ankylosis,  or,  in  the  case  of  larger  joints,  possibly  to 
death  from  pyaemia  and  septic  poisoning.  The  treatment  consists  of 
the  application  of  the  principles  of  antisepsis  already  enunciated  for 
the  treatment  of  lacerated  wounds,  together  with  reduction  of  the 
dislocation.  If  necessary,  the  wound  in  the  skin  must  be  enlarged, 
in  order  to  allow  of  the  replacement  of  the  bone,  and,  should  the 
latter  structure  be  much  bruised  or  injured,  it  may  be  advisable  to 
resect  it  at  once.  If,  however,  vessels  and  nerves  are  also  injured, 
or  if  the  patient  is  old  or  debilitated,  amputation  may  be  required. 


Special  Dislocations. 

Dislocation  of  the  Lower  Jaw  forwards  is  not  a  very  common 
accident,  and  usually  results  either  from  muscular  action,  or  from 
a  blow  on  the  chin  when  the  mouth  is  widely  open,  as  in  gaping, 
laughing,  or  attempting  to  take  a  large  bite.  It  has  also  been 
produced  in  dentistry  by  a  violent  strain  during  tooth-drawing,  or 

from  digging  out  roots  with 
an  elevator.  In  some  persons 
the  accident  happens  with  the 
greatest  ease,  and  constantly 
recurs,  owing  probably  to 
laxity  of  the  capsule  or  in- 
sufficient development  of  the 
eminentia  articularis. 

The  mechanism  of  the  dis- 
location is  as  follows  :  When 
the  mouth  is  opened,  the 
condyle  of  the  jaw  slips  for- 
wards on  to  the  eminentia 
articularis,  and  it  requires 
very  little  force  to  displace  it 
still  further  into  the  zygo- 
matic fossa  (Fig.  193).  The  inter-articular  cartilage  sometimes 
follows  the  condyle,  and  the  attachment  of  the  external  pterygoid 
muscle  to  that  structure  and  to  the  bone  explains  the  occurrence 
of  dislocation  from  muscular  action. 

The  displacement  may  be  unilateral  or  bilateral,  more  frequently 
the  latter.  The  mouth  remains  widely  open,  the  teeth  and  the 
jaws  being  separated  by  an  interval  of  about  an  inch.  The  lower 
jaw  projects  unduly,  and  is  fixed,  saliva  dribbling  over  the  lip  ; 
speech  and  deglutition  are  impaired,  the  pronunciation  of  the 
labial  consonants  being   especially  difficult.     A   hollow   can    be 


Fig     193— Dislocation  of  Jaw. 


INJURIES  OF  JOINTS— DISLOCATIONS  549 

detected  immediately  in  front  of  the  tragus,  where  the  condyle  is 
normally  lodged,  and  in  front  of  this  hollow  the  condyle  can  be 
felt,  being  recognised  by  the  slight  amount  of  passive  movement 
still  possible.  A  finger  inserted  into  the  mouth  may  be  able  to 
make  out  the  coronoid  process  in  an  abnormal  position  beneath 
the  zygoma. 

When  the  dislocation  is  unilateral,  the  symptoms  are  much  less 
marked.  Some  amount  of  movement  of  the  jaw  still  remains, 
whilst  the  chin  is  displaced  towards  the  sound  side. 

Treatment. — The  reduction  of  the  bone  is  in  most  cases  easily 
effected.  All  that  is  needed  is  to  depress  the  condyle  below  the 
level  of  the  eminentia  articularis,  when  the  masseter,  temporal 
and  internal  pterygoid  muscles  speedily  draw  it  back  into  the 
glenoid  cavity.  The  patient  is  seated  in  a  chair  ;  the  surgeon 
standing  in  front  guards  his  thumbs  with  thick  napkins  to  prevent 
being  bitten,  and  introduces  them  into  the  mouth,  pressing  upon 
the  lower  molar  teeth.  Pressure  is  continued  in  a  downward  and 
backward  direction  until  the  condyle  is  free,  and  then  the  chin  is 
raised  by  the  fingers  on  either  side.  The  jaw  is  kept  at  rest  for  a 
few  days  by  means  of  a  four-tailed  bandage. 

A  few  cases  are  on  record  of  displacement  of  the  condyle  of 
the  jaw  backwards,  associated  with  fracture  of  the  tympanic  plate 
and  tearing  or  separation  of  the  cartilage  of  the  auricle,  leading 
to  bleeding  from  the  ear.  Displacement  upwards  into  the  cranial 
cavity  through  the  roof  of  the  glenoid  fossa  has  also  been  described, 
the  patient  in  one  case  dying  of  meningitis. 

Dislocation  of  the  Sternal  End  of  the  Clavicle. — It  might  be 
supposed  that  displacement  at  this  joint  would  not  be  uncommon, 
when  the  shape  and  relative  sizes  of  its  articular  surfaces  are  con- 
sidered, together  with  the  great  strains  to  which  it  is  subjected. 
Owing,  however,  to  the  strength  of  the  ligaments  surrounding  it, 
particularly  of  the  rhomboid,  this  is  not  the  case,  the  clavicle  being 
broken  rather  than  displaced.  The  cause  of  such  displacements  is 
violence  directed  to  the  acromial  end  of  the  clavicle.  If  the  force 
acts  from  in  front,  the  bone  may  be  thrown  forwards  ;  if  from 
above,  downwards  and  inwards,  the  upward  dislocation  may 
occur  ;  if  the  shoulder  is  driven  forwards  and  inwards,  the  head 
of  the  bone  may  pass  backwards.  Three  varieties  are  described 
according  to  whether  the  head  of  the  bone  travels  fonvards,  back- 
wards, or  upwards. 

In  the  forward  dislocation  the  end  of  the  bone  lies  on  the 
anterior  surface  of  the  manubrium,  where  it  can  be  easily  de- 
tected ;  all  the  ligaments  of  the  joint  are  torn,  except,  perhaps, 
the  interclavicular.  The  point  of  the  shoulder  is  approximated 
to  the  middle  line.  Treatment. — Reduction  is  effected  by  placing 
the  knee  against  the  spine  between  the  scapula?,  and  drawing  the 
shoulders  backwards,  the  elbow  on  the  affected  side  being  kept  in 


5So  A  MANUAL  OF  SURGERY 


front  of  the  mid-axillary  line.  The  displacement  is  very  likely  to 
recur,  and  to  prevent  this  a  pad  is  kept  over  the  end  of  the  bone 
by  a  figure-of-8  bandage,  whilst  the  point  of  the  shoulder  is 
pushed  outwards  by  placing  a  pad  in  the  axilla,  and  binding  the 
arm  to  the  side.  It  is  advisable  to  keep  the  patient  in  bed  for  a 
few  days,  so  as  to  give  the  ligaments  a  better  chance  of  reuniting, 
but  some  amount  of  forward  displacement  is  very  likely  to 
persist.  No  bad  result  follows,  even  should  the  dislocation 
remain  unreduced. 

The  backward  dislocation  is  not  often  met  with.  The  head  of 
the  bone  lies  behind  the  upper  part  of  the  sternum,  close  to  the 
origin  of  the  sterno-hyoid  and  sterno-thyroid  muscles.  All  the 
ligaments  are  ruptured,  including  the  rhomboid.  A  depression  is 
felt  in  the  usual  position  of  the  head  of  the  bone,  which  may  be 
sometimes  detected  lying  deeply  in  the  superior  mediastinum. 
The  shoulder  is  thrown  forwards,  and  situated  nearer  the  middle 
line  of  the  body  than  usual,  whilst  the  movements  of  the  head 
and  neck  are  painful  and  limited.  Pressure  of  the  bone  upon  the 
trachea,  oesophagus,  and  vessels  of  the  neck  gives  rise  to  diffi- 
culty in  breathing  and  swallowing,  whilst  the  consequent  conges- 
tion of  the  head  may  even  cause  semi-coma.  Reduction  by  exten- 
sion of  the  shoulders  backwards  is  usually  accomplished  without 
much  trouble.  In  cases  of  difficulty,  a  firm  pad  can  be  placed  in 
the  axilla,  and  the  shoulder  levered  outwards  by  using  it  as  a  ful- 
crum, the  elbow  being  pressed  to  the  side.  It  is  retained  in  position 
by  keeping  the  shoulders  well  extended  by  the  use  of  two  hand- 
kerchiefs, as  suggested  in  the  treatment  of  fractured  clavicle.  If 
the  condition  cannot  be  reduced,  and  serious  symptoms  of  pressure 
result,  the  head  of  the  bone  should  be 
excised. 

The  upward  dislocation  is  one  of  ex- 
treme rarity.  The  head  of  the  bone  is 
felt  in  front  of  the  trachea,  in  which 
situation  it  may  compress  both  windpipe 
and  oesophagus,  especially  when  the 
patient  sits  up  or  leans  forwards.  To 
effect  reduction,  a  pad  is  placed  in  the 
axilla,  and  the  arm  pressed  inwards  over 
it  ;  the  elbow  is  subsequently  bandaged 
to  the  side  and  well  elevated.     A  pad  is 

nov3^i)cI^LA0.CATI0N    at  the  same  time  kept  over  the  end  of 
Downwards  of  Acromiom      .  •    .  .  .      .       r  .     .  ,        , 

from    the   End   of    the    tne  bone,  but  it  is  very   probable  that 
Clavicle.     (Tillmanns.)     some    amount     of     displacement     will 
persist. 

Dislocation  at  the  Acromio-clavicular  Joint  consists  in  the 
acromion  being  forced  either  above  or  below  the  outer  end  of  the 
clavicle,  more  commonly  the  latter.     The  displacement  is  easily 


INJURIES  OF  JOINTS— DISLOCATIONS  551 


recognised  by  the  abnormal  prominence  of  one  or  other  of  the 
bones  (Fig.  194).  It  usually  results  from  violence  directed  to  the 
scapula.  No  difficulty  is  experienced  in  reduction,  but  the  dis- 
placement is  very  liable  to  recur,  especially  in  the  more  common 
form.  The  elbow  is  then  flexed  to  a  right  angle,  and  pads  of  lint 
or  small  towels  placed  over  the  acromion  and  beneath  the  elbow  ; 
a  bandage  or  strap  is  then  applied  over  the  shoulder  and  under 
the  elbow,  and  suffices  to  maintain  the  bone  in  position.  It  is  kept 
from  slipping  by  passing  a  bandage  under  the  strap  round  the 
opposite  side  of  the  chest.  Should  the  displacement  persist,  and 
give  rise  to  pain  or  impair  the  movements  of  the  arm,  the  bones 
may  be  wired  together  after  removing  the  cartilaginous  surfaces. 

A  condition  is  sometimes  met  with,  described  as  a  Dislocation  of 
the  Lower  Angle  of  the  Scapula,  or,  better,  Winged  Scapula.  It  is 
characterized  by  projection  backwards  of  that  part  of  the  bone 
when  the  arms  are  thrust  forwards  ;  and  is  due  rather  to  paralysis 
of  the  serratus  magnus  and  rhomboids  than  to  slipping  of  the 
fibres  of  the  latissimus  dorsi  from  the  lower  angle,  as  was  formerly 
supposed.  In  several  cases  we  have  noticed  pain  and  tenderness 
over  the  roots  of  the  5th  and  6th  nerves  in  the  neck,  suggesting 
its  dependence  on  a  chronic  neuritis  of  these  trunks.  A  similar 
condition  is  sometimes  noted  in  progressive  muscular  atrophy. 
The  Treatment  consists  in  the  administration  of  strychnine,  and 
the  use  of  massage  and  of  the  faradic  current,  whilst,  if  per- 
sistent, a  properly  applied  apparatus  may  correct  the  deformity. 

Dislocation  of  the  Shoulder  occurs  almost  as  frequently  as  all 
the  other  dislocations  of  the  body  put  together.  The  shallowness 
of  the  glenoid  cavity,  the  size  of  the  head  of  the  humerus,  the 
laxity  of  the  capsule,  the  extent  and  force  of  the  movements 
possible,  and  the  exposed  position  of  the  shoulder,  explain  the 
great  frequency  of  the  accident.  It  usually  results  from  falls 
upon  the  hand  or  elbow,  the  arm  at  the  time  of  the  accident 
being  widely  outstretched,  to  enable  the  individual  if  possible  to 
save  himself.  The  weak  lower  and  inner  part  of  the  capsule 
receives  the  chief  portion  of  the  shock,  and  yields,  the  head  of  the 
bone  being  primarily  displaced  downwards  into  the  axilla  (sub- 
glenoid variety),  and  then,  according  to  the  direction  of  the  force, 
or  the  character  of  the  subsequent  manipulations,  the  head  travels 
either  forwards  (subcoracoid  or  subclavicular  dislocation)  or  back- 
wards (subspinous).  Falls  on  the  elbow  or  shoulder  may,  how- 
ever, cause  a  direct  forward  or  backward  displacement. 

The  Signs  of  a  dislocation  of  the  shoulder  are  sufficiently 
obvious,  and  certain  characteristic  features  are  met  with  in  almost 
all  varieties.  (1)  The  shoulder  looks  flattened,  owing  to  displace- 
ment of  the  head  inwards  (Figs.  138,  B  and  197),  and  as  a  result 
of  this  the  acromion  process  is  unduly  prominent,  and  a  hollow  felt 
below  it,  occupied  by  the  tense  deltoid.     (2)  The  head  of  the  bone 


552 


A  MANUAL  OF  SURGERY 


lies  in  some  abnormal  position,  and  the  glenoid  cavity  is  empty. 
(3)  The  elbow  is  displaced  away  from  the  side,  and  it  is  im- 
possible to  make  it  touch  the  chest  wall  at  the  same  time  that 
the  hand  is  placed  on  the  opposite  shoulder  (Dugas'  test) ;  this 
does  not  always  obtain  in  the  subcoracoid  type.  (4)  The  vertical 
measurement  round  the  axilla  is  increased  in  all  the  varieties  (Call- 
away's test)  ;  whilst  inspection  reveals  a  lowering  of  the  anterior 
or  posterior  axillary  fold  (Bryant's  test).  (5)  A  ruler  or  straight- 
edge can  be  made  to  touch  both  the  acromion  process  and  the  outer 
condyle  of  the  elbow  in  most  cases  of  dislocation  (Hamilton's  ruler 
test) ;  this  is  impossible  when  the  head  of  the  bone  is  in  its  normal 
position,  but  can  also  occur  in  fractures  of  the  anatomical  neck. 
At  the  same  time,  the  usual  signs  of  a  dislocation,  viz.,  rigidity 
and  local  bruising,  are  also  present. 


Fig.  195.— Subglenoid  Dislocation     Fig.  196.— Subcoracoid  Dislocation 
of  Shoulder.     (Tillmanns.)  of  Shoulder.     (Tillmanns.) 


Subglenoid  Dislocation  (Fig.  195)  is  the  primary  condition  met 
with  in  all  cases  where  the  accident  is  due  to  a  fall  upon  the  out- 
stretched arm,  but  is  not  commonly  seen,  since  the  head  of  the 
bone  usually  slips  up  under  the  coracoid,  as  before  stated.  The 
head  of  the  bone  passes  downwards  into  the  axilla,  resting 
against  the  outer  border  of  the  scapula  below  the  glenoid  cavity, 
between  the  subscapularis  above  and  the  teres  minor  below, 
whilst  the  long  head  of  the  triceps  is  placed  behind.  The  capsular 
ligament  and  muscles  passing  to  the  tuberosities  are  lacerated, 
whilst  the  axillary  vessels  and  nerves  may  be  seriously  com- 
pressed. The  head  of  the  bone  is  detected  in  the  axilla,  and 
the  anterior  axillary  fold  is  much  lowered ;  the  elbow  is  directed 
away  from  the  side  and  slightly  backwards ;  the  arm  is 
lengthened,  perhaps  to  the  extent  of  1  inch,  whilst  the  forearm 
is  usually  flexed,  and  the  fingers  may  be  numbed  from  pressure 
on  the  nerves. 


INJURIES  OF  JOINTS— DISLOCATIONS 


553 


A  few  cases  have  been  recorded  in  which  the  arm  was  abducted 
and  displaced  vertically  upwards,  although  the  head  of  the  bone 
was  in  the  usual  position  of  a  subglenoid  dislocation.  This 
variety  is  known  as  the  luxatio  erecta. 

Subcoracoid  Dislocation  (Figs.  196  and  197)  is,  without  doubt, 
the  most  common  form.  In  it  the  head  of  the  bone  lies  under 
the  coracoid  process  on  the  anterior  part  of  the  neck  of  the 
scapula,  immediately  in  front  of  the  glenoid  cavity,  the  anato- 
mical neck  impinging  en  its  anterior  border.     In  this  position  it 


Fig.  197. — Subcoracoid  Dislocation  of  the  Right  Shoulder. 


is  above  the  tendon  of  the  subscapularis,  which  is  either  torn  or 
stretched  over  the  neck  as  a  tense  band,  and  may  considerably 
impede  reduction.  Two  forms  of  this  displacement  are  described 
by  Malgaigne,  according  to  whether  the  muscles  attached  to  the 
great  tuberosity  are  intact,  resulting  in  marked  external  rotation 
of  the  limb  (subcoracoid  variety),  or  whether  they  are  lacerated, 
or  even  the  great  tuberosity  itself  pulled  off,  the  humerus  being 
then  rotated  inwards  (intracoracoid  variety).  In  both  types  the 
elbow  is  displaced  backwards  and  outwards,  and  the  head  of  the 
bone  can  be  usually  felt  with  ease,  especially  on  rotation  of  the 
arm,  under  the  outer  third  of  the  clavicle,  except  in  stout  people 


554 


A   MANUAL  OF  SURGERY 


or  where  the  muscles  are  greatly  developed.    Comparatively  little 
alteration  in  the  length  of  the  arm  is  produced. 

The  Subclavicular  variety  is  very  uncommon,  and  merely  an 
exaggeration  of  the  subcoracoid.  The  head  of  the  humerus 
passes  further  inwards,  and  lies  deeply  under  the  pectoralis  major, 
on  the  second  and  third  ribs.  The  capsule  and  surrounding 
muscles  are  much  lacerated,  or  perhaps  the  great  tuberosity  torn 
off;  the  elbow  is  markedly  separated  from  the  side  and  directed 
a  little  backwards,  whilst  distinct  shortening  is  present. 

The  Subspinous  Dislocation  (Fig.  198)  is  not  frequently  met 
with.  The  head  of  the  bone  lies  in  the  infraspinous  fossa,  im- 
mediately behind  the  glenoid  cavity,  between  the  infraspinatus 
and  teres  minor  muscles,  the  subscapularis  being  usually  torn. 
Malgaigne  states  the  head  of  the  humerus  is  most  commonly 
found  resting  on  the  posterior  edge  of  the  glenoid  cavity  im- 
mediately below  the  acromion  process 
(subacromial  variety).  The  elbow  is  dis- 
placed considerably  forwards,  but  can 
be  made  to  touch  the  chest  wall ;  the 
arm  is  rotated  inwards,  so  that  the  hand 
is  thrown  across  the  front  of  the  body. 
There  is  usually  a  marked  hollow  be- 
neath the  coracoid  process,  whilst  a 
distinct  prominence  is  caused  by  the 
head  of  the  bone  in  its  false  position. 
The  length  of  the  limb  is  frequently 
unaffected,  or  if  any  change  is  present, 
the  arm  is  slightly  lengthened. 

Three  or  four  cases  have  been  de- 
scribed of  what  is  known  as  a  Supra- 
coracoid  Dislocation.  The  head  of  the 
bone  is  here  displaced  upwards,  and 
either  the  coracoid  or  acromion  process  is  broken,  more  commonly 
the  former.  Replacement  with  crepitus  is  easily  obtained,  but 
the  dislocation  is  liable  to  recur. 

The  Treatment  of  Dislocation  of  the  Shoulder  consists  in  reduc- 
tion by  manipulation  or  extension. 

1.  For  reduction  by  manipulation  an  anaesthetic  is  advisable,  though 
not  absolutely  essential,  and  preferably  chloroform,  although 
where  the  patient  is  in  a  bad  state  for  the  administration — i.e.,  with 
his  stomach  full  of  food — ether  may  be  preferable.  It  is  only  right 
to  draw  attention  to  the  fact  that  a  large  number  of  fatal  cases  of 
chloroform  administration  have  been  reported  as  occurring  in  the 
treatment  of  shoulder  dislocations  ;  this  is  due  mainly  to  two 
causes,  viz.,  the  deep  anaesthesia  required,  and  the  want  of  pre- 
paration of  the  patient.  The  greatest  care  must  therefore  be 
exercised  in  giving  the  anaesthetic. 

Many  different  methods  of  manipulation  have  been  suggested, 


Fig.  iq». — Subspinous  Dis- 
location of  Shoulder. 
(Tillmanns.) 


INJURIES  OF  JOINTS—DISLOCATIONS  555 


of  which  the  following  are  the  more  important.  Not  unfrequently, 
when  the  muscles  are  relaxed,  any  slight  rotary  movement  suffices 
to  '  put  the  bone  in.' 

Kocher's  Method. — The  surgeon  standing  in  front  of  his  patient, 
who  is  seated  or  reclining,  and  supported  by  an  assistant,  grasps 
the  elbowr  after  flexion  of  the  forearm,  and  presses  it  to  the  side. 
The  arm  is  now  rotated  firmly  and  steadily  outwards  until  the 
forearm  is  at  right  angles  to  the  body,  when  distinct  resistance 
will  be  felt.  This  causes  the  head  of  the  humerus  to  roll  out 
beneath  the  acromion,  and  is  often  sufficient  to  effect  reduction  ; 
but  if  the  limb  is  still  displaced,  the  arm  should  be  drawn  forwards 
to  the  median  line  and  elevated  almost  to  a  right  angle  with  the 
trunk,  with  the  hand  still  abducted  and  everted,  whilst  finally  the 
arm  is  rotated  inwards  so  as  to  carry  the  hand  towards  the 
opposite  shoulder,  and  the  elbow  lowered.  This  plan  is  most 
useful  in  subcoracoid  dislocations,  and  its  value,  according  to 
Kocher,  turns  on  the  fact  that  the  posterior  part  of  the  capsule 
and  the  scapular  tendons  inserted  therein  are  usually  untorn  and 
stretched  tightly  across  the  glenoid  fossa.  Rotation  outwrards 
relaxes  this  structure  and  removes  it  from  the  fossa,  whilst  the 
rent  in  the  capsule  gapes,  but  owing  to  the  fact  that  the  upper 
and  lower  margins  of  the  opening  are  still  tight,  the  head  of  the 
humerus  remains  fixed  against  the  neck  of  the  scapula  until  the 
elbow  is  carried  forwards  and  raised.  The  upper  part  of  the 
capsule  then  relaxes,  and  the  lower  part  which  remains  tense 
guides  the  head  of  the  bone  into  the  joint. 

Smith's  Method  varies  somewhat  in  its  application,  according  to 
whether  the  head  of  the  bone  is  displaced  anteriorly  or  posteriorly. 
For  anterior  displacements  the  surgeon  stands  in  front  of  the 
patient,  and  grasps  the  shoulder,  using  the  right  hand  for  the 
right  shoulder  and  the  left  for  the  left,  so  that  the  thumb  rests  on 
the  head  of  the  bone,  and  the  fingers  grasp  and  steady  the  scapula. 
With  the  other  hand  he  seizes  the  arm  near  the  elbow  which  has 
been  flexed,  and  raises  it  from  the  side,  extending  and  everting  it. 
Having  thus  raised  it  to  a  right  angle,  the  limb  is  steadily  and 
continuously  circumducted  inwards,  the  thumb  following  the  head 
of  the  bone  and  assisting  it  to  reach  the  lower  and  under  side  of 
the  capsule,  and  thus  enter  the  socket  through  the  rent.  For  the 
subspinous  dislocation,  the  surgeon  stands  behind  the  patient  and 
grasps  the  shoulder  with  one  hand,  raising  the  arm  with  the 
other,  and  making  extension  backwards  combined  with  external 
rotation  ;  i.e.,  the  limb  is  circumducted  outwards,  and  finally 
brought  to  the  side. 

2.  Extension  may  be  made  in  different  ways,  the  object  of  all, 
however,  being  to  overcome  the  tension  of  surrounding  ligaments 
and  muscles.  It  may  be  applied  directly  downwards  by  the 
surgeon  grasping  and  pulling  on  the  arm,  whilst  his  unbooted 
foot  is  used  as  a  counter-extending  force  in  the  axilla,  the  patient 


550 


A   MANUAL  OF  SURGERY 


lying  flat  on  a  mattress  placed  on  the  ground,  and  the  surgeon 
sitting  by  the  side.  Another  plan  consists  in  using  the  knee  as  a 
fulcrum  instead  of  the  heel,  the  patient  sitting  in  a  chair.  Occa- 
sionally the  foot  has  been  placed  against  the  thoracic  wall,  and 
extension  made  directly  outwards  at  right  angles  to  the  body,  as 
recommended  by  Sir  Astley  Cooper.  White,  of  Manchester, 
suggested  vertical  traction,  the  arm  being  pulled  directly  upwards, 
the  surgeon's  foot  having  been  placed  over  the  acromion,  the 
patient  being  in  the  recumbent  posture.  The  only  objection  to 
this  last  method,  which  may  succeed  when  other  plans  fail,  is 
that  the  axillary  vessels  are  somewhat  exposed  to  injury. 

Dislocations  of  the  Elbow- Joint  are  not  very  uncommon,  occur- 
ring particularly  in  young  people,  and  are  due  to  either  direct  or 

indirect  violence.  The  diagnosis  is 
often  difficult  from  the  amount  of 
swelling  that  quickly  follows.  A 
careful  investigation  of  the  relative 
position  of  the  bony  points  (p.  456), 
and  of  the  degree  of  mobility  of  the 
different  parts  on  each  other,  is  essen- 
tial in  order  to  arrive  at  a  definite 
conclusion  as  to  the  exact  nature  of 
the  lesion.  In  cases  of  doubt,  a  skia- 
gram should  be  taken. 

1.  Dislocation  of  Both  Bones  may 
occur  either  backwards,  forwards,  or 
laterally. 

The  backward  variety  (Fig.  142  A) 
is  that  most  often  met  with  ;  it  usually 
occurs    without    either    the    coronoid 
process  or  the  olecranon   being  frac- 
£H  \  tured,  although  occasionally  the  former. 

Il\   I  is  detached.     If  the  coronoid  remains 

intact,  it  sometimes  becomes  locked 
in  the  olecranon  fossa,  and  renders 
the  arm  immobile ;  if,  however,  it  is 
broken,  considerable  mobility  of  both 
Fig.  199.— Reduction  of  Back-  bones  occurs,  with  crepitus.  The  fore- 
ward  Dislocations  at  the  arm  ;s  semi.flexed,  the  hand  held  mid- 
way between  pronation  and  supination, 
and  the  displaced  bones  form  a  con- 
siderable swelling  at  the  back  of  the  joint,  above  which  is  a 
marked  hollow,  crossed  by  the  triceps.  The  lower  end  of  the 
humerus  projects  in  front,  and  the  artery  and  the  soft  parts  are 
displaced  forwards.  The  measurement  from  the  acromion  process 
to  the  external  condyle  remains  unaltered,  but  that  from  the 
condyle  to  the  styloid  process  of  the  radius  is  distinctly  shortened, 


Elbow. 


INJURIES  OF  JOINTS— DISLOCATIONS  557 

and  the  distance  between  the  condyles  and  the  olecranon  process 
is  increased. 

Dislocation  forwards  of  both  bones  rarely  occurs  without  fracture 
of  the  olecranon  process,  although  a  few  cases  of  this  unusual 
accident  are  on  record.  The  displacement  is  readily  detected,  the 
forearm  being  lengthened  perhaps  to  the  extent  of  an  inch.  The 
arm  is  in  a  condition  of  flexion,  and,  indeed,  the  accident  can 
only  take  place  from  falling  backwards  on  the  point  of  the  elbow 
when  in  this  position.  The  triceps  muscle  may  be  considerably 
lacerated. 

Lateral  dislocations  of  the  forearm  are  almost  always  incom- 
plete and  are  not  very  frequent ;  the  bones  may  be  displaced  either 
inwards  or  outwards,  the  latter  being  the  more  common.  They 
are  recognised  by  a  careful  examination  of  the  relative  position 
of  the  bony  prominences. 

2.  Dislocation  of  the  Ulna  alone  occurs  only  in  a  backward 
direction.  It  is  an  occurrence  of  the  greatest  rarity,  owing  to 
the  position  and  strength  of  the  orbicular  and  oblique  ligaments 
and  of  the  interosseous  membrane.  If,  however,  the  bones  of 
the  forearm  are  rotated  backwards  upon  the  head  of  the  radius  as 
a  fulcrum,  and  then  the  forearm  adducted,  this  displacement  can 
occur  without  extensive  ligamentous  lacerations,  which,  indeed, 
have  not  been  noted  in  any  of  the  cases  observed. 

In  the  Treatment  of  the  above  dislocations,  all  that  is  neces- 
sary is  to  unhitch  the  interlocking  bony  prominences,  so  as  to 
allow  the  bones  to  return  to  their  normal  positions  by  muscular 
contraction.  This  is  usually  ac- 
complished by  the  method  de- 
scribed by  Sir  Astley  Cooper. 
The  patient  being  in  a  sitting 
position,  the  surgeon  presses  back- 
wards, with  his  knee  in  the  bend 
of  the  elbow,  against  the  lower 
end  of  the  humerus;  at  the  same 
time  he  grasps  the  patient's  wrist, 
and  slowly  and  forcibly  bends  the 
forearm  (Fig.  199). 

3.  Dislocations    of    the   Radius 
alone  may  occur  either  forwards,   Fig.   200.— Dislocation  of  the 
backwards,  or  outwards.  Radius  Forwards.     (Pick.) 

The  forward  dislocation 
(Fig.  200)  is  that  usually  seen,  and  results  from  falls  on  the  hand 
when  the  forearm  is  in  a  state  of  extreme  pronation.  The  head 
of  the  radius  rests  against  the  lower  end  of  the  humerus  in  the 
hollow  above  the  capitellum,  and  the  most  characteristic  feature 
consists  in  the  inability  of  the  patient  to  flex  his  forearm,  owing 
to  the  bone  impinging  against  the  lower  end  of  the  humerus.  It 
can  be  readily  detected  in  this  situation,  rotating  with  the  move- 


558 


A   MANUAL  OF  SURGERY 


ments  of  the  forearm,  whilst  a  deep  hollow  is  felt  behind,  imme- 
diately below  the  external  condyle.  The  forearm  is  somewhat 
flexed,  and  midway  between  pronation  and  supination  ;  the  former 
act  can  be  satisfactorily  accomplished,  but  supination  cannot  be 
carried  further  than  half-way.  A  marked  fulness  exists  on  the 
anterior  aspect  of  the  limb  when  the  arm  is  extended.  Fracture  of 
the  upper  third  of  the  ulna  sometimes  accompanies  this  accident, 
especially  when  produced  by  direct  violence  (Plate  XXVII.).  If 
this  luxation  is  not  reduced,  very  great  impairment  of  the  mobility 
of  the  limb  results,  flexion  beyond  an  obtuse  angle  becoming 
impossible.  Treatment. — Reduction  is  accomplished  by  traction 
from  the  wrist,  with  the  forearm  flexed  to  a  right  angle,  combined 
with  pressure  over  the  head  of  the  bone.  Owing  to  the  fact  that 
the  orbicular  ligament  is  ruptured,  the  deformity  is  very  likely 
to  recur,  and  hence  active  movements  of  the  limb  must  be  inter- 
dicted for  three  or  four  weeks  ;  a  pad  is  placed  anteriorly  over  the 
head  of  the  bone,  and  the  limb  flexed  on  a  splint. 

Dislocation  backwards  is  less  common.     The  head  lies  behind 

the  external  condyle  on  the  outer 
side  of  the  olecranon,  where  it 
can  be  detected  on  rotating  the 
limb  (Fig.  201).  The  forearm  is 
flexed,  and  the  limb  pronated. 
Even  if  left  unreduced,  it  leads  to 
but  little  inconvenience. 

Dislocation  outwards  is  also 
rare,  the  head  of  the  bone  being- 
displaced  to  the  outer  side  of 
the  external  condyle,  where  it 
can  easily  be  felt,  causing  con- 
siderable impairment  of  the 
natural  movements.  Reduction 
is  accomplished  without  diffi- 
culty. 

Occasionally  a  rare  form  of 
dislocation  is  met  with  in  which  the  ulna  passes  backwards  and 
the  radius  forwards,  resulting  in  great  deformity. 

A  very  common  accident  in  children  consists  of  a  subluxa- 
tion of  the  head  of  the  radius  downwards  within  the  orbicular 
ligament,  so  that  a  portion  of  it  slips  up  and  becomes  nipped 
between  the  head  and  capitellum.  It  results  from  forcible  traction 
of  the  hand,  and  is  a  common  nursery  accident,  popularly  known 
as  pulled  elbow.  The  limb  becomes  fixed  in  a  position  of  semi- 
flexion, and  the  child  cries  out  with  the  pain;  it  is  readily  treated 
by  completely  flexing  the  iimb,  and  subsequently  extending  it, 
and  leaves  no  bad  results. 

lit  must  not  be  forgotten  that  we  have  here  merely  described 
the  pure  dislocations.    In  actual  practice  complications  of  a  serious 


Fig.  201.  —  Dislocation  of  the 
Radius  Backwards.  (Diagram- 
matic.) 


PLATE  XXtfll. 


Dislocation  of  Radius  forwards,  and  Fracture  of  Upper  Third  of  Ulna. 

To  face  /.  558.] 


INJURIES  OF  JOINTS— DISLOCATIONS  559 

nature  are  frequently  present  in  the  shape  of  fracture  of  one  or 
both  condyles,  which  lead  to  much  difficulty  in  diagnosis.  These 
fracture-dislocations  give  rise  to  so  much  haemorrhage  that  it 
is  frequently  impossible  to  come  to  a  correct  conclusion  as  to 
the  nature  of  the  case  without  the  assistance  of  the  Rontgen  rays. 
It  is  doubtful,  however,  whether  even  an  accurate  knowlege  of 
the  nature  and  extent  of  the  lesion  will  enable  us  to  improve  on 
the  results  hitherto  gained,  apart  from  operation.  So  much  callus 
is  formed,  and  fibrous  adhesions  of  such  strength  are  developed, 
that  considerable  impairment  of  function  is  almost  certain  to 
ensue.  Probably  the  best  line  of  practice  is  to  keep  the  elbow  at 
rest  on  a  rectangular  splint  for  a  few  days,  so  as  to  allow  the 
immediate  effects  of  the  accident  to  pass  off,  and  then  to  make  an 
aseptic  incision,  dealing  with  the  condition  of  affairs  in  the  way 
best  suited  to  the  requirements  of  the  particular  case. 

Dislocation  of  the  Wrist  is  a  very  uncommon  accident,  and  may 
occur  forivards  or  backwards.  The  lower  ends  of  the  radius  and 
ulna  become  prominent  under  the  skin,  and  especially  the  styloid 
processes.  By  this  means  it  is  easily  distinguished  from  a  fracture 
of  the  lower  ends  of  the  bones. 

Occasionally  the  radius,  carrying  with  it  the  hand,  is  dislocated 
from  the  lower  end  of  the  ulna,  as  a  result  of  forcible  pronation. 
This  is  usually  described  as  a  backivavd  dislocation  of  the  ulna,  and 
is  easily  reduced  by  manipulation. 

Dislocations  of  various  Carpal  Bones  have  been  described,  but 
the  only  one  which  is  at  all  common  is  a  displacement  of  the  os 
magnum  backwards.  It  forms  a  rounded  prominence  under  the 
skin  in  the  usual  situation  of  the  bone,  which  becomes  more 
prominent  on  flexion,  and  may  disappear  on  extension.  As  a  rule, 
it  is  readily  reduced,  but  is  very  likely  to  recur. 

Dislocations  of  the  Metacarpal  Bones  and   Phalanges  are  not 

unfrequent,  but  need  no  special  mention,  except  in  the  case  of 
Dislocation  Backwards  of  the  First  Phalanx  of  the  Thumb.  The 
chief  interest  in  this  case  lies  in  the  difficulty  experienced  in  re- 
duction, which  was  erroneously  attributed  to  the  head  slipping 
between  the  two  portions  of  the  flexor  brevis  pollicis  and  being 
grasped  by  them,  as  a  button  in  a  buttonhole.  It  has  now  been 
shown  that  there  are  two  much  more  important  factors,  viz.,  the 
tension  of  the  long  flexor  tendon,  which  hitches  round  the  neck 
(Fig.  202),  and  the  arrangement  of  the  glenoid  ligament.  This 
structure  passes  between  the  two  heads  of  insertion  of  the 
short  flexor,  and  is  thus  incorporated  between  the  two  sesa- 
moid bones ;  it  consists  of  fibro-cartilage,  and,  whilst  firmly 
attached  to  the  base  of  the  phalanx,  is  but  loosely  connected  with 
the  head  of  the  metacarpal  bone,  so  that  it  accompanies  the 
phalanx  in  its  dislocation.     It  thus  comes  to  be  situated  imme- 


560 


A   MANUAL  OF  SURGERY 


diately  behind  the  head  of  the  metacarpal,  and  opposes  any 
attempts  at  reduction.  Treatment. — -Traction  and  manipulation 
are  always  attempted  in  the  first  instance.  The  thumb  is  grasped 
by  a  suitable  apparatus  and  hyper-extended  to  a  right  angle,  thus 
making  the  head  of  the  metacarpal  project  still  further  through 
the  muscular  interspace,  and,  as  it  were,  enlarging  the  buttonhole. 
Still  maintaining  the  traction,  the  thumb  is  rapidly  flexed  into  the 
palm,  the  metacarpal  bone  being  at  the  same  time  pressed  inwards. 
Should  this  fail,  as  it  often  will,  a  purified  tenotome  should  be 

inserted  in  the  middle  line 
of  the  thumb  behind,  im- 
mediately above  the  base  of 
the  phalanx,  and  should  be 
pushed  on  till  it  reaches  and 
divides  the  glenoid  fibro- 
cartilage  between  the  sesa- 
moid bones  ;  this  little 
manoeuvre  will  at  once 
render  replacement  simple. 

Dislocation    of    the    Hip, 

though  not  very  common, 
is  a  condition  of  extreme 
gravity.  The  depth  of  the 
socket  in  which  the  femur 
rests,  and  the  strength  of 
the  muscles  and  ligaments 
surrounding  the  articulation, 
explain  the  comparative  in- 
Fig.  202. -Dislocation  of  Thumb,  frequency  of  the  accident. 
showing  Head  of  the  Metacarpal    t    h.         j  ,         ,     , 

Bone  protruding  Forwards  between  ^  1S  never  produced  by 
the  Heads  of  the  Short  Flexor  direct  violence,  but  always 
Muscle.     (Pick.)  results  from  a  force  applied 

to  the  feet  or  knees,  or,  if 
the  legs  be  fixed,  to  the  back.  It  is  rarely  met  with  except  in 
young  people  or  adults,  since  after  the  age  of  forty-five  fractures 
of  the  neck  of  the  bone  are  much  more  likely  to  occur. 

In  considering  these  dislocations,  the  relative  strength  or  weak- 
ness of  the  different  parts  of  the  capsule  and  its  surrounding 
structures  must  be  remembered.  Thus,  the  weakest  part  of  the 
capsule  is  placed  below  and  behind,  and  the  fibres  here  are  easily 
lacerated :  indeed,  it  is  through  a  rent  in  this  part  of  the  capsule 
that  the  b^ad  of  the  bone  most  frequently  escapes.  In  front,  the 
ilio-femoral  or  Y-shaped  ligament  of  Bigelow,  extending  from  the 
anterior  inferior  iliac  spine  to  the  anterior  intertrochanteric  line, 
is  a  structure  of  much  strength,  on  the  integrity  of  which  depends 
the  fact  whether  the  displaced  head  of  the  bone  shall  occupy  some 
definite  position  or  be  freely  moveable.     Bigelow,  to  whom  we 


INJURIES  OF  JOINTS— DISLOCATIONS  561 


owe  so  much  in  the  elucidation  of  the  mechanism  of  these  dis- 
locations, has  divided  them  into  two  classes — the  regular  and  the 
irregular — according  to  whether  this  ligament  is  intact  or  com- 
pletely lacerated.  Posteriorly,  the  plicated  tendon  of  the  obturator 
internus  is  the  most  important  structure,  and  the  position  and 
level  of  the  bone  on  the  dorsum  ilii  depends  in  some  measure  on 
whether  it  remains  intact  or  is  ruptured.  It  must  also  be  remem- 
bered that  the  ligamentum  teres  is  relaxed  when  the  thigh  is 
forcibly  abducted,  and  is  made  tense  by  adduction. 

Four  chief  varieties  of  dislocation  are  described,  in  two  of 
which  the  head  of  the  bone  is  displaced  posteriorly,  and  in  two 
anteriorly.  The  two  former  are  known  as  the  Dorsal  and  the 
Sciatic  varieties,  although  Dorsal  below  the  tendon,  as  originally 
suggested  by  Sir  Astley  Cooper,  is  the  better  appellation  for  the 
latter  variety.  The  two  anterior  dislocations  are  known  as  the 
Obturator  or  Thyroid,  and  the  Pubic;  in  the  former  the  head 
of  the  bone  is  located  in  the  obturator  notch,  and  in  the  latter 
upon  the  pubic  ramus.  The  relative  frequency  of  these  disloca- 
tions is  as  follows :  About  50  to  55  per  cent,  of  the  cases  are 
of  the  dorsal  type,  20  to  25  per  cent,  sciatic,  10  to  15  per  cent, 
obturator,  and  5  to  10  per  cent,  pubic.  In  addition  to  these  four 
varieties,  many  other  slight  modifications  have  been  described, 
which  it  will  be  unnecessary  to  further  particularize. 

Mechanism.  —  Some  surgeons  strongly  maintain  the  opinion 
that  the  limb  is  always  in  a  position  of  abduction  at  the  moment 
of  dislocation,  the  head  of  the  bone  escaping  from  the  capsule 
through  a  rent  in  the  lower  and  back  part  of  the  ligament,  and 
thus  being  primarily  displaced  downwards.  The  type  of  accident 
responsible  for  this  is  a  fall  with  the  legs  widely  separated,  or 
when  the  limbs  are  drawn  forcibly  apart,  as,  for  instance,  when 
one  leg  is  placed  on  a  boat  just  moving  away  from  a  pier  on 
which  the  other  is  fixed.  The  direction  of  the  violence,  or  the 
subsequent  manipulations  performed  by  willing  but  ignorant 
friends,  or  the  voluntary  movements  of  the  individual,  determine 
what  form  of  dislocation  is  to  be  subsequently  produced.  If  the 
limb  is  externally  rotated  and  extended,  the  head  travels  forwards, 
and  either  the  pubic  or  obturator  variety  results.  If,  however, 
the  leg  is  inverted  and  flexed,  the  head  of  the  bone  passes  back- 
wards, and  either  the  dorsal  or  sciatic  form  is  produced.  Again, 
in  the  posterior  dislocations,  if  the  obturator  internus  tendon 
remains  intact,  it  may  hitch  across  the  front  of  the  neck,  and 
prevent  any  further  upward  displacement  of  the  bone,  thus  giving 
rise  to  the  so-called  sciatic  variety ;  but  if  the  tendon  is  ruptured, 
or  if  the  head  of  the  bone  slips  in  front  of  it,  there  is  no  obstacle 
to  its  upward  displacement  on  the  dorsum  ilii. 

Bigelow,  however,  and  with  him  many  other  surgeons,  main- 
tain that  dislocation  of  the  hip  does  not  only  occur  with  the  limb 
in  a  position  of  abduction.     Under  certain  circumstances,  it  may 

36 


562 


A   MANUAL  OF  SURGERY 


also  result  when  the  limb  is  in  a  position  of  adduction,  a  direct 
dorsal  dislocation  being  thus  produced,  the  head  of  the  bone  escaping 
from  the  capsule  above  the  tendon  of  the  obturator  internus  ;  such 
an  accident  is  sometimes,  but  not  always,  associated  with  fracture 
of  the  posterior  lip  of  the  acetabulum.  The  type  of  violence 
leading  to  this  occurrence  is  when  a  heavy  weight  falls  on  the 
back  of  a  person  whilst  kneeling,  or  when,  his  knee  being  fixed, 
the  body  is  thrust  forwards,  so  that  the 
limb  is  forcibly  inverted.  If,  however, 
the  thigh  is  in  a  position  of  extreme 
flexion,  the  head  may  be  displaced  below 
the  tendon  of  the  obturator  internus, 
and  the  sciatic  variety  will  then  result. 

i.  Dorsal  Dislocation  (Fig.  203). — 
The  head  of  the  bone  in  this  form  is 
found  lying  on  the  dorsum  ilii,  a  variable 
distance  above  and  behind  the  aceta- 
bulum, and  always  above  the  obturator 
internus  tendon.  It  may  be  detected  on 
manipulation  of  the  limb,  although  in 
muscular  subjects  this  is  difficult.  The 
ligamentum  teres  is  necessarily  ruptured, 
as  also  the  capsule,  the  rent  being 
situated  either  below  or  above  the 
obturator  tendon  according  to  whether 
the  dislocation  is  due  to  forcible  abduc- 
tion or  adduction.  The  small  external 
rotator  muscles  are  usually  lacerated, 
and  perhaps  even  the  glutei  and  the 
pectineus.  The  ilio-femoral  ligament 
usually  remains  intact.  The  great 
sciatic  nerve  is  sometimes  compressed 
or  contused.  The  trochanter  is  raised 
above  Nelaton's  line  (p.  473),  and  ap- 
proximated to  the  anterior  superior 
spine ;  the  ilio-tibial  band  of  fascia  is 
therefore  relaxed,  and  there  is  consider- 
able shortening  of  the  limb,  amounting 
often  to  2  or  3  inches.  The  leg  is  in  a 
position  of  flexion,  adduction,  and  in- 
version, so  that  the  axis  of  the  femur  crosses  the  lower  third  of 
the  sound  thigh.  The  knee  is  semi-flexed,  and  the  ball  of  the 
great  toe  rests  against  the  opposite  instep ;  the  heel  is  somewhat 
raised.  A  marked  hollow  is  felt  in  the  upper  part  of  Scarpa's 
triangle,  and  the  main  vessels  of  the  limb  appear  to  be  unsup- 
ported. 

The  Diagnosis  should  be  easy,  the  only  difficulty  being  experi- 
enced   in    distinguishing    it    from    an    impacted    extra-capsular 


Fig.  203. — Dorsal  Dislo 

CATION       OF       THE       HlP 
fTlLLMANNS.) 


INJURIES  OF  JOINTS— DISLOCATIONS 


563 


fracture.  The  character  of  the  accident,  the  presence  of  adduction 
and  inversion,  the  increased  breadth  of  the  trochanter  in  the 
case  of  fracture,  and  the  abnormally  placed  head  of  the  bone 
in  dislocation,  are  the  points  to  which  attention  must  be  directed. 

2.  Sciatic  Dislocation,  or  dorsal  below  the  tendon,  is  one  in 
which  the  head  of  the  bone  is  prevented  from  travelling  upwards 
to  the  dorsum  ilii  by  the  integrity  of  the  obturator  internus  tendon. 
It  may  occur  either  from  forced  abduction  of  the  limb,  or  from 
extreme  flexion  in  the  adducted  position.  The  lesions  of  muscles 
and  ligaments  are  practically  the  same  as  for  the  dorsal  variety. 
The  ilio-femoral  ligament  is  uninjured. 

The  Signs  resemble  those  of  a  dorsal  dislocation,  but  are  less 
marked.  There  is  less  shortening,  often  not  more  than  ^  to  1  inch  ; 
the  limb  is  flexed,  adducted,  and  inverted,  but  the  axis  of  the 
femur  is  directed  across  the  opposite  knee,  and  the  great  toe  rests 
against  the  ball  of  the  great  toe  of  the  opposite  side.  The  head 
of  the  bone  is  often  much  less  distinct,  owing  to  the  greater  thick- 
ness of  the  glutei  muscles  at  that  level. 

Treatment  of  the  Two  Backward  Dislocations  is  effected  in  much 
the  same  way,  whether  the  dorsal  or  sciatic  variety  is  present. 
The  most  usual  method  is  that  of  mani- 
pulation and  rotation,  so  accurately  worked 
out  by  Bigelow.  The  patient  is  anaesthe- 
tized, preferably  on  a  mattress  placed  on 
the  floor.  The  leg  is  first  flexed  on  the 
thigh,  and  the  thigh  on  the  abdomen,  the 
position  of  adduction  being  still  maintained, 
so  that  the  knee  extends  beyond  the  middle 
line  of  the  body  (Fig.  204).  This  position 
is  maintained  for  some  moments,  and  then 
the  limb  is  freely  circumducted  outwards, 
and  brought  rapidly  down  into  a  position 
of  extension  parallel  with  the  other.  By 
this  manoeuvre  the  tense  structures  in  front 
of  the  joint  are  relaxed,  and  then  the  head 
of  the  bone  is  made  to  retrace  its  course 
towards  the  rent  in  the  capsule,  and  finally 
directed  upwards  into  the  acetabular  cavity. 
These  movements  are  tersely  summarized  in  Bigelow's  words — 
1  Lift  up,  bend  out,  roll  out.'' 

If  this  plan  does  not  succeed,  the  following  method  of  traction 
may  be  employed.  The  patient,  lying  on  his  back,  is  firmly  fixed 
by  a  bandage  or  towel  passed  over  the  pelvis  and  secured  to  two 
or  three  hooks  or  staples  driven  into  the  floor.  The  surgeon 
stands  over  the  patient,  whose  thigh  is  flexed  to  a  right  angle  on 
the  abdomen,  as  also  the  knee  upon  the  thigh.  The  surgeon's 
arms  are  passed  under  the  knee  sufficiently  far  to  enable  him  to 
grasp  his  own  elbows,  and  the  front  of  the  leg  is  steadied  against 

36—2 


Fig.  204. — Reduction  of 
Dorsal  Dislocation 
of  Hip.     (Bryant.) 


564 


A   MANUAL  OF  SURGERY 


the  operator's  perineum.  Direct  and  forcible  traction  upwards  can 
now  be  made,  and  this  is  often  sufficient  in  itself  to  lift  the  head 
of  the  bone  into  the  acetabulum.  If  this  is  unsuccessful,  the  move- 
ments described  above  can  be  energetically  repeated  in  this  posi- 
tion. The  above  plans,  combined  with  the  use  of  an  anaesthetic, 
rarely  fail  in  reducing  a  backward  dislocation  of  the  hip,  and  hence 
extension  by  means  of  pulleys  is  rarely  required.  If,  however,  it  is 
needed,  traction  should  always  be  made  in  the  direction  of  the 
displaced  limb,  i.e.,  across  the  other  thigh,  counter-extension  being 
obtained  by  a  jack-towel  passed  between   the  injured  thigh  and 


Fig.  205.— Dislocation  of  the  Hip: 
Obturator  Variety.    (Tillmanns.) 


Fig.  206. —  Dislocation  of  the 
Hip  Forwards:  Pubic  Variety. 
(Tillmanns ) 


the  perineum,  and  fixed  to  a  staple  in  the  floor,  close  to  the  head 
of  the  patient,  and  on  the  side  of  the  dislocation.  When  sufficient 
force  has  been  applied,  the  surgeon  rotates  the  limb  outwards  so 
as  to  allow  the  head  of  the  bone  to  once  more  slip  into  its  socket. 
3.  Thyroid  or  Obturator  Dislocation  (Fig.  205). — The  head  of 
the  bone  in  this  case  passes  downwards  through  a  rent  in  the 
lower  part  of  the  capsule,  and  its  position  is  subsequently  but 
little  altered,  a  slight  forward  and  upward  movement  being  alone 
superadded.  The  ilio-femoral  ligament  is  untorn,  but  the  pectineus 
and   adductors  are  very  tense,   or    may   even   be   lacerated ;    the 


INJURIES  OF  JOINTS— DISLOCATIONS 


565 


ligamentum  teres  is,  of  course,  ruptured.  The  head  lies  on  the 
obturator  externus  muscle,  and  can  be  detected  in  the  perineum. 
The  trochanter  is  less  prominent  than  usual,  and,  indeed,  its 
normal  position  may  be  represented  by  a  depression.  The  limb 
is  slightly  abducted  and  everted,  as  well  as  lengthened,  perhaps 
to  the  extent  of  2  inches,  though  this  is  more  apparent  than  real. 
It  is  also  flexed,  owing  to  the  tension  of  the  ilio-psoas  muscle,  and 
advanced  before  the  other,  with  the  toes  pointing  outwards.  The 
adductor  longus  tendon  stands  out  prominently,  and  much  pain 
may  be  experienced  from  pressure  on  the  obturator  nerve.  If  the 
patient  stands,  the  body  is  bent  forwards,  whilst  it  is  interesting 
to  note  that  if  the  dislocation  remains  unreduced  the  patient  may 
be  able  to  walk  without  much  pain  or  inconvenience,  though  in  a 
more  or  less  stooping  position. 

4.  Pubic  Dislocation  (Fig.  206). — In  this  variety  the  head  of 
the  bone  lies  on  the  horizontal  ramus  of  the  pubes,  just  internal 
to  the  anterior  inferior  spinous  process 
of  the  ilium,  where  it  can  be  felt  roll- 
ing under  the  finger  on  any  move- 
ment of  the  limb.  The  vessels  are 
pushed  inwards,  and  considerable  pain 
may  be  felt  down  the  limb  from 
pressure  on  the  anterior  crural  nerve. 
The  ilio-femoral  ligament  is  untorn, 
whilst  the  ligamentum  teres  and 
capsular  ligament  are  ruptured ;  the 
small  external  rotator  muscles,  with 
the  exception  of  the  obturator  internus, 
are  usually  torn.  There  is  marked 
flattening  of  the  hip,  the  trochanter 
being  approximated  to  the  middle  line 
and  raised.  The  iimb  is  shortened  to 
the  extent  of  1  inch,  and  there  is 
considerable  abduction  and  eversion,  so  that  the  inner  aspect  of 
the  limb  looks  forwards.  The  thigh  is  slightly  flexed  to  relax  the 
ilio-psoas  muscle. 

Treatment  of  the  thyroid  and  pubic  dislocations  is  undertaken 
along  similar  lines  as  for  the  posterior  dislocations.  The  patient 
is  anaesthetized ;  the  knee  is  flexed,  as  also  the  thigh  upon  the 
abdomen,  but  in  a  position  of  abduction  ;  circumduction  inwards 
follows  (Fig.  207),  and  on  extension  of  the  limb  the  head  again 
enters  the  acetabulum.  The  thyroid  variety  may  sometimes  be 
reduced  by  upward  and  outward  traction  when  the  limb  has  been 
flexed  to  a  right  angle  in  the  abducted  position,  the  unbooted  foot 
being  placed  against  the  pelvis  to  steady  it. 

If  extension  by  pulleys  is  required  in  the  thyroid  dislocation, 
it  is  made  transversely  outwards  across  the  upper  part  of  the  thigh, 
counter-extension  being  obtained  by  means  of  a  band  passed  round 


Fig.  207.  — -Reduction  of  An- 
terior Dislocations  of 
the  hip.     (Bryant.) 


566  A   MANUAL  OF  SURGERY 


the  abdomen.  The  limb,  at  first  in  a  position  of  abduction,  is 
subsequently  adducted  forcibly  by  drawing  the  ankle  inwards,  the 
band  by  means  of  which  extension  is  being  made  acting  as  a 
fulcrum  to  lever  the  head  of  the  bone  into  the  acetabulum.  In 
the  pubic  variety  traction  is  made  downwards,  outwards,  and 
backwards,  and  the  head  of  the  bone  drawn  into  its  socket  by  a 
towel  passed  transversely  across  the  limb. 

After  reduction  of  any  form  of  dislocation  of  the  hip,  the  patient 
should  be  kept  in  bed  with  the  legs  tied  together  for  about  a 
fortnight,  and  then  passive  movement  may  be  commenced,  but 
with  considerable  caution  ;  voluntary  movements  should  not  be 
undertaken  for  another  week  or  two. 

Should  the  dislocation  recur,  it  may  be  due  to  fracture  of  the 
posterior  lip  of  the  acetabulum,  or  to  some  involuntary  move- 
ments of  the  patient,  or  perhaps  to  the  fact  that  the  displacement 
has  not  been  fully  reduced.  Under  such  circumstances  further 
attempts  at  replacement  should  be  undertaken,  and  the  limb  sub- 
sequently kept  immobilized  for  a  longer  period  than  usual. 

Irregular  dislocations  of  the  hip  occur  when  the  Y-shaped 
ligament  is  completely  torn  through,  so  that  the  head  of  the  bone 
is  not  restricted,  but  can  be  moved  round  the  acetabular  cavity. 
Reduction  is  usually  easy. 

Dislocation  of  the  Patella  may  occur  outwards,  inwards,  or  edgeways. 
A  dislocation  upwards  resulting  from  rupture  of  the  ligamentum 
patellae  is  sometimes  described,  but  it  is  scarcely  to  be  included 
in  the  same  category  as  the  others.  The  displacement  may  be 
complete  or  incomplete  ;  in  the  former  the  capsule  is  always 
lacerated  ;  in  the  latter,  not  necessarily  so. 

The  outward  variety  is  much  the  commonest  on  account  of 
the  obliquity  of  the  limb,  and  may  result  from  muscular  action, 
especially  in  people  suffering  from  genu  valgum ;  it  also  arises 
from  direct  violence.  In  either  case  it  occurs  most  frequently 
when  the  limb  is  extended,  since  during  flexion  the  bone  is 
firmly  lodged  in  the  intercondyloid  notch.  When  completely 
displaced,  it  lies  upon  the  outer  surface  of  the  condyle,  with  its 
inner  margin  projecting  forwards.  In  this  situation  it  is  easily 
felt,  whilst  the  knee  appears  flattened  and  broader  than  usual, 
the  intercondyloid  notch  being  plainly  distinguishable  in  the  posi- 
tion usually  occupied  by  the  patella.  It  is  not  unfrequently, 
however,  incomplete,  and  then  the  inner  half  of  the  articular 
surface  of  the  patella  lies  in  contact  with  the  cartilaginous  surface 
of  the  outer  condyle,  with  its  outer  border  projecting  forwards. 
Reduction  may  take  place  spontaneously,  but  is  usually  effected 
by  manipulation.  The  thigh  is  flexed  on  the  abdomen,  and  the 
knee  extended,  so  as  to  relax  the  quadriceps,  and  then  a  little 
pressure  on  its  outer  margin  causes  the  bone  to  slip  back  into 
place.     In  the  incomplete  form  where  one  of  the  borders  of  the 


INJURIES  OF  JOINTS— DISLOCATIONS  567 


bone  is  lodged  in  the  intercondyloid  notch,  reduction  is  sometimes 
very  difficult,  and  to  effect  it  an  open  operation  may  be  required. 

The  inward  dislocation  is  rare,  being  always  due  to  direct 
violence.  In  characters  and  treatment  it  is  the  exact  converse  of 
those  met  with  when  the  bone  is  displaced  outwards. 

A  dislocation  edgeways,  or  Vertical  Kotation  of  the  patella,  is 
an  interesting  condition  in  which  the  bone  is  said  to  be  twisted 
vertically  upon  its  own  axis,  and  even  to  have  been  turned  com- 
pletely round.  Incomplete  rotation  is  practically  identical  with 
that  just  described  as  an  incomplete  lateral  dislocation,  whilst  the 
complete  rotation  of  the  patella  must  indeed  be  a  rare  accident. 

Dislocations  of  the  Knee  may  occur  laterally,  as  also  forwards  or 
backwards.  When  due  to  disease  of  the  joint,  the  backward  dis- 
location is  commonest ;  but  when  arising  from  traumatic  causes, 
the  lateral  is  the  most  frequent. 

The  lateral  displacements  are  rarely  complete,  and  are  usually 
associated  with  a  certain  amount  of  rotation  ;  the  leg  is  partially 
flexed.     Reduction  is  effected  without  difficulty. 

Dislocation  of  the  tibia  forwards  is  more  common  than  dis- 
placement backwards.  It  is  frequently  complete,  the  lower  end 
of  the  femur  projecting  into  the  popliteal  space,  and  compressing 
the  vessels.  The  upper  end  of  the  tibia,  carrying  with  it  the 
patella,  lies  in  front,  forming  a  well-marked  swelling  with  a 
hollow  above  it.  There  is  usually  considerable  shortening  of  the 
limb  if  the  articular  surfaces  overlap. 

Dislocation  of  the  tibia  backwards  is  a  much  rarer  accident,  and 
is  more  often  incomplete  than  the  former.  The  signs  are  exceed- 
ingly characteristic,  the  pressure  effects  upon  the  popliteal  vessels 
and  nerves  being  less  pronounced. 

Reduction  of  either  of  these  conditions  is  easily  accomplished 
by  traction  on  the  limb,  whilst  the  thigh  is  flexed,  combined  with 
manipulation  in  order  to  guide  the  head  of  the  tibia  into  its 
normal  position.  The  limb  must  subsequently  be  kept  at  rest 
in  splints  for  two  or  three  weeks. 

Displacement  of  a  Semilunar  Cartilage  (Syn.  :  Subluxation  of  the 
Knee,  Internal  Derangement  of  the  Knee-joint)  is  a  condition  fre- 
quently met  with,  resulting  from  sprains  and  strains  of  the  joint. 
In  any  rotary  movement  of  the  knee,  which,  however,  can  only  be 
undertaken  when  the  limb  is  flexed,  the  pressure  of  the  condyles 
always  tends  to  modify  the  position  of  the  cartilages  ;  moreover, 
with  the  limb  in  a  state  of  flexion,  they  are  relaxed  and  more 
freely  moveable  on  the  upper  surface  of  the  tibia  than  in  exten- 
sion. Any  sudden  strain  or  wrench,  e.g.,  turning  quickly  round  in 
such  games  as  tennis,  or  slipping  off  the  kerbstone  with  the  knee 
bent,  may  lead  to  this  accident.  The  internal  cartilage  is  much 
more  frequently  affected  than  the  external,  and  the  character  and 


56S  A   MANUAL  OF  SURGERY 

extent  of  the  lesion  varies  much  in  different  cases.  Not  unfre- 
quently  its  anterior  tibial  attachment  is  torn  through,  thereby  per- 
mitting considerable  lateral  mobility.  Its  peripheral  connections 
with  the  capsule  and  internal  lateral  ligament  may  also  be  ruptured, 
whilst  sometimes  a  portion  is  more  or  less  detached  from  its  free 
border,  and  in  other  cases  the  cartilage  has  been  broken  across  a 
little  behind  its  centre.  It  is  obvious  that  when  once  its  connec- 
tions have  been  loosened  it  can  be  displaced  readily,  and  may  pass 
into  the  intercondyloid  notch,  or  may  slip  out  from  between  the 
tibia  and  femur,  or  may  even  be  doubled  over.  After  displacement 
it  becomes  inflamed  and  swollen,  and  unless  properly  treated 
this  will  be  likely  to  predispose  to  a  renewal  of  the  displace- 
ment. 

The  Symptoms  produced  by  this  accident  are  a  sudden  sicken- 
ing pain  of  much  severity,  located  in  the  knee,  which  becomes 
partially  locked  in  a  position  of  flexion,  with  inability  to  extend. 
The  patient  may  be  able  to  '  wriggle  '  his  joint  free,  or  the  limb 
may  remain  stiff  for  some  hours,  or  even  a  day  or  two,  when 
movement  suddenly  returns  more  or  less  spontaneously,  a  snap 
being  at  the  same  time  felt  within  the  joint.  An  attack  of  sub- 
acute synovitis  usually  follows.  In  other  cases  the  cartilage 
remains  out  of  place,  until  reduced  by  the  surgeon,  with  or  with- 
out an  anaesthetic.  If  the  case  is  not  carefully  treated,  the  dis- 
placement is  liable  to  recur,  the  cartilage  constantly  slipping  in 
and  out,  and  getting  nipped  between  the  bones ;  as  time  goes  on, 
this  becomes  more  and  more  easy,  owing  to  the  ligaments  of  the 
joint  being  relaxed  from  the  recurrent  attacks  of  synovitis.  In 
fact,  the  limb  may  pass  into  such  a  state  of  chronic  weakness  as 
to  seriously  interfere  with  the  patient's  comfort.  No  physical 
changes  can  as  a  rule  be  detected  between  the  attacks,  but  there 
is  usually  a  spot  of  localized  pain  in  the  front  of  the  joint,  cor- 
responding to  the  upper  surface  of  the  tibia ;  possibly  there  may 
be  some  amount  of  lateral  mobility  of  the  leg,  and  movement  of 
the  cartilage  may  ba  detected  on  flexing  and  extending  the  knee. 

The  Treatment  in  the  early  stages  consists  in  replacement  of 
the  cartilage  by  manipulation.  The  limb  is  fully  flexed  and  then 
suddenly  extended,  pressure  being  applied  at  the  same  time  in  the 
neighbourhood  of  the  displaced  cartilage,  which  often  returns  into 
position  with  a  distinct  snap.  The  limb  is  subsequently  kept  at 
rest  on  a  back-splint,  and  cooling  lotions  are  applied  until  the  in- 
flammation has  subsided ;  it  is  then  further  immobilized  for  some 
weeks  in  plaster  of  Paris  or  water-glass,  so  as  to  allow  the 
lacerated  ligaments  to  reunite  and  consolidate.  At  the  expiration 
of  six  or  eight  weeks  after  the  accident  an  elastic  knee-cap  is 
applied,  and  the  patient  again  allowed  to  move  the  joint. 

When  the  cartilage  has  become  loose  and  is  constantly  slipping 
out  of  place,  immobilization  of  the  limb,  with  pressure  over  the 
painful    spot    by  an  elastic  knee-clip,   as    recommended    by  Mr. 


INJURIES  OF  JOINTS— DISLOCATIONS  569 


Howard  Marsh,  may  be  useful.     Should   this  not  prove  satis- 
factory, operative  proceedings  must  be  undertaken. 

The  knee-joint  is  opened  by  an  incision  on  the  appropriate  side 
of  the  patella,  more  or  less  transverse  in  direction,  and  the  con- 
dition of  the  cartilage  ascertained.  If  of  normal  shape  and  merely 
loose  and  moveable,  it  may  be  readily  stitched  to  the  periosteum 
over  the  head  of  the  tibia,  so  as  to  keep  it  from  again  slipping 
between  the  bones  ;  this  is  perhaps  best  accomplished  by  splitting 
the  cartilage  diagonally  into  two  portions,  and  securing  each  of 
these  by  two  or  three  catgut  stitches.  If,  however,  it  is  doubled 
on  itself,  or  deformed,  or  if  fixation  seems  impracticable,  it  may 
be  removed  ;  it  is  astonishing  how  well  patients  get  on  after  such 
an  operation.  The  greatest  care  must  be  taken  to  maintain 
asepsis,  and  no  strong  or  irritating  antiseptic  should  be  allowed 
access  to  the  joint  cavity,  which  is  closed  by  a  series  of  buried 
sutures,  dealing  in  order  with  the  synovial  membrane,  the  capsule, 
the  superjacent  tendinous  tissues,  and,  finally,  the  skin.  It  is 
advisable  to  drain  the  joint  for  twenty-four  hours,  and,  as  an 
additional  precaution  against  infection,  it  may  be  well  to  immunize 
the  patient  by  preparatory  injections  of  antistreptococcic  serum. 

Dislocations  of  the  Ankle-joint  may  occur  in  the  following 
directions  :  outwards,  inwards,  backwards,  forivards,  and  upwards,  this 
being  the  order  of  their  frequency.  Owing  to  the  fact  that  the 
astragalus  is  wedged  like  a  block  into  the  mortice  formed  by  the 
lower  ends  of  the  tibia  and  fibula,  it  is  obvious  that  fractures  of 
these  bones  are  frequently  met  with  as  complications. 

The  lateral  dislocations  are  in  reality  fracture-dislocations,  and 
have  been  already  described  in  the  chapter  on  fractures  (p.  489). 

Although  the  upper  articular  surface  of  the  astragalus  is  broader 
in  front  than  behind,  dislocation  of  the  foot  backwards  is  a  more 
common  accident  than  displacement  forwards.  It  results  from 
falls  on  the  feet  while  running  or  jumping,  or  by  sudden  violence 
applied  to  the  limb  when  the  foot  is  fixed.  Usually  both  malleoli 
are  fractured,  and  the  articular  surface  of  the  astragalus  is  thrown 
behind  the  lower  end  of  the  tibia.  The  heel  projects  unduly 
backwards  and  the  lower  end  of  the  tibia  usually  rests  upon  the 
neck  of  the  astragalus,  the  scaphoid,  or  even  the  cuneiform  bones. 

Dislocation  forwards  is  very  uncommon,  and  may  occur  with- 
out any  associated  fracture  of  the  bones  of  the  leg.  The  foot  is 
apparently  lengthened,  and  the  tibia  rests  upon  the  posterior  part 
of  the  upper  surface  of  the  os  calcis,  behind  the  astragalus.  The 
prominence  of  the  heel  and  of  the  tendo  Achillis  is  lost,  and  the 
normal  depression  in  front  of  the  latter  structure  is  occupied  by 
the  lower  ends  of  the  bones  of  the  leg. 

The  treatment  of  antero-posterior  dislocations  consists  in  reduc- 
tion by  traction.  The  leg  is  flexed  upon  the  thigh,  so  as  to  relax 
the  tendo  Achdlis,  or,  if  necessary,  this  structure  is  divided.     The 


57c 


A   MANUAL  OF  SURGERY 


ankle  is  commanded  by  a  pair  of  Cline's  side-splints,  care  being 
taken  to  ascertain  that  the  foot  is  at  right  angles  to  the  leg,  and 
that  the  articular  surfaces  of  the  astragalus  and  tibia  are  exactly 
in  apposition,  thus  preventing  any  displacement  of  the  heel  back- 
wards or  forwards.  A  Roughton's  splint — i.e.,  an  external  splint 
with  a  sole-piece — is  sometimes  useful. 

A  dislocation  upwards  has  been  described  in  which  the  astra- 
galus, together  with  the  foot,  is  carried  up  between  the  tibia  and 
fibula.  To  allow  of  such,  the  inferior  tibio-fibular  ligament  and 
the  lower  end  of  the  interosseous  ligament  must  have  been 
ruptured.     Impracticable  as  such  an  accident  appears,  competent 


Fig    20S. — Dislocation  of  the  Astragalus  Forwards. 


observers  maintain  that  they  have  met  with  it.    The  displacement 
js  very  marked,  and  the  character  of  the  lesion  very  evident. 

Dislocations  of  the  Astragalus  alone  are  by  no  means  common, 
although  their  distinguishing  features  are  well  recognised.  They 
consist  in  a  partial  or  complete  detachment  of  the  bone  from  all 
its  normal  connections,  both  to  the  bones  of  the  leg  and  of  the 
foot,  and  its  displacement  from  under  the  tibio-fibular  arch.  It 
may  travel  backwards  or  forwards  with  or  without  lateral  rotation. 

Dislocation  forwards  (Fig.  208)  is  much  the  more  common 
variety,  although  it  is  usually  associated  with  partial  rotation,  the 
displacement  occurring  more  frequently  outwards  than  inwards. 
When  complete,  the  bone  is  entirely  detached  from  its  connec- 
tions with  the  os  calcis,  scaphoid,  and  bones  of  the  leg,  and  lies 
upon  the  upper  surface  of  the  scaphoid  and  cuneiform  bones,  the 


INJURIES  OF  JOINTS—DISLOCATIONS  571 


skin  of  the  dorsum  of  the  foot  being  tightly  stretched  over  it,  or 
even  torn.  The  limb  is  shortened,  and  the  malleoli  are  approxi- 
mated to  the  sole,  the  lower  end  of  the  tibia  resting  on  the  upper 
surface  of  the  os  calcis. 

In  the  incomplete  variety,  the  head  of  the  astragalus  impinges 
either  upon  the  scaphoid  on  the  inner  side,  or  the  cuboid  on  the 
outer,  whilst  the  lower  end  of  the  tibia  rests  on  the  posterior  half 
of  the  articular  surface  of  the  astragalus. 

Dislocation  backwards  is  almost  always  complete,  and  may  or 
may  not  be  associated  with  rotation  of  the  bone,  which  can  easily 
be  felt  between  the  tendo  Achillis  and  the  malleoli. 

Treatment. — Reduction  is  only  possible  in  the  incomplete  forms 
of  dislocation.  The  patient  is  anaesthetized,  the  knee  flexed  to 
relax  the  muscles  or  the  tendo  Achillis  divided,  and  traction  upon 
the  foot  established,  so  as  to  enable  the  surgeon  to  apply  direct 
pressure  upon  the  displaced  bone  in  a  suitable  direction.  In  the 
complete  variety  reduction  is  impracticable,  owing  to  the  fact  that 
the  os  calcis  is  drawn  up  into  contact  with  the  malleolar  arch.  In 
such  cases  manipulation  is  useless,  and  excision  of  the  bone  is 
necessary.  Comparatively  little  impairment  in  the  function  of 
the  foot  results  from  this  operation. 

Subastragaloid  Dislocation. — By  this  term  is  meant  a  displace- 
ment of  all  the  bones  of  the  foot  from  below  the  astragalus,  which 
retains  its  normal  position  between  the  malleoli.  The  interosseous 
and  other  ligaments  passing  from  the  malleoli  and  astragalus  to 
the  other  tarsal  bones  are  necessarily  ruptured.  The  cause  of 
this,  as  of  other  dislocations  in  the  neighbourhood,  is  some  violent 
strain  or  wrench  of  the  foot. 

Displacement  of  the  foot  may  occur  either  forwards  or  back- 
wards, but  in  the  great  majority  of  cases  it  is  either  backwards  and 
inwards  or  backwards  and  outwards.  The  luxation  is  rarely  complete 
as  regards  the  calcaneo-astragaloid  joint,  but  the  articular  surfaces 
of  the  head  of  the  astragalus  and  scaphoid  are  completely  separated, 
the  former  structure  lying  on  the  dorsal  surface  of  the  latter  bone. 
The  foot  is  greatly  deformed,  the  anterior  portion  being  shortened, 
the  heel  projecting,  and  the  toes  pointing  downwards.  The  head 
of  the  astragalus  is  very  evident,  forming  a  rounded  globular 
swelling  under  the  tense  skin.  In  a  compound  dislocation  of  this 
nature  which  we  recently  examined,  post  mortem,  the  inner  edge  of 
the  under  surface  of  the  astragalus  had  burst  through  the  skin  ; 
the  vessels  and  nerves  were  torn  or  stretched,  and  even  when  the 
wound  in  the  skin  had  been  enlarged,  reduction  was  impossible 
owing  to  the  tendons  which  had  become  caught  around  the  neck 
of  the  astragalus.  In  such  a  case  removal  of  the  astragalus  would 
have  been  the  only  practicable  treatment. 

In  the  inward  displacements,  the  foot  is  somewhat  inverted, 
so  that  the  outer  malleolus  is  unduly  prominent,  and  the  inner 


572  A  MANUAL  OF  SURGERY 

malleolus  is  lost  in  a  deep  depression  caused  by  the  lateral  dis- 
placement of  the  os  calcis ;  the  foot  is  thus  in  a  position  somewhat 
simulating  talipes  equino-varus.  In  the  outward  dislocations, 
the  foot  is  everted,  the  inner  malleolus  prominent,  and  the  outer 
buried,  a  position  of  talipes  equino-valgus  being  thus  assumed. 
In  both  forms  the  tendo  Achillis  is  curved,  with  its  concavity 
towards  the  displacement.  Treatment  consists  in  reduction  by 
manipulation,  which  is  sometimes  readily  accomplished,  but  may 
be  a  matter  of  the  greatest  difficulty,  probably  from  the  tibial 
tendons  becoming  bitched  around  the  neck  of  the  astragalus. 
Section  of  the  tendo  Achillis  is  occasionally  needed. 


CHAPTER    XX. 

DISEASES  OF  JOINTS. 

Acute  Synovitis. 

By  Synovitis  is  meant  an  inflammation  limited  almost  entirely  to 
the  synovial  membrane,  the  ligaments  and  other  structures  of  the 
joint  being  usually  but  little  affected. 

The  Causes  are  local  and  general.  Local  conditions  include 
cold  and  injury  ;  general  or  constitutional  comprise  rheumatism, 
gout,  syphilis,  pyaemia,  and  gonorrhoea. 

Pathological  Anatomy. — Acute  synovitis  results  in  hyperaemiaof 
the  synovial  membrane,  and  exudation  of  plasma  and  leucocytes, 
firstly  into  the  substance  of  the  membrane,  causing  it  to  be 
thickened  and  spongy,  and  subsequently  into  the  joint ;  the 
endothelium  also  proliferates,  and  is  shed.  In  the  early  stages 
the  effusion  consists  of  synovia,  diluted  with  blood  plasma,  and 
often  discoloured  with  blood  in  traumatic  cases,  and  hence  on 
removal  is  spontaneously  coagulable ;  after  a  time  the  plasma 
may  coagulate,  depositing  lymph  upon  the  articular  surface  whilst 
serum  remains.  The  lymph  thus  deposited  may  either  be  removed 
by  a  natural  process  of  absorption  when  the  inflammation  comes 
to  an  end,  or  it  may  organize,  so  as  to  form  adhesions.  In  the 
later  stages  the  synovial  membrane  becomes  somewhat  thickened, 
and  the  ligaments  possibly  a  little  infiltrated  and  relaxed. 

The  Clinical  Signs  of  acute  synovitis  consist  in  the  joint  be- 
coming painful  and  distended,  whilst  if  the  articulation  is  super- 
ficial, as  in  the  knee,  a  sense  of  heat  may  be  imparted  to  the  hand, 
and  the  surface  may  even  be  red  and  hyperaemic.  The  limb  is 
maintained  by  muscular  spasm  in  that  position  which  gives  the 
most  ease,  viz.,  that  in  which  its  capacity  is  the  greatest,  and  this 
is  usually  one  of  slight  flexion,  but  if  the  condition  is  neglected, 
the  flexion  may  increase  considerably,  the  muscles  undergoing 
tonic  contraction,  and  the  limb  remaining  more  or  less  fixed  in  an 
undesirable  position.  The  muscles  governing  the  movements  of 
the  joint  occasionally  undergo  rapid  atrophy,  probably  resulting 
from  a  reflex  disturbance  of  their  trophic  centres  in  the  cord. 


574  A  MANUAL  OF  SURGERY 


Evidence  of  Effusion  into  Various  Joints. — Shoulder  :  The  curva- 
ture of  the  shoulder  is  increased,  and  the  deltoid  expanded  by  a 
fluid  swelling  beneath  it,  which  is  especially  noticeable  at  its 
anterior  border  along  the  bicipital  groove,  and  sometimes  pos- 
teriorly;  in  the  axilla  a  painful  intumescence  may  also  be  felt. 
These  symptoms  may  be  somewhat  simulated  by  inflammation 
of  the  multilocular  subdeltoid  bursa,  but  the  latter  condition  is 
recognised  by  the  absence  of  any  axillary  swelling,  by  its  not 
encroaching  on  the  anterior  and  posterior  borders  of  the  deltoid, 
and  by  the  fact  that,  although  when  the  patient  voluntarily  moves 
his  arm  pain  is  produced,  yet  when  the  surgeon  gently  manipu- 
lates it,  so  as  to  press  the  head  of  the  bone  against  the  glenoid 
cavity,  there  may  be  none.  Elbow :  The  hollows  on  either  side 
of  the  olecranon  and  tendon  of  the  triceps  are  replaced  by  soft 
fluid  swellings,  the  outer  of  which  also  extends  down  to,  and 
masks,  the  head  of  the  radius  ;  there  is  usually  a  little  general 
puffiness  in  front  of  the  joint.  It  is  readily  distinguished  from 
inflammation  of  the  olecranon  bursa  by  the  fact  that  in  the  latter 
condition  there  is  a  central  fluid  prominence  over  the  bone,  whilst 
in  the  former  the  swellings  are  placed  on  either  side  of  and  above 
the  bony  projection.  Wrist :  There  is  a  general  fulness  both  on 
the  anterior  and  posterior  aspects  of  the  joint,  whilst  fluctuation 
may  be  detected  beneath  the  dorsal  tendons,  which  are  slightly 
separated  and  displaced.  It  is  distinguished  from  synovitis  of  the 
superjacent  tendon  sheaths  by  the  fact  of  its  strict  limitation  to  the 
neighbourhood  of  the  joint,  and  the  absence  of  the  superficial 
crepitus,  so  characteristic  of  the  latter  condition.  Effusion  into 
the  Hip-joint  cannot  be  easily  detected  by  digital  examination. 
There  may  be  a  little  fulness  and  tenderness  in  the  gluteal  region, 
or  in  the  upper  and  outer  part  of  Scarpa's  triangle.  The  most 
characteristic  feature,  however,  is  the  position  of  flexion,  abduc- 
tion, and  eversion  taken  by  the  limb,  whilst  limitation  of  move- 
ment is  equally  marked.  The  Knee,  when  distended  with  fluid, 
presents  a  rounded  outline,  in  which  all  the  normal  hollows, 
especially  those  on  either  side  of  the  patella  and  ligamentum 
patellae,  have  disappeared.  There  is  also  a  swelling  correspond- 
ing to  the  subcrureal  pouch,  more  marked  on  the  inner  than  the 
outer  side,  and  extending  for  3  or  4  inches  above  the  patella. 
Fluctuation  can  be  readily  detected  when  one  hand  is  placed 
above  the  patella,  and  the  fingers  of  the  other  hand  compress 
the  tissues  on  either  side  of  the  ligamentum  patellae  below,  or 
by  alternate  pressure  on  either  side  of  the  rectus  tendon.  When 
the  effusion  is  large  in  amount,  the  patella  is  felt  to  float,  and 
on  pressing  it  sharply  backwards  can  be  made  to  tap  against  the 
intercondyloid  notch  of  the  femur  (patella  tap).  Enlargement  of 
the  bursa  patellae  is  easily  distinguished  from  it  by  the  swelling 
in  the  former  case  being  central  and  in  front  of  the  patella,  so  that 
its  outline  is  obscured.     Ankle  :  The  hollows  between  the  tendo 


DISEASES  OF  JOINTS  575 

Achillis  and  the  malleoli  are  replaced  by  fluctuating  swellings 
whilst  the  dorsal  tendons  are  displaced  forwards,  and  a  fluid 
swelling  appears  in  front  of  each  malleolus.  Enlargement  of  the 
bursa  beneath  the  tendo  Achillis  is  so  obviously  confined  to  the 
back  of  the  joint  that  it  should  never  be  mistaken  for  true  synovitis 
of  the  ankle. 

When  the  acute  stage  has  passed,  the  joint  is  usually  left  in 
a  somewhat  weak  and  relaxed  condition,  with  a  little  passive 
effusion,  or  perhaps  some  adhesions.  The  adhesions  which  follow 
acute  synovitis  are  usually  slight  in  character,  if  the  case  has  been 
properly  treated  ;  they  result  from  the  union  of  patches  of  lymph 
on  opposing  surfaces  of  synovial  membrane  or  bone,  which 
become  organized  into  loose  fibro-cicatricial  tissue,  containing  a 
few  delicate  bloodvessels,  and  covered  by  endothelium  extending 
over  them  from  the  adjacent  serous  membrane.  The  charac- 
teristic signs  of  such  a  condition  are  painful  limitation  of  move- 
ment in  some  particular  direction,  and  possibly  a  little  soft 
crepitus. 

The  Treatment  of  acute  synovitis  consists  in  so  immobilizing 
the  joint  as  to  give  the  patient  the  greatest  amount  of  ease, 
whilst,  should  ankylosis  result,  the  limb  is  left  in  as  favourable  a 
position  as  possible  for  subsequent  utility.  Thus,  the  shoulder 
should  be  bandaged  to  the  side  and  the  hand  kept  in  a  sling ;  the 
elbow  is  placed  on  an  internal  angular  splint,  and  flexed  to  a  little 
more  than  a  right  angle,  whilst  the  hand  is  midway  between 
pronation  and  supination  ;  for  the  wrist  all  that  is  needed  is  to 
apply  a  palmar  splint  to  the  forearm  ;  the  hip  is  immobilized  by 
the  application  either  of  a  Thomas's  splint  or  of  a  Liston's  long 
splint,  or  by  placing  the  limb  between  sandbags  and  adjusting  an 
extension  apparatus  to  the  foot ;  the  knee  is  put  on  a  back-splint, 
perhaps  slightly  flexed ;  whilst  the  ankle  is  best  kept  at  rest  by 
applying  what  is  known  as  a  Roughton's  splint,  i.e.,  an  external 
splint  with  a  foot-piece.  Necessarily,  in  all  severe  cases  of  acute 
synovitis  the  patient  should  be  confined  to  bed  and  the  limb 
elevated.  If  the  case  has  been  neglected  and  the  limb  has 
assumed  a  vicious  position,  the  patient  should  be  anaesthetized 
and  the  malposition  corrected ;  or  gradual  extension  made  by 
means  of  a  weight  and  pulley,  until  the  correct  position  is 
attained.  In  the  early  stages  cold  should  be  applied  to  the  joint 
by  means  of  evaporating  lotion,  an  icebag  or  Leiter's  tubes,  but 
this  is  not  advisable  in  old  people.  In  the  later  stages  fomenta- 
tions give  greater  relief,  whilst  the  application  of  a  few  leeches 
may  also  be  beneficial.  When  the  distension  is  considerable, 
removal  of  some  of  the  fluid  by  a  carefully  purified  aspirator,  or 
trocar  and  cannula,  may  diminish  pain  and  hasten  recovery. 

In  the  subacute  stage,  when  the  joint  is  weak  and  relaxed, 
massage  or  friction  with  stimulating  liniments  should  be  em- 
ployed, whilst  in  the  more  chronic  forms  firm  pressure,  and  pre- 


576 


A   MANUAL  OF  SURGERY 


ferably  by  means  of  a  Martin's  bandage,  is  most  useful  as  an 
additional  measure. 

If  adhesions  are  present,  they  should  be  carefully  broken  down 
under  chloroform  ;  the  limb  is  subsequently  kept  at  rest  for  a 
few  days  upon  a  splint,  whilst  passive  movements  and  massage 
are  afterwards  adopted. 


Chronic  Synovitis. 

This  affection  follows  an  acute  attack,  or  may  be  lighted  up  by 
some  injury  or  condition  insufficient  to  determine  a  more  violent 

form  of  inflammation.  The 
synovial  membrane  becomes 
thick  and  infiltrated,  whilst  the 
effusion  is  sometimes  relatively 
less  than  in  the  acute  form, 
sometimes  excessive,  then  con- 
stituting the  condition  de- 
scribed as  chronic  serous  synovitis 
(Fig.  209),  a  phenomenon  often 
seen  affecting  the  knees  after 
rising  from  a  prolonged  stay 
in  bed.  The  pain  is  usually 
not  severe,  being  replaced  by  a 
sense  of  uselessness  and  weak- 
ness. It  is  interesting  to  note 
that,  in  cases  where  the  effu- 
sion is  well  marked,  the  bursae 
communicating  with  the  joint 
frequently  become  distended  ; 
they  are  prevented  from  par- 
ticipating in  the  acute  forms 
of  inflammation  by  the  fact 
that  the  apertures  of  com- 
munication with  the  interior 
of  the  joint  are  narrow  and  slit 
like,  and  thus  readily  become 
occluded  by  the  swelling  of 
the  membrane.  Crepitus  is 
sometimes  met  with  in  chronic 
synovitis,  possibly  from  a  roughening  of  the  articular  surfaces  on 
which  lymph  has  been  deposited,  or  between  which  fibrous 
adhesions  have  formed. 

Occasionally  the  synovial  fringes  become  hypertrophied,  giving 
rise  to  a  condition  similar  to  that  described  under  osteo-arthritis 
(p.  598).  The  overgrown  villi  usually  spring  from  the  reflections 
of  the  synovial  membrane  close  to  the  bone,  and  may  be  loaded 
with   fat,  constituting    the    condition    known   as   '  Lipoma   arbo- 


Fig.  209. — Chronic  Serous  Synovitis 
of  Knee,  with  Distension  of  the 
subcrureal  pouch.  (from  col- 
LEGE of  Surgeons'  Museum.) 


DISEASES  OF  JOINTS 


577 


rescens.'  In  the  knee-joint  the  fringes  may  be  felt  rolling  under 
the  fingers,  and  painful  symptoms  may  be  caused  by  the  loose 
ends  being  caught  and  nipped  between  the  bones. 

Treatment  consists  in  fixing  the  joint  in  a  suitable  position,  and 
applying  counter-irritation  and  pressure ;  blisters  are  especially 
useful  in  this  affection.  At  a  somewhat  later  stage  elastic 
pressure  by  a  Martin's  bandage  may  be  employed,  together  with 
friction  with  stimulating  liniments,  or  even  hot-air  baths.  Re- 
moval of  some  of  the  fluid  by  aspiration  and  subsequent  com- 
pression may  also  do  good  ;  but  if  the  affection  resists  such  treat- 
ment, the  best  procedure  consists  in  opening  the  joint,  washing  it 


Fig    210. — Baker's  Cysts  from  Back  of  Knee.     (Howard  Marsh  ) 

out  with  normal  saline  solution  or  with  a  solution  of  corrosive 
sublimate  (i  in  4,000),  and  draining  it  for  a  few  days. 

Should  enlarged  villi  be  present  and  give  rise  to  trouble,  the 
joint  should  be  opened,  and  if  they  are  limited  in  their  distribution 
they  may  be  clipped  away,  or  the  synovial  membrane  from  which 
they  grow  dissected  out.  When  very  extensive,  so  that  removal 
would  involve  total  excision  of  the  synovial  membrane  and  con- 
sequent stiffness,  it  may  be  wise  to  wash  out  and  drain,  in  the 
hope  that  they  may  become  fixed,  before  undertaking  complete 
extirpation  of  the  membrane. 

Hydrarthrosis  (Hydrops  Articuli)  is  the  term  applied  to  any 
condition  of  a  chronic  nature  in  which  the  joint  is  much  distended 
with  fluid.  It  may  arise  from  at  least  five  different  affections  : 
(a)  Chronic  serous  synovitis;  (b)  in  osteo-arthritis,  a  very  common 
cause;  (c)  in  Charcot's  disease;  (d)  in  secondary  syphilitic 
synovitis  ;  and  (e)  very  rarely  in  tuberculous  synovitis.     It  must 

37 


578  A   MANUAL  OF  SURGERY 


be  remembered  that  it  is  but  a  symptom,  and  not  a  disease  sui 
generis,  and  treatment  necessarily  varies  with  the  cause. 

Baker's  Cysts. — This  condition,  first  described  by  the  late 
Mr.  Morrant  Baker,  consists  in  a  hernial  protrusion  of  the 
synovial  membrane  of  a  joint  through  an  aperture  in  its  fibrous 
capsule  (Fig.  210).  It  is  usually  due  to  some  chronic  affection 
of  the  articulation,  especially  osteo-arthritis,  or  tuberculous 
disease,  whereby  the  intra-articular  pressure  is  increased,  and 
not  uncommonly  several  such  sacs  are  connected  with  the  same 
joint.  They  vary  much  in  size,  contain  synovial  fluid,  and, 
though  at  first  communicating  with  the  joint  cavity,  have  a 
tendency  to  travel  away  from  it,  burrowing  along  muscular 
and  fascial  planes,  and  coming,  perhaps,  to  the  surface  some 
distance  from  their  origin,  the  aperture  of  communication  with 
the  joint  having  in  some  instances  been  shut  off.  If  causing 
no  troublesome  symptoms,  there  is  no  necessity  to  interfere  ;  but 
if  they  become  inconvenient  or  painful,  it  is  easy  to  dissect  them 
out,  closing  where  necessary  by  ligature  or  suture  the  narrow  neck 
which  leads  into  the  joint.  Of  course,  the  strictest  asepsis  must 
be  maintained  in  all  such  proceedings,  and  the  causative  affection 
must  not  be  forgotten. 

Acute  Arthritis. 

By  the  term  Arthritis  is  meant  any  inflammation  of  a  joint 
which  involves  all  the  structures  of  which  it  is  composed,  viz., 
bones,  ligaments,  cartilages,  and  synovial  membrane. 

Causation. — Acute  arthritis  is  practically  always  due  to  infection 
of  the  joint  cavity  with  bacteria,  which  reach  it  either  from  within 
or  without  the  body,  (i.)  It  may  be  due  to  the  entrance  of  cocci 
through  a  punctured  or  valvular  wound  of  the  joint,  or  during 
operations.  It  is  interesting  to  note  how  extremely  prone  to  in- 
flammation is  the  synovial  membrane  when  opened,  even  after  the 
most  careful  antiseptic  precautions.  The  micro-organism  most 
commonly  present  is  a  modification  of  the  Streptococcus  pyogenes, 
known  as  the  Strep,  articulorum  ;  it  is  pathogenic  to  mice  and 
rabbits,  but  not  to  guinea-pigs,  and  when  injected  into  a  rabbit 
seems  to  especially  select  the  joints.  Various  non-pathogenic 
organisms  have  also  been  found  in  special  cases,  (ii.)  It  may  arise 
in  a  manner  exactly  analogous  to  that  in  which  acute  infective 
osteomyelitis  is  produced — i.e.,  the  patient  is  in  a  low  state  of 
health,  his  natural  germicidal  powers  are  diminished,  pyogenic 
organisms  are  present  in  the  blood-stream,  gaining  access  through 
some  breach  of  surface,  and,  finally  attacking  any  weak  or 
damaged  tissue,  produce  therein  suppurative  inflammation.  A 
slight  injury,  e.g.,  a  sprain  or  strain  occurring  in  a  weakly  child, 
convalescent  from  measles  or  scarlet  fever,  may  result  in  this 
affection,  (iii.)  It  may  be  produced  by  the  lodgment  of  a  pyaemic 
embolus,  and  in  a  similar  way  it  not  unfrequently  follows  as  a 


DISEASES  OF  JOINTS  579 

sequela  of  fevers,  such  as  enteric  or  pneumonia,  by  direct  trans- 
mission of  some  infective  material,  (iv.)  It  is  sometimes  met  with 
as  a  result  of  gonorrhoea,  and  may  then  run  its  course  with  or 
without  suppuration,  (v.)  It  may  be  lighted  up  as  a  result  of  the 
extension  of  inflammation  from  the  end  of  a  neighbouring  bone, 
or  from  the  bursting  of  a  subcutaneous  or  bursal  abscess  into  the 
joint.  Acute  arthritis  of  the  hip-joint  is  commonly  due  to  the 
former  of  these  conditions,  being  consecutive  to  an  acute  infective 
osteomyelitis  of  the  upper  end  of  the  femur,  (vi.)  It  is  occasion- 
ally observed  as  a  result  of  rheumatism ,  the  inflammation  running 
a  very  acute  course,  and  leading  to  disorganization  of  the  joint, 
though  without  suppuration.  Such  attacks  are  undoubtedly 
bacterial  in  origin. 

Course  of  the  Case. — In  the  early  stages  acute  arthritis  manifests 
itself  as  a  hyperacute  synovitis,  combined  with  severe  pain  and 
fever.  The  pain  is  often  so  intense  that  the  patient  cannot  bear 
the  part  to  be  touched  or  the  bed  shaken,  and  indeed  the  slightest 
jar  of  the  limb  is  so  exquisitely  painful  that  the  patient  may 
scream  with  agony.  The  joint  itself  is  distended  with  a  turbid 
effusion,  which  rapidly  becomes  purulent,  and  the  tissues  around 
are  hyperaemic  and  cedematous.  The  patient  naturally  places 
himself  in  that  position  in  which  the  limb  obtains  the  greatest 
ease,  and  therefore  usually  semiflexes  the  joint  and  fixes  it  by 
muscular  contraction. 

As  the  disease  progresses,  pus  is  formed  within  the  capsule, 
bursting  through  it,  and  either  travelling  directly  to  the  surface, 
or  burrowing  deeply  into  the  substance  of  the  limb  ;  thus,  in 
the  knee  an  enormous  abscess  may  collect  beneath  the  vasti 
muscles,  stripping  them  from  the  bone  for  a  considerable  distance. 
The  pain  increases  whilst  the  abscesses  are  forming,  and  becomes 
especially  distressing  at  night,  the  patient  being  often  waked  by  a 
painful  start  just  as  he  has  fallen  asleep.  This  condition  usually 
indicates  that  the  articular  cartilages  are  becoming  affected,  and 
is  explained  by  the  fact  that,  just  as  the  patient  loses  conscious- 
ness, the  muscles  which  fix  the  joint  are  relaxed,  and  allow  the 
inflamed  surfaces  to  slightly  shift  their  position,  exciting  severe 
pain  and  a  sudden  spasmodic  contraction  of  the  muscles.  Gradu- 
ally the  deformity  becomes  more  and  more  obvious,  whilst  the 
infiltration  and  relaxation  of  the  ligaments  sometimes  allow  of 
abnormal  movements,  e.g.,  of  lateral  mobility  in  the  knee-joint ; 
the  ends  of  the  bones  become  carious,  and  absolute  displacement 
or  dislocation  may  follow.  Sinuses  may  open  in  all  directions, 
and  the  patient  suffer  from  recurrent  rigors,  caused  by  toxaemia 
or  the  onset  of  pyaemia.  The  constitutional  effects  are  always 
severe,  consisting  of  high  fever,  and  rapid  exhaustion  from  the 
pain,  sleeplessness,  and  absorption  of  toxins. 

The  terminations  of  this  affection  are  as  follow  :  {a)  Recovery, 
rarely  with  a  moveable  joint,  and   then  only  after  active  inter- 

37~2 


58o 


A  MANUAL  OF  SURGERY 


i 


ference  ;  in  most  cases  ankylosis  in  a  good  or  bad  position,  accord- 
ing to  the  treatment,  is  the  best  result  that  can  be  expected. 
(b)  During  the  acute  stage  the  patient  may  die  of  pyaemia,  or  acute 
toxaemia  and  exhaustion,  (c)  If  he  survive  the  acute  stage,  chronic 
suppuration  may  ensue,  and  symptoms  of  hectic  and  amyloid  de- 
generation in  the  viscera  may  supervene.  In  such  cases  sinuses 
leading  down  to  carious  bones  exist,  and, 
unless  efficient  measures  are  taken  to  obtain 
asepsis,  or  to  remove  the  diseased  structures, 
perhaps  by  amputation,  the  patient  is  likely 
to  die  from  exhaustion  or  chronic  sapraemia. 

Pathological  Anatomy. — The  synovial  mem- 
brane, at  first  merely  infiltrated  and  hyper- 
aemic,  soon  becomes  converted  into  granula- 
tion tissue  from  within  outwards,  exuding 
abundant  pus.  The  ligaments  in  turn  are 
sodden  and  relaxed  by  the  presence  of  a 
plastic  exudation  between  the  fibres,  render- 
ing them  soft  and  cedematous,  so  that  the  tonic 
contraction  of  the  muscles  easily  stretches 
them  and  brings  about  displacement. 

The  articular  cartilages  are  disintegrated  and 
destroyed  in  various  ways,  according  to  the 
acuteness  of  the  inflammation  and  the  amount 
of  pressure  to  which  they  are  exposed.  In 
acute  cases  they  early  lose  their  normal  bluish- 
white  appearance,  and  become  opaque  and 
slightly  yellow.  The  central  parts,  which  are 
exposed  to  pressure  between  the  ends  of  the 
bones,  soon  disappear,  whilst  the  peripheral 
portions  are  eroded  by  the  growth  of  the 
granulation  tissue  developing  from  the  synovial 
membrane.  When  once  the  cartilage  has  been 
perforated  at  any  one  spot,  the  suppurative 
inflammation  spreads  along  its  under  surface, 
stripping  it  from  the  bone,  and  thus  inducing 
necrosis,  as  a  result  of  which  isolated  portions 
of  dead  cartilage  may  be  found  lying  in  the 
joint.  In  the  more  chronic  forms  of  the 
disease,  proliferation  of  the  cartilage  cells 
occurs,  whereby  the  capsules  become  dis- 
tended, and  the  matrix  encroached  upon  ;  some  of  these  cavities 
burst  into  the  joint,  and  leave  more  or  less  flask -shaped 
openings  into  which  pyogenic  organisms  find  their  way,  thus 
aggravating  the  mischief;  others  nearer  the  deep  aspect  of  the 
cartilage  become  transformed  into  granulation  tissue  by  vascu- 
larization from  the  vessels  in  the  bone.  In  these  ways  the  carti- 
lage is  destroyed  or  replaced  by  granulation  tissue,  a  proceeding 


Fig.  2ii. — Ends  of 
the  Bones  after 
Acute  Arthritis 
of  Elbow,  show- 
ing the  Carious 
Surfaces  devoid 
of  Cartilage, 
and  the  De- 
velopment of 
Stalactitiform 
Osteophytes. 
(From  King's  Col- 
lege Museum.) 


DISEASES  OF  JOINTS  581 


analogous  to  ulceration  of  the  softer  parts.  The  intcvavticular 
cartilages  are  affected  in  a  very  similar  manner,  and  quickly  dis- 
appear. 

The  ends  of  the  bone  pass  into  a  condition  of  acute  osteitis 
resulting  in  the  transformation  of  the  medulla  into  granulation 
tissue,  absorption  of  the  bony  cancelli  with  or  without  suppura- 
tion, and  sometimes  necrosis  of  small  portions  of  the  cancellous 
tissue  {caries  necrotica).  The  veins  within  the  cancelli  become 
thrombosed,  and  hence  pyaemia  may  result.  The  periosteum 
covering  the  ends  of  the  bones  is  also  inflamed  and  hyperaemic,  in 
consequence  of  which  spiculated  or  stalactitiform  osteophytes 
are  produced  (Fig.  211).  The  muscles  in  the  neighbourhood  of  the 
joint  undergo  rapid  atrophy  and  fatty  degeneration,  probably  as 
a  result  of  some  reflex  disturbance  of  the  trophic  centres. 

Treatment. — In  the  early  stages  the  limb  must  be  elevated,  abso- 
lutely immobilized,  and  put  into  such  a  position  that,  if  ankylosis 
subsequently  obtains,  it  may  be  of  some  use  to  the  patient. 
Fomentations  or  an  icebag  may  be  temporarily  applied,  but  as 
soon  as  the  symptoms  point  to  suppuration,  the  joint  should  be 
freely  opened  in  one  or  two  places,  washed  out  with  some  sterile 
or  antiseptic  solution,  and  drainage-tubes  inserted,  whilst  neces- 
sarily any  peri-articular  abscesses  are  dealt  with  in  the  same  way. 
Openings  should  preferably  be  made  on  opposite  sides  of  the 
joint,  so  as  to  allow  the  cavity  to  be  frequently  flushed  out,  or,  if 
considered  desirable,  for  continuous  irrigation  of  the  joint  with 
some  mild  antiseptic  (e.g.,  weak  boracic  lotion,  or  sublimate  solu- 
tion, 1  in  8,000),  or  some  bland  unirritating  fluid,  such  as  sterilized 
normal  saline  solution.  The  fixation  of  the  limb  is  maintained, 
and  the  general  health  attended  to.  Irrigation  should  be  continued 
until  all  signs  of  inflammation,  pain,  heat,  and  startings  of  the 
limb  have  passed  away.  Under  such  a  regime  it  is  sometimes 
possible  to  obtain  a  moveable  joint,  but  more  frequently  ankylosis 
must  be  expected.  Excision  may  be  required  in  order  to  prevent 
or  remedy  faulty  ankylosis,  or  to  place  the  limb  in  a  good  position  ; 
it  is  also  undertaken  in  some  cases  of  chronic  suppuration,  with 
caries  of  the  ends  of  the  bones  and  displacement,  but,  as  a  rule, 
not  until  all  acute  symptoms  have  passed  away.  If  the  patient 
is  suffering  from  severe  toxaemic  or  pyaemic  symptoms  threatening 
life,  amputation  may  be  required,  as  also  for  exhaustion  from 
long-standing  suppuration  and  hectic  fever. 

Acute  Arthritis  of  Special  Joints. 

In  the  Shoulder,  infection  sometimes  occurs  through  the  axilla 
where  the  capsule  is  weak  and  easily  invaded  by  organisms, 
as  after  an  axillary  cellulitis ;  more  frequently  it  follows  a  pene- 
trating injury.  Severe  pain  is  caused  by  any  movement  of  the 
arm  affecting  the  joint,  and    the  pus   in    the  distended  synovial 


S82  A  MANUAL  OF  SURGERY 

membrane  comes  to  the  surface  in  front  of  or  behind  the  deltoid, 
or  in  the  axilla.  It  may  suffice  to  open  the  articulation  anteriorly 
and  flush  it  out,  but,  if  possible,  a  counter-opening  should  be  made 
behind  by  cutting  down  on  a  pair  of  dressing  forceps  pushed  back- 
wards through  the  capsule.  In  many  instances  the  patient's 
condition  will  not  improve  until  the  head  of  the  bone  has  been 
excised.  The  subsequent  results  as  regards  movement  and  power 
of  the  arm  are,  on  the  whole,  very  satisfactory. 

In  the  Elbow,  there  are  no  points  requiring  special  mention  as 
to  clinical  history  or  results,  although  it  must  be  remembered  that 
the  superior  radio-ulnar  articulation  is  necessarily  involved,  and 
hence  the  power  of  pronation  and  supination  of  the  hand  is 
threatened.  As  to  treatment,  incisions  should  be  made  on  either 
side  of  the  olecranon,  the  ulnar  nerve  being  avoided.  The  limb 
is  then  placed  on  a  rectangular  splint,  and  with  the  hand  midway 
between  pronation  and  supination  ;  of  course,  the  patient  is  kept  in 
bed,  with  the  arm  raised  on  a  pillow.  In  an  adult  excision  may 
be  undertaken  as  soon  as  the  acute  stage  has  passed,  in  order  to 
obtain  a  moveable  elbow  ;  but  in  children,  where  the  growth  is 
incomplete,  it  is  better  to  allow  ankylosis  to  occur,  and  excise",  if 
need  be,  at  a  later  date. 

The  Wrist  may  be  infected  secondarily  to  septic  conditions 
following  operations  on  ganglia  in  the  neighbourhood,  or  through 
direct  injury.  The  essential  treatment  consists  in  free  incisions 
parallel  with  the  tendons,  and  avoiding  the  sheaths.  Ankylosis 
usually  results,  and  excision  is  not  resorted  to  except  when  the 
disease  has  become  very  chronic,  with  extensive  caries  of  the 
carpus. 

Acute  arthritis  of  the  Hip-joint  is  usually  a  sequela  of  acute 
infective  osteomyelitis  attacking  the  upper  end  of  the  shaft  of 
the  femur,  and  involving  the  joint,  owing  to  the  epiphyseal  car- 
tilage being  intracapsular  ;  it  also  results  from  pyaemia,  and 
rarely  from  penetrating  injuries.  The  symptoms  are  similar  to 
those  of  the  first  stage  of  ordinary  tuberculous  disease  (p.  613), 
but  much  more  acute.  There  is  high  fever,  together  with  intense 
pain,  marked  flexion  and  eversion  of  the  limb,  early  suppuration, 
and  rapid  disorganization  if  not  properly  treated  ;  indeed,  where 
nothing  is  done,  and  the  patient  lives  long  enough,  the  head  of 
the  bone  may  be  entirely  absorbed,  or  is  detached,  and  remains 
as  a  sequestrum  in  the  disintegrated  articular  cavity.  As  soon 
as  the  capsule  gives  way,  the  pus  may  come  to  the  surface  in 
any  of  the  usual  localities  for  hip-joint  abscesses.  In  treating 
these  cases,  the  joint  should  be  freely  laid  open  in  the  situation 
which  appears  most  favourable.  The  anterior  incision  is  more 
suitable  for  the  early,  and  the  posterior  for  the  later  stages,  when 
the  head  of  the  bone  is  either  dislocated,  or  remains  in  situ  and 
separated  from  the  shaft.  A  double  opening  may  sometimes  be 
utilized  with  advantage. 


DISEASES  OF  JOINTS  5S3 

The  Knee-joint  is  more  frequently  involved  by  this  disease  than 
any  other,  and  is  usually  infected  from  without.  The  symptoms 
are  exceedingly  typical :  the  pain  is  very  acute  and  the  joint  hot 
and  distended  to  its  utmost  capacity,  the  limb  lying  semiflexed 
and  on  its  outer  side.  Left  to  itself,  the  capsule  gives  way,  and 
suppuration  rapidly  extends  upwards  beneath  the  vasti  or  down- 
wards into  the  leg,  the  pus  ultimately  finding  its  way  to  the 
surface.  The  deformity  gradually  increases,  until  in  the  worst 
forms  the  tibia  slips  behind  the  condyles  of  the  femur,  the  leg  is 
flexed  to  a  right  angle  and  rotated  outwards,  and  if  the  limb  has 
long  rested  on  its  outer  side,  considerable  lateral  displacement 
may  also  occur.  Early  and  efficient  treatment  will  usually 
prevent  such  a  disaster.  The  joint  should  be  freely  incised  on 
each  side  of  the  patella,  so  as  to  open  up  the  subcrureal  pouch, 
and  the  whole  articular  cavity  well  washed  out.  In  some  cases  a 
counter-opening  may  be  made  with  advantage  and  a  drain-tube 
inserted,  by  passing  a  pair  of  sinus  forceps  through  the  outer 
portion  of  the  posterior  ligament  of  Winslow,  and  cutting  down 
on  it  to  the  inner  side  of  the  biceps  tendon  and  clear  of  the  ex- 
ternal popliteal  nerve.  By  this  means  more  efficient  drainage  of 
the  articular  cavity  is  obtained. 

When  the  Ankle-joint  is  involved,  amputation  has  often  to  be 
resorted  to,  in  consequence  of  the  difficulty  of  securing  good 
drainage,  although  excision  of  the  astragalus  will  sometimes  cut 
short  the  disease  and  lead  to  a  good  result. 

Special  Forms  of  Synovitis  and  Arthritis. 

Rheumatic  Synovitis  is  met  with  in  the  course  of  acute  rheu- 
matism, or  as  a  chronic  affection  from  the  commencement.  The 
former  is  recognised  by  the  presence  of  fever,  acid  sweats,  high- 
coloured  urine  loaded  with  lithates,  and  a  tendency  to  metastasis, 
one  joint  after  another  being  involved ;  complete  resolution 
usually  follows,  but  there  may  be  some  thickening  of  ligaments 
and  consequent  impairment  of  mobility.  If  the  disease  is  limited 
to  one  joint,  absolute  disorganization,  though  without  suppura- 
tion, may  ensue  (acute  rheumatic  arthritis). 

The  chronic  variety  is  characterized  by  swelling  of  the  joints, 
due  partly  to  effusion,  partly  to  thickening  of  the  synovial  mem- 
brane and  of  the  capsular  and  other  ligaments.  If  neglected,  it 
may  produce  fixity  of  the  joint,  due  mainly  to  ligamentous 
changes,  but  also  resulting  from  the  development  of  intra-articular 
adhesions ;  but  there  is  never  any  lipping  of  the  cartilages  or  new 
formation  of  bone,  as  in  osteo-arthritis.  Not  unfrequently  other 
evidences  of  rheumatism  may  be  present,  such  as  chorea,  ery- 
thema, etc.,  whilst  rheumatic  nodules  {i.e.,  new  growths  of  fibrous 
tissue  in  the  subcutaneous  tissues,  perhaps  reaching  the  size  of  a 
walnut,  but  more  often  much  smaller)  may  also  develop. 


584  A  MANUAL  OF  SURGERY 

The  Treatment  of  the  acute  form  is  rather  constitutional  than 
local,  and  consists  in  the  administration  of  large  doses  of  salicy- 
late of  soda ;  at  first,  when  the  temperature  is  considerably  raised, 
20-grain  doses  are  given  every  three  or  four  hours,  but  as  the 
pyrexial  phenomena  disappear,  these  are  gradually  diminished  in 
frequency  and  amount,  until  merely  io-grain  doses  are  given 
thrice  daily.  Some  patients  cannot  take  salicylates,  as  they 
induce  maniacal  attacks  of  alarming  severity  ;  under  these  circum- 
stances the  practitioner  must  depend  on  quinine  and  bicarbonate 
of  potash.  Locally,  the  joints  should  be  wrapped  in  warm  cotton- 
wool, or,  perhaps  better,  soda  fomentations  may  be  applied. 
Should  the  inflammation  resist  such  measures,  it  is  quite  justifiable 
to  open  and  wash  out  the  joint,  which  is  found  to  be  occupied  by 
a  greenish,  semi-puriform  effusion. 

In  the  more  chronic  forms  salicine  and  iodide  of  potash  are 
perhaps  more  effectual,  together  with  alkaline  mineral  waters, 
whilst  stimulating  friction  and  massage  may  also  be  adopted. 
Counter-irritation  in  the  form  of  frequently  repeated  blisters,  or 
even  of  the  actual  cautery,  may  prove  beneficial ;  localized  hot- 
air  baths  may  also  be  used  with  advantage  in  the  earlier  stages. 
Failing  such  treatment,  a  visit  to  some  of  the  home  or  Continental 
spas  may  be  recommended. 

Gouty  Arthritis  is  characterized  by  certain  well-marked  features. 
It  often  attacks  the  metatarso-phalangeal  articulation  of  the  great 
toe  (podagra),  or  the  metacarpo-phalangeal  joint  of  the  thumb 
(cheiragra).  Its  onset  is  usually  sudden,  and  it  frequently  com- 
mences in  the  middle  of  the  night.  The  tissues  around  the  joint 
become  swollen,  red,  shiny,  and  cedematous,  whilst  the  super- 
ficial veins  are  prominent.  The  attack  is  exceedingly  painful, 
and  the  skin  exquisitely  tender.  These  symptoms  pass  off  in 
the  course  of  a  few  days,  leaving  the  articulation  swollen  and 
sensitive. 

Even  a  single  attack  results  in  a  slight  deposit  of  biurate  of  soda 
in  acicular  crystals  in  the  matrix  of  the  articular  cartilage  close  to 
the  surface  ;  but  when  the  joint  has  been  several  times  inflamed 
the  whole  thickness  of  the  cartilage  may  be  invaded  by  this 
chalky  deposit,  whilst  the  ligaments  and  ends  of  the  bones  are 
also  infiltrated.  In  the  smaller  joints  it  may  increase  to  such  an 
extent  as  to  form  well-marked  swellings,  or  '  tophi,'  similar  in 
character  to  those  so  commonly  seen  in  the  external  ear.  The 
skin  sometimes  gives  way  over  these,  and  a  chalky  discharge 
results.  In  some  cases  the  cartilages  are  eroded,  and  eburnation 
of  the  exposed  bone  may  follow,  as  in  osteo-arthritis.  The  treat- 
ment of  acute  gout  consists  in  well  fomenting  the  parts  or  applying 
glycerine  of  belladonna,  whilst  colchicum,  citrate  of  lithia,  and 
alkaline  purgatives  are  administered.  In  the  more  chronic  forms 
iodide  of  potassium,  and  possibly  piperazine,  may  be  given,  and 
the  diet  and  drink  are  carefully  regulated. 


DISEASES  OF  JOINTS  585 

Pyasmic  Synovitis  is  due  to  embolic  infection  from  some  sup- 
purating focus.  The  joint  becomes  rapidly  distended  with  pus, 
and  often  without  pain.  If  the  joint  is  promptly  opened,  washed 
out  and  drained,  its  disorganization  may  be  in  many  cases  pre- 
vented (vide  Pyaemia,  p.  106) ;  otherwise  destructive  changes  will 
quickly  follow. 

Typhoid  Disease  of  Joints. —  Several  well-defined  varieties  of 
joint  trouble  arise  in  connection  with  typhoid  fever.  1.  A  simple 
chronic  synovitis  occurs  in  one  or  more  joints  with  but  slight  effusion 
and  little  inflammatory  disturbance.  It  is  somewhat  resistant  to 
treatment,  and  hence  may  cause  limitation  of  movement.  Possibly 
it  is  due  to  the  action  of  toxins  rather  than  of  the  living  organism. 
2.  The  tvue  typhoid  arthritis,  due  to  the  Bac.  typhosus,  is  character- 
ized by  a  marked  inflammatory  effusion  into  one  or  more  joints, 
and  is  liable  to  end  in  spontaneous  dislocation.  The  hip-joint  is 
specially  liable  to  this  trouble.  Suppuration,  however,  is  rare,  and 
the  prognosis  good,  provided  the  limb  is  kept  in  a  good  position. 
The  presence  of  a  large  effusion  indicates  aspiration.  3.  A  mixed 
pyogenic  and  typhoid  infection  results  in  active  suppuration  within 
the  joints,  the  Bac.  typhosus  playing  quite  a  subsidiary  part. 
4.  A  pure  pyogenic  infection.  In  these  latter  two  varieties  the 
ordinary  symptoms  of  acute  suppurative  arthritis  occur,  and  the 
treatment  for  that  affection  must  be  instituted. 

Pneumococcal  Arthritis. — In  the  course  of  an  acute  pneumonia 
the  pneumococcus  is  occasionally  disseminated  through  the  body, 
and  is  then  very  likely  to  attack  a  joint  which  has  been  already 
damaged,  giving  rise  to  a  suppurative  arthritis,  with  an  effusion 
of  thick  creamy  pus,  or  sometimes  to  a  milder  form  of  synovitis. 
Males  are  more  often  affected  than  females,  and  the  upper 
rather  than  the  lower  extremity.  Occasionally  more  than  one 
joint  is  involved,  and,  with  the  exception  of  the  hip,  the  larger 
joints  are  attacked  rather  than  the  smaller.  There  are  no  special 
peculiarities  in  the  course  of  the  disease,  but  it  must  be  recognised 
as  merely  part  of  a  general  infection,  and  hence  a  high  mortality 
is  associated  with  it.  Suppuration  usually  occurs,  and  its  onset 
is  always  an  indication  for  incising,  washing  out,  and  draining 
the  joint. 

Gonorrhceal  Disease  of  Joints  is  always  due  to  infection  with  the 
gonococcus,  transmitted  by  the  blood  from  the  primary  focus  of 
mischief.  Naturally,  it  is  usually  seen  in  connection  with 
gonorrhceal  urethritis,  but  it  has  been  known  to  follow  ophthalmia 
neonatorum,  and  has  been  lighted  up  by  passing  a  full-sized 
bougie  on  a  patient  with  gleet.  Under  ordinary  circumstances 
it  generally  commences  after  the  third  week  of  the  gonor- 
rheal attack,  when  the  discharge  is  becoming  subacute.  It 
may  attack  one  or  many  joints,  the  knee,  ankle,  and  wrist  being 


586  A  MANUAL  OF  SURGERY 


most  frequently  involved,  and  perhaps  on  both  sides  of  the  body. 
Two  distinct  types  of  trouble  may  manifest  themselves,  but  they 
are  not  unfrequently  combined.  In  one,  the  synovial  membrane  is 
mainly  affected,  and  the  effusion  is  chiefly  intra-articular,  so  that  the 
condition  closely  resembles  an  ordinary  attack  of  acute  traumatic 
synovitis.  In  the  other,  the  peri-articular  structures  bear  the 
brunt  of  the  mischief;  and  there  is  at  first  but  little  effusion  in  the 
joint,  but  much  around  it,  the  parts  even  becoming  cedematous  ; 
the  ligaments  are  infiltrated  and  softened,  so  that  displacement 
readily  occurs  ;  surrounding  muscles  atrophy  rapidly  ;  the  patient 
suffers  from  severe  pain  and  a  good  deal  of  fever,  so  that  he 
becomes  thin  and  worn.  In  the  worst  cases  the  intra-articular 
effusion  increases  and  is  sero-purulent,  yellowish-green  in  colour, 
and  contains  flakes  of  lymph,  but  it  is  never  truly  purulent. 
Both  forms  are  very  chronic  and  resistant  to  treatment,  and  hence 
ankylosis,  with  or  without  disorganization,  is  very  liable  to  follow. 
Treatment  is  not  very  satisfactory.  The  urethral  discharges 
must  be  arrested  as  soon  as  possible,  whilst  the  affected  joints  are 
kept  at  rest ;  moderate  pressure  and  counter-irritation,  as  by 
Scott's  dressing,  are  perhaps  the  best  means  of  dealing  with  the 
later  stages  in  simple  cases.  Iodide  of  potassium,  mercury,  and 
quinine  may  be  administered  internally.  Should  the  local 
phenomena  be  at  all  severe,  the  joint  must  be  opened,  irrigated, 
and  drained,  but  even  then  ankylosis  is  likely  to  follow. 

Tuberculous  Disease  of  Joints. 

Tuberculous  Arthritis  {Syn. :  Pulpy  Degeneration  of  the  Synovial 
Membrane,  White  Swelling,  etc.)  may  commence  either  in  the 
synovial  membrane  or  in  the  articular  end  of  the  adjacent  bone 
(tuberculous  epiphysitis,  p.  518)  ;  or  it  may  spread  from  the 
periosteum  to  the  synovial  membrane,  as  a  result  of  a  tuber- 
culous periostitis,  or  from  a  neighbouring  bursa.  There  is  some 
slight  difference  of  opinion  as  to  the  relative  frequency  of  the 
synovial  and  osseous  varieties,  but  the  latest  investigations  cer- 
tainly seem  to  indicate  that  in  children  the  disease  commences 
most  frequently  in  the  epiphyses,  whilst  in  adults  it  may  start 
either  in  membrane  or  bone  with  about  equal  frequency. 

The  Causes  may  be  summed  up  as  follows  :  The  individual  is 
predisposed  to  the  development  of  tuberculous  disease,  usually  as 
the  result  of  an  inherited  tendency,  a  family  history  of  tubercle 
being  often  obtainable  ;  the  general  health  of  the  patient  may  be 
at  fault,  owing  to  insufficient  or  inappropriate  food,  bad  hygienic 
surroundings,  or  exposure  to  cold.  Some  slight  injury  of  which 
but  little  notice  is  taken  may  lead  to  the  actual  deposit  of  the 
Bac.  tuberculosis,  which  gains  access  to  the  body  through  some 
breach  of  surface,  or  even  perhaps  through  a  healthy  mucous 
membrane.      Severe  articular   lesions,  such  as  dislocations,  are 


DISEASES  OF  JOINTS  587 

much  less  likely  to  induce  tuberculous  disease,  partly  because  their 
gravity  demands  efficient  treatment,  partly  because  the  activity  of 
the  reparative  process  is  capable  of  dealing  with  the  organisms, 
even  if  they  are  brought  to  the  spot. 

Pathological  Anatomy. — The  synovial  membrane  becomes  thick- 
ened, pulpy,  and  cedematous,  and  in  the  early  stages,  on  naked-eye 
examination,  may  be  found  to  be  studded  with  small  gelatinous 
nodules,  about  the  size  of  a  pin's  head,  situated  immediately 
beneath  the  serous  lining ;  later  on,  these  may  amalgamate  into 
caseous  masses  which  burst  and  discharge  into  the  joint,  leaving 
ulcerated  surfaces.  Finally,  the  synovial  membrane  is  changed 
into  a  so-called  pyogenic  membrane,  consisting  of  granulation 
tissue  similar  to  that  lining  the  cavity  of  a  chronic  abscess,  and 
more  or  less  closely  attached  to  the  surrounding  structures,  which 
are  transformed  into  cedematous  fibro-cicatricial  tissue,  whilst 
the  superficial  parts  undergo  fatty  or  necrotic  changes.  Micro- 
scopically, one  finds  all  the  ordinary  appearances  of  tuberculous 
disease,  the  vessels  being  in  a  state  of  endarteritis  for  some  distance 
from  the  serous  surface.  Fringes  of  the  synovial  membrane, 
swollen  and  succulent,  spread  over  the  margins  of  the  articular 
cartilage,  and  as  they  increase  in  size  become  adherent  to  it,  just 
as,  according  to  Billroth's  classical  description,  ivy  creeps  along  a 
wall.  On  lifting  the  edges  of  these  fringes,  the  underlying  cartilage 
is  found  hollowed  out  and  eroded.  As  soon  as  the  whole  thick- 
ness is  destroyed  at  any  one  spot,  the  cancellous  tissue  at  the  end 
of  the  bone  becomes  similarly  affected,  and  the  granulations  spread 
along  under  the  cartilage,  cutting  it  off  from  its  nutritive  supply, 
and  thus  necrosis,  as  well  as  superficial  ulceration,  may  assist  in 
its  destruction.  As  a  result  of  the  hyperaemic  condition  of  the  end 
of  the  bone,  especially  when  sepsis  is  super-added,  a  new  formation 
of  subperiosteal  osteophytes,  stalactitiform  in  character,  sometimes 
takes  place,  but  not  to  such  an  extent  as  in  acute  arthritis.  Occa- 
sionally the  periosteum  itself  is  involved  in  the  tuberculous  process, 
and  the  disease  may  then  extend  some  distance  from  the  joint. 

When  the  bone  becomes  involved,  either  primarily  or  secondarily, 
any  of  the  manifestations  of  tuberculous  disease  described  in 
Chapter  XVIII.  may  be  met  with,  and  thus  it  is  not  uncommon 
to  find  sequestra  in  connection  with  tuberculous  arthritis.  When 
it  originates  in  the  bone  in  adults,  the  tissue  directly  contiguous  to 
the  articular  cartilage  is  often  that  primarily  attacked ;  but  in 
children  it  more  frequently  starts  in  connection  with  the  epiphyseal 
cartilage.  The  joint  is  usually  infected  by  extension  of  the  disease 
through  the  articular  cartilage,  but  when  the  synovial  membrane 
extends  along  the  bone  beyond  the  cartilage,  the  latter  structure 
may  escape.  Sometimes  a  pre-tuberculous  synovial  effusion  of  a 
simple  nature  occurs,  but  gives  place  to  the  more  typical  mani- 
festations when  infection  has  followed.  Should  the  perforation  be 
a  large  one,  e.g.,  when  a  tuberculous  abscess  bursts  into  a  joint, 


5»» 


A  MANUAL  OF  SURGERY 


f- 


S 


'•''■ 


? 


I 


acute  symptoms  supervene,  but  gradually  quiet  down,  and  the 
usual  chronic  phenomena  subsequently  develop.  More  com- 
monly the  infection  is  slow 
and  gradual,  and  the  onset  of 
the  articular  symptoms  is  of  a 
similar  character.  The  extent 
of  the  mischief  in  the  bones 
may  sometimes  be  ascertained 
by  the  X  rays  (see  Plates 
XXVIII.  and  XXIX.). 

Clinical  History. — The 
disease  usually  commences  in 
a  most  insidious  manner.  It 
may  be  dated  back  to  some 
injury,  but  as  often  as  not  no 
such  occurrence  has  been 
noted.  Slight  impairment  of 
movement,  together  with  some 
pain,  especially  when  the  limb 
is  jarred  or  twisted,  is  perhaps 
the  first  sign,  causing  the 
patient  to  limp  if  one  of  the 
lower  extremities  is  involved. 
This  becomes  more  and  more 
marked,  and  the  joint  is  fixed, 
usually  in  a  semiflexed  posi- 
tion, whilst  it  looks  slightly 
swollen.  On  inspection  it  is 
white,  smooth,  and  rounded, 
the  swelling  being  more 
apparent  on  account  of  the 
wasting  of  adjacent  muscles. 
On  palpation,  the  part  is  found 
to  be  hotter  than  that  on  the 
opposite  side  of  the  body, 
whilst  fluctuation  is  not  readily 
detected,  there  being  but  little 
fluid  in  the  joint,  though  the 
affected  tissues  are  elastic  and 
puffy.  In  a  few  rare  cases, 
where  the  synovial  membrane 
is  widely  involved,  the  affec- 
tion commences  with  consider- 
able serous  exudation,  giving 
rise  to  the  condition  known 
as  tuberculous  hydrops ;  after 
persisting  for  a  while,  the  usual  manifestations  of  the  disease  show 
themselves.     According   to   Konig   a   number   of  joints   may   be 


Vc^ 


Fig.  212. — Bones  entering  into  For- 
mation of  Knee-joint,  which  has 
been  disorganized  by  tuberculous 
Disease.  (From  College  of  Sur- 
geons' Museum.) 

The  cartilage  is  almost  entirely  de- 
stroyed, and  the  exposed  bone  is 
carious  and  eroded. 


PLATE  XXVIII. 


Tuberculous  Disease  of  Knee-Joint,  showing  Invasion  of  Patella. 
To  /ace  p.  588.] 


DISEASES  OF  JOINTS  589 

affected  with  hydrops  in  the  first  place,  but  all  clear  up  except 
one,  and  that  becomes  tuberculous.  In  this  type  fibrinous 
melon-seed  bodies  are  occasionally  found. 

From  time  to  time  exacerbations  of  pain  and  increase  of  swelling 
occur,  which  subside  after  a  few  days,  but  leave  the  joint  more 
and  more  crippled.  Sooner  or  later  abscesses  are  likely  to 
develop,  with  increased  local  disturbance,  and  often  starting  pains 
at  night,  due  to  the  erosion  of  cartilages,  together  with  slight 
general  fever  and  malaise.  If  they  burst,  temporary  relief  follows  ; 
but  if  the  discharge  continues,  and  fresh  abscesses  form,  septic 
phenomena  are  usually  added  to  those  already  present.  The 
patient  develops  a  hectic  temperature ;  amyloid  degeneration  of 
the  viscera  may  supervene,  the  joint  becomes  more  and  more 
deformed,  abnormal  movements  from  relaxation  of  ligaments  may 
exist,  and  finally  the  patient,  exhausted  partly  by  the  discharge, 
partly  by  the  pain,  and  partly  by  the  want  of  sleep,  becomes 
emaciated,  and  may  even  die,  unless  prompt  measures  are  taken 
for  his  relief. 

Results. — (a)  If  seen  in  the  early  stages,  and  suitably  treated, 
the  disease  may  be  entirely  cured,  and  a  moveable  joint  result. 

(b)  More  frequently  the  articular  structures  are  so  severely 
damaged,  that  a  cure  can  only  be  established  by  means  of  anky- 
losis. Unless  measures  have  been  adopted  to  maintain  the 
limb  in  a  satisfactory  position,  permanent  deformity  may  ensue. 

(c)  If  sepsis  has  been  admitted,  the  patient  will  probably  develop 
hectic  or  amyloid  disease  from  chronic  toxaemia,  and  from  this 
he  may  succumb.  On  the  other  hand,  in  a  few  instances  he 
may  survive  such  dangers,  the  sinuses  alternately  drying  up  and 
discharging,  although  he  remains  a  permanent  invalid,  and  the 
joint  is  crippled,  (d)  Acute  miliary  tuberculosis  is  occasionally 
met  with  as  a  complication  of  this  affection,  whilst  similar 
associated  disease  of  the  lungs,  brain,  kidneys,  or  other  viscera, 
may  be  lighted  up. 

The  Prognosis  is  mainly  influenced  by  the  condition  of  the 
individual  and  his  surroundings.  In  children  of  the  better  classes, 
where  every  hygienic  and  medical  assistance  can  be  given,  re- 
covery generally  follows,  unless  there  is  a  strong  counterbalancing 
hereditary  tendency.  Amongst  the  poorer  classes,  and  especially 
in  '  slum  children,'  the  outlook  is  correspondingly  serious.  More- 
over, the  extremes  of  life  are  unfavourable :  babies  resist  tuber- 
culous invasion  badly,  and  patients  over  fifty  have  comparatively 
little  recuperative  power  ;  hence  radical  rather  than  conservative 
measures  have  often  to  be  resorted  to  in  these  two  classes. 

The  Treatment  of  tuberculous  joints  varies  not  only  with  the 
articulation  affected,  but  also  with  the  type  of  patient,  and  the 
extent  to  which  the  disease  has  advanced. 

1.  Hygienic  Treatment. — Local  tuberculosis  is  a  manifestation  of 
a  general  condition  of  weakness  which  can  often  be  eradicated 


59Q  A   MANUAL  OF  SURGERY 


from  the  system  by  suitable  constitutional  treatment.  Conse- 
quently, in  the  early  stages,  many  cases  of  tuberculous  synovitis 
can  be  cured  by  keeping  the  limb  absolutely  at  rest,  by  means  of 
splints,  plaster  of  Paris,  etc.,  and  elevating  it  if  there  is  much  pain. 
The  general  health  should  be  improved  by  sending  the  child  to 
the  seaside,  giving  it  plenty  of  good  food,  and  administering  cpd- 
liver-oil  and  syrup  of  the  iodide  of  iron.  An  endeavour  must  be 
made  at  the  same  time  to  correct  any  faulty  position  of  the  limb 
by  a  process  of  gradual  extension,  made  at  first  in  the  direction 
of  the  displacement,  and  with  only  just  sufficient  energy  to  keep 
the  joint  surfaces  at  rest  and  counteract  the  tonic  muscular  con- 
traction which  is  tending  to  produce  a  fixed  deformity  ;  it  may  be 
necessary  to  employ  tenotomy  for  this  purpose.  Any  form  of 
apparatus  which  depends  upon  a  screw  mechanism  to  straighten 
out  a  limb  is  certain  to  increase  intra-articular  tension,  and  there- 
fore is  not  to  be  used.  The  sudden  application  of  force  under  an 
anaesthetic  is  also  unadvisable,  since  tuberculous  material  may 
thereby  be  disseminated  through  the  system.  Counter-irritation 
by  blistering  or  iodine  paint,  or  combined  with  pressure  in  the 
form  of  Scott's  dressing,  is  often  useful  in  promoting  repair. 
Possibly  the  severe  pain  experienced  when  the  contiguous  osseous 
tissues  are  involved  may  be  relieved  by  an  application  of  the 
actual  cautery,  but  it  is  doubtful  whether  the  progress  of  the 
disease  can  be  checked  by  such  means. 

2.  Parenchymatous  injections  of  iodoform  suspended  in  glycerine 
into  the  articular  cavity,  or  into  the  substance  of  the  synovial 
membrane,  have  been  much  recommended  of  late,  and  have 
apparently  done  good  ;  10  parts  of  iodoform  are  mixed  with  20  of 
sterilized  water,  and  made  up  to  100  with  pure  glycerine,  and 
about  an  ounce  of  this  fluid  is  injected.  The  limb  is  at  the  same 
time  immobilized.  The  injection  usually  needs  to  be  repeated 
more  than  once.  /3-naphthol  and  some  other  antiseptics  have 
also  been  employed  in  a  similar  fashion. 

3.  A  new  plan  of  treatment  was  suggested  by  Bier  of  Kiel 
a  few  years  back  ;  it  consists  in  inducing  venous  engorgement  of  the 
diseased  tissues  by  applying  an  elastic  bandage  above  and  below 
the  joint,  but  only  loosely  over  it ;  the  pressure  is  kept  on  for 
two  or  three  hours  daily,  if  the  patient  can  bear  it,  and  during 
the  intervals  a  splint  is  applied.  The  general  health  must  also  be 
attended  to  during  the  treatment.  The  process  is  based  on  the 
observation  that  phthisis  rarely  develops  in  association  with 
mitral  regurgitation,  whereby  pulmonary  engorgement  is  induced  ; 
whilst  if  the  cardiac  lesion  supervenes  in  a  phthisical  subject,  the 
lung  symptoms  improve.  It  is  too  early  yet  to  say  what  the  final 
verdict  as  to  this  method  will  be,  but  the  results  hitherto  gained 
are   encouraging.*       It    must   never   be   employed   when   septic 

*  Archiv.  j.  klin.  Chirwgie,  vol.  xlviii.,  bd.  ii.,  p.  306. 


DISEASES  OF  JOINTS  591 

sinuses  are  present,  as  it  considerably  aggravates  the  trouble  by 
providing  increased  pabulum  for  the  micro-organisms. 

4.  Abscesses  are,  if  possible,  dealt  with  sufficiently  early  and  in 
such  a  manner  as  to  obviate  the  need  for  prolonged  drainage.  To 
this  end  they  must  never  be  left  long  enough  to  allow  the  skin 
and  subcutaneous  tissues  to  become  involved,  but  as  soon  as  a 
collection  can  be  detected  it  should  be  tapped  by  a  large  trocar 
and  cannula,  the  cavity  well  irrigated,  and  injected  with  iodoform 
emulsion.  It  is  wise  to  incise  the  skin  with  a  knife,  and  not  to 
puncture  it  with  the  trocar ;  the  irregular  wound  made  by  the 
latter  might  not  heal  quickly ;  a  stitch  closes  the  incision  and 
assists  satisfactory  healing. 

Of  course,  when  the  skin  is  reddened,  and  the  pus  subcutaneous, 
the  abscess  must  be  incised  and  drained  in  the  usual  manner,  any 
thin  and  undermined  skin  being  snipped  away. 

5.  In  other  cases  where  expectant  treatment  cannot  satis- 
factorily be  carried  out,  or  where  the  disease  is  progressing, 
arthrectomy,  or  total  removal  of  the  diseased  tissues  with  the  least 
possible  disturbance  of  the  parts,  should  be  undertaken.  This 
treatment  is  only  feasible  in  certain  joints,  viz.,  the  elbow,  knee, 
and  ankle,  which  can  be  readily  reached,  and  more  or  less 
efficiently  dealt  with.  It  consists  in  freely  opening  the  articular 
cavity,  and  cutting  or  scraping  away  the  diseased  membrane, 
whilst  carious  foci  in  the  bone  are  scraped  and  purified.  The 
advantages  claimed  for  it  are,  that  it  interferes  neither  with  the 
immediate  length  nor  with  the  subsequent  growth  of  the  limb, 
and  that  no  bone  is  cut  through,  and  hence  risk  of  tuberculous 
infection  of  this  structure  is  avoided.  As  to  its  practical  value — 
if  the  proceeding  is  limited  to  the  synovial  membrane,  we  have 
little  confidence  in  it,  recurrences  being  frequently  met  with  ;  but 
if  it  is  modified  in  the  knee  and  ankle  by  the  additional  removal 
of  a  thin  slice  of  articular  cartilage,  so  that  it  is  converted  into  a 
limited  excision,  and  osseous  ankylosis  between  the  two  epiphyses 
is  obtained,  good  results  may  be  anticipated.  At  the  knee, 
however,  there  is  some  tendency  to  subsequent  flexion  and  dis- 
placement. 

6.  Excision  is  at  the  present  time  being  utilized  much  less 
frequently  in  the  treatment  of  tuberculous  joints  than  a  short  time 
back,  owing  to  increased  confidence  in  conservative  measures ;  it 
is  quite  possible  that  this  neglect  of  operation  is  being  carried  too 
far.  We  advise  its  employment  under  the  following  circum- 
stances :  {a)  To  cut  short  the  course  of  the  disease  where  con- 
stitutional and  expectant  treatment  cannot  be  efficiently  carried 
out,  or  where  owing  to  constitutional  weakness  or  defective 
hygiene  it  has  failed  ;  (b)  where  extensive  superficial  abscesses 
have  formed,  requiring  prolonged  drainage,  and  the  disease  has 
seriously  involved  the  bones ;  (c)  for  total  disorganization  of  the 
joint ;  (d)  to  prevent  ankylosis  in  certain  joints,  viz.,  the  elbow 


592  A  MANUAL  OF  SURGERY 


and  temporo-maxillary  ;  and  (e)  to  remedy  ankylosis  in  a  faulty 
position.  In  determining  whether  or  not  excision  is  advisable,  the 
following  considerations  must  be  passed  under  review  :  (i.)  The 
operation  makes  a  considerable  call  upon  the  recuperative  powers 
of  the  individual,  and  hence  is  not  to  be  recommended  in  infants 
or  in  patients  of  advanced  age.  Various  age-limits  are  given  by 
different  authorities,  but,  speaking  generally,  we  would  say  that 
the  operation  should  only  be  undertaken  upon  those  between  five 
and  forty-five  years  of  age.  In  infants  arthrotomy,  or  at  most 
arthrectomy,  is  all  that  is  practicable  ;  the  ends  of  the  bones  are 
so  largely  cartilaginous  that  extensive  osseous  trouble  is  not 
likely  to  be  present.  In  the  hip-joint,  however,  removal  of  the 
head  of  the  femur  often  gives  excellent  results  even  in  the  young. 
The  latter  limit  depends  more  on  the  vitality  than  on  the  actual 
age  of  the  individual,  whilst  some  joints  are  more  amenable  to 
excision  in  elderly  patients  than  others  ;  thus,  one  would  excise 
the  knee  or  shoulder  in  cases  where  one  would  not  think  of 
dealing  with  the  wrist,  ankle,  or  elbow  in  this  manner,  (ii.)  More- 
over, the  general  health  of  the  individual  must  be  sufficiently 
good,  otherwise  repair  will  not  be  satisfactorily  accomplished. 
Hectic  and  amyloid  disease,  unless  very  advanced,  do  not  contra- 
indicate  this  proceeding,  but  in  weakly  children  living  in  the  slums 
it  is  often  better  practice  to  amputate,  (iii.)  The  extent  of  the 
disease  in  the  bones  is  also  a  matter  of  importance,  since,  if  a 
large  amount  of  bone  has  to  be  removed,  a  shortened  or  flail-like, 
useless  limb  is  almost  certain  to  follow.  More  bone  can,  however, 
be  removed  without  detriment  in  the  upper  than  in  the  lower 
extremity,  (iv.)  Again,  the  disease  must  not  have  invaded  the 
soft  parts  too  extensively ;  if  the  skin  is  unhealthy  and  riddled 
with  sinuses,  removal  of  the  limb  is  often  preferable,  (v.)  Finally, 
no  acute  or  subacute  septic  trouble  should  be  present,  for  fear  of 
lighting  up  similar  disease  in  the  bones.  Under  such  circum- 
stances the  limb  may  sometimes  be  saved  by  making  free  incisions 
to  relieve  tension,  and  deferring  excision  until  the  more  active 
symptoms  have  subsided. 

7.  If,  after  carefully  weighing  the  preceding  considerations, 
excision  is  not  thought  desirable,  and  the  case  is  steadily  pro- 
gressing from  bad  to  worse,  amputation  would  appear  to  be  the 
only  treatment  available.  In  addition,  it  is  indicated  in  patients 
where  excision  has  been  undertaken  and  failed,  either  from  the 
limb  becoming  subsequently  flail-like  or  useless,  or  from  recurrence 
owing  to  incomplete  eradication,  or  from  the  advent  of  sepsis. 
Lastly,  if  the  disease  is  present  in  two  joints  at  one  time,  or  in  a 
joint  and  some  other  organ,  neither  of  which  is  improving,  total 
removal  of  one  focus  of  mischief  will  often  induce  a  rapidly  favour- 
able change  in  the  other. 


DISEASES  OF  JOINTS  593 

Tuberculous  Disease  of  Special  Joints. 

The  Shoulder -joint  is  but  rarely  affected  in  children,  and  not 
very  commonly  in  adults.  The  disease  usually  starts  in  the  head 
of  the  humerus,  affecting  subsequently  the  synovial  membrane, 
and  perhaps  also  the  glenoid  cavity.  If  abscesses  form,  they  are 
likely  to  point  either  in  front  of  or  behind  the  deltoid,  in  the  former 
case  extending  along  the  synovial  membrane  lining  the  bicipital 
groove.  Excision  of  the  head  of  the  bone  is  almost  always 
required  in  order  to  effect  a  cure. 

In  the  Elbow  the  disease  is  most  common  in  young  adults,  and 
is  often  primarily  osseous,  commencing  in  the  olecranon  or  outer 
condyle  of  the  humerus.  If  the  synovial  membrane  is  first 
affected,  it  frequently  starts  in  the  superior  radio-ulnar  articula- 
tion. The  swollen  synovial  membrane  bulges  on  either  side  of 
the  olecranon  and  tendon  of  the  biceps.  Sinuses  form  by  the  side 
of  the  olecranon,  or  an  abscess  may  burrow  upwards  along  the 
ulnar  nerve  and  open  on  the  inner  aspect  of  the  arm.  Prolonged 
immobilization,  followed,  if  need  be,  by  incision  and  partial 
removal  of  the  synovial  membrane,  often  suffices  in  children, 
leaving,  however,  a  stiff  elbow  ;  in  adults  excision  is  the  correct 
practice,  and  the  results  are  very  satisfactory,  provided  that  a 
sufficient  amount  of  bone  is  removed,  and  the  muscular  attach- 
ments interfered  with  as  little  as  possible.  If  expectant  treatment 
is  adopted,  the  arm  should  be  flexed  to  a  right  angle,  and  with 
the  hand  midway  between  pronation  and  supination,  so  that,  if 
ankylosis  follows,  the  limb  may  be  in  the  most  useful  position. 
Arthrectomy  is  occasionally  adopted,  and  is  best  accomplished 
by  means  of  an  H-shaped  incision  over  the  olecranon,  which 
process  of  bone  is  divided  at  its  base  and  turned  upwards,  so  as 
to  thoroughly  expose  the  interior  of  the  articulation.  After 
removing  all  diseased  tissue,  the  olecranon  is  replaced  and  wired 
to  the  shaft  of  the  ulna. 

In  the  Wrist  diffuse  disease  of  the  synovial  membrane  and 
bones  is  met  with,  starting  most  frequently  from  the  former 
structure  ;  if  primarily  osseous,  it  usually  commences  in  the  lower 
end  of  the  radius.  It  may  also  extend  from  a  tuberculous  affec- 
tion of  the  adjacent  tendon  sheaths.  A  characteristic  doughy 
swelling  forms  over  the  dorsum,  displacing  the  extensor  tendons, 
and  sinuses  often  develop  on  the  dorsal  aspect  or  by  the  side  of 
the  flexor  carpi  radialis  tendon.  Conservative  measures  may 
bring  about  a  cure,  and  every  effort  should  be  made  to  avoid 
excision,  since  the  result  of  this  proceeding  is  almost  always  the 
production  of  a  weak  and  flail-like  hand,  so  that  the  constant  use 
of  a  leather  support  is  essential  after  healing  has  occurred.  In 
elderly  people  amputation  is  often  the  only  resource. 

Diseases  of  the  Hip-joint  and  of  the  Sacroiliac  Articulation 
are  separately  considered  (pp.  611  and  619). 

38 


594 


A   MANUAL  OF  SURGERY 


The  Knee-joint  is,  perhaps,  more  often  affected  with  tuber- 
culous disease  than  any  other  articulation.  It  appears  to  start 
in  the  synovial  membrane  or  bone  with  almost  equal  frequency  ; 
if  the  bones  are  first  affected,  the  primary  focus  is  usually  situated 
on  the  inner  aspect  of  either  the  femur  or  tibia.  Sequestra  are 
found  in  nearly  one  half  of  the  cases  in  which  the  bone  is  affected, 
becoming  more  frequent  as  the  age  advances.  The  disease  runs 
a  typical  course,  and  needs  no  special  comment.  When  the  joint 
has  become  disorganized,  the  tibia  is  liable  to  be  displaced 
horizontally  backwards,  flexed  and  externally  rotated,  and  anky- 
losis in  this  position  is  difficult  to  remedy,  even  by  operation. 
Prolonged  immobilization  on  a  back-splint,  or,  preferably, 
the  application  of  a  Thomas's  knee-splint 
(Fig.  213),  together  with  iodoform  injections 
and  constitutional  treatment,  will  be  effectual 
in  many  cases.  Failing  this,  a  modified 
arthrectomy  may  be  undertaken,  and  to  carry 
it  out  an  incision  should  be  made  across  the 
front  of  the  joint  from  condyle  to  condyle, 
as  for  an  excision,  dividing  either  the  liga- 
mentum  patellae,  or  perhaps  the  patella, 
which  is  subsequently  wired  together.  The 
whole  of  the  synovial  membrane  is  then  dis- 
sected away,  special  attention  being  directed 
to  the  subcrureal  pouch  and  the  back  of  the 
joint.  A  thin  slice  should  be  removed  from 
the  surfaces  of  both  tibia  and  femur,  and  if 
the  epiphyseal  cartilages  are  not  encroached 
upon,  the  growth  of  the  limb  is  not  impaired 
to  any  great  extent,  although  it  may  become 
irregular  and  lead  to  some  deformity,  e.g., 
well-marked  flexion,  or  genu-recurvatum 
(p.  398).  In  suitable  cases,  where  the  bones 
are  not  too  extensively  involved,  so  that 
on  section  broad  healthy  surfaces  can  be 
apposed,  excision  is  a  most  satisfactory 
operation,  provided  that  the  bulk  of  the 
synovial  disease  can  be  removed.  In  adults, 
where  it  is  desirable  to  cut  short  the  disease, 
one  may  always  undertake  this  proceeding 
when  the  patella  has  become  fixed  to  the 
femur,  thereby  determining  ankylosis.  Re- 
currence usually  results  from  a  focal  point 
of  disease  being  left  in  the  synovial  mem- 
plied.  brane   or   in    the   bone.       If    amputation    is 

necessary,  the  supra-condyloid  operation  can 
generally  be  adopted  ;  when  the  joint  has  been  already  resected, 
or  sinuses  still  persist  in  front,  a  long  posterior  flap  is  often  the 
only  healthy  tissue  available  for  covering  the  bone. 


Fig.  213. — Thomas's 
Knee-splint    ap- 


DISEASES  OF  JOINTS  595 

The  Ankle-joint. — Tuberculous  disease  of  this  joint  usually  com- 
mences in  the  synovial  membrane  rather  than  in  the  bone.  If 
primarily  osseous,  the  astragalus  is  more  frequently  affected  than 
the  lower  end  of  the  tibia.  The  whole  region  becomes  occupied  by 
a  pulpy  swelling,  which  first  pushes  forwards  the  extensor  tendons 
and  bulges  in  front  of  the  malleoli,  and  subsequently  appears  on 
either  side  of  the  tendo  Achillis.  The  foot  is  maintained  in  a  position 
of  plantar-flexion  so  as  to  bring  the  narrower  portion  erf  the  upper 
surface  of  the  astragalus  into  the  tibio-fibular  mortice.  Flexion  and 
extension  of  the  foot  are  of  course  lost,  but  with  care  the  lateral 
movements  (inversion  and  eversion)  which  occur  at  the  mid-tarsal 
and  sub-astragaloid  joints  can  be  undertaken  without  pain.  In  the 
early  stages  prolonged  rest  and  immobilization  in  plaster  of  Paris 
are  all  that  is  required.  Excision  of  the  joint  gives  fairly  satis- 
factory results  in  adults,  but  not  unfrequently  fails  to  eradicate  the 
disease,  owing  to  the  fact  that,  when  once  the  astragalus  is  involved, 
the  tuberculous  process  is  likely  to  spread  to  the  articulations 
placed  beneath  it,  and  so  to  the  other  bones  of  the  foot.  When 
there  is  any  doubt  as  to  the  condition  of  the  astragalus,  that  bone 
should  be  removed  at  the  same  time  as  the  lower  ends  of  the  tibia 
and  fibula.  Where  the  disease  is  more  extensive,  a  supramalleolar 
amputation  of  the  foot  will  be  necessary. 

For  diseases  of  the  Bones  and  Joints  of  the  Foot,  see  p.  515. 

Syphilitic  Diseases  of  Joints. 

Although  syphilitic  disease  of  joints  is  rare  in  proportion  to  the 
prevalence  of  syphilis,  yet  several  varieties  have  been  differentiated 
and  recognised.  (1)  In  the  later  stage  of  the  secondary  period  a 
chronic  form  of  synovitis  occurs,  evidenced  by  passive  effusion  into 
the  joint,  with  or  without  pain,  and  usually  persisting  for  some 
time.  Any  joint  may  be  attacked  in  this  way,  perhaps  the  knee 
most  commonly,  and  the  affection  is  often  symmetrical  in  its  dis- 
tribution. The  effusion  may  be  only  slight,  but  is  frequently  very 
considerable  (hydrarthrosis),  and  a  marked  feature  in  the  condition 
consists  in  the  rapid  variations  in  the  amount  of  swelling,  even 
from  day  to  day.  In  some  few  cases  this  affection  resists  all 
treatment,  and  leads  to  ultimate  disorganization.  (2)  Gummatous 
inflammation  of  the  perisynovial  fibrous  tissue,  which  may  or 
may  not  extend  to  the  adjacent  bone,  is  met  with  in  the  tertiary 
period.  It  either  appears  as  a  localized  hard  nodule,  resembling 
in  measure  a  fibrous  tumour,  and  then  causing  but  little  trouble 
beyond  a  sense  of  painful  weakness  in  the  articulation ;  or  it  is  more 
diffuse  in  its  distribution,  leading  to  a  moderate  effusion,  and  later 
on  to  much  thickening  and  infiltration  of  the  capsular  and  other 
ligaments,  and  resulting  in  considerable  impairment  of  its  move- 
ments from  cicatricial  contraction.  Some  of  these  gummatous 
nodules  may  break  down  and  ulcerate.  (3)  A  diffuse  gummatous 
infiltration  of  the  synovial  membrane  itself  is  also  seen.     It  closely 

38—2 


596  A   MANUAL  OF  SURGERY 


simulates  a  tuberculous  synovitis,  from  which  it  is  often  impossible 
to  distinguish  it,  except  by  the  rapid  onset  and  the  presence  of 
other  syphilitic  phenomena.  (4)  A  chondro -arthritis,  described 
originally  by  Virchow,  is  the  syphilitic  analogue  of  osteo-arthritis. 
It  commences  by  fibrillation  of  the  matrix  of  the  cartilage,  and 
proliferation  of  the  cells.  The  cartilage  softens,  and  becomes 
eroded  by  friction  of  the  articular  surfaces.  The  bone  thus 
exposed  is  worn  away,  and  curiously  '  pitted '  and  excavated.  It 
is  recognised  from  osteo-arthritis  by  the  facts  that  there  is  usually 
but  little  or  no  pain ;  that  the  eburnation  of  the  exposed  bone  is 
less  extensive,  and  therefore  crepitus  is  but  little  marked  ;  whilst 
the  typical  osteophytic  growths,  causing  '  lipping  '  of  the  joint 
margins,  are  absent.  The  eroded  areas,  moreover,  do  not  corre- 
spond with  the  sites  of  intra-articular  pressure,  and  are  more 
rounded  and  punched  out,  and  not  arranged  in  linear  grooves,  as 
in  the  latter  disease.  It  is  not  uncommonly  associated  with  a 
gummatous  thickening  of  the  synovial  membrane,  and,  indeed, 
the  hollows  or  pits  above  mentioned  may  be  filled  with  caseous 
material,  derived  from  degeneration  of  this  tissue. 

The  Treatment  in  the  early  manifestation  consists  in  the 
administration  of  mercury,  and  the  judicious  application  of  pres- 
sure with  or  without  immobilization,  according  to  the  require- 
ments of  the  case  and  the  joint  affected.  In  the  tertiary  forms 
iodide  of  potassium  in  gradually  increasing  doses  has  a  rapidly 
beneficial  action,  which  confirms  the  diagnosis  ;  it  may  be 
occasionally  combined  with  a  small  amount  of  mercury,  either 
given  internally,  or  applied  locally  if  any  ulcerative  lesion  exists. 
In  the  most  pronounced  cases,  where  the  pain  is  severe  and 
disorganization  of  the  joint  has  occurred,  excision  may  be  neces- 
sary, and  the  results  are  often  very  satisfactory. 

Osteo-arthritis. 

Although  this  disease  is  extremely  common  in  this  country  and 
has  well-marked  characteristics,  its  nature  is  still  extremely 
obscure,  as  is  evident  from  the  large  number  of  names  that  have 
been  applied  to  it,  such  as  chronic  rheumatoid  arthritis,  rheumatic 
gout,  arthritis  deformans,  arthritis  senilis,  arthritis  sicca,  etc.  There  is 
not  the  slightest  doubt  that  several  distinct  types  of  disease  have 
been  confounded  together  under  this  title,  and  although  at  the 
present  time  it  is  admitted  that  rheumatic  and  gouty  conditions 
are  to  be  excluded,  yet  it  is  probable  that  we  are  still  including 
more  than  one  type  of  chronic  articular  trouble. 

etiology. — Exposure  to  damp  and  cold  is  doubtless  an  im- 
portant factor  in  the  production  of  osteo-arthritis,  especially  in 
elderly  people,  or  when  some  depressed  condition  of  the  nervous 
system  is  superadded,  whether  such  be  due  to  worry,  anxiety,  or 
to  defective  nutrition.  In  other  cases  where  there  is  no  question 
of  exposure,  the  affection  is  by  some  attributed  to  nervous 
influences  (Senator,   Ord),  and   particularly  to   affection    of  the 


DISEASES  OF  JOINTS 


597 


uterus  and  ovaries,  which  it  is  supposed  are  capable  of  inducing 
reflex  changes  in  the  joints.  Such  an  idea  may  explain  some  of 
the  trophic  and  nervous  phenomena  associated  with  this  trouble, 
but  it  is  a  little  difficult  to  accept  the  theory  in  its  entirety. 
Others  again  attribute  it  to  auto-intoxication  due  to  indigestion 
of  duodenal  origin.  Recently  a  theory  of  bacterial  causation 
has  been  propounded,  and  although  it  cannot  be  considered  as 
proven,  yet  evidence  in  favour  of  its  probability  is  steadily 
accumulating.  It  is  supposed  that  the  organisms  find  their 
way  into  the  joints  from  some  other  focus  of  infection,  and  in 
this  connection  it  is  interesting  to  note  the  statement  that  in  a 
large  series  of  cases  55  per  cent,  were  preceded  by  some  other 
infective  fever  or  disease  (Bannatyne).  They  develop  in  the  joints 
and  produce  toxic  bodies  which  act  locally  by  inducing  destructive 
phenomena  of  a  special  type,  whilst  by  their  general  absorption 
various  trophic  and  nervous  symptoms  are  caused,  whose  existence 
has  been  constantly  noted,  but  for  which  hitherto  there  has  been 
no  adequate  explanation.  Such  an  origin  will  also  explain  the 
presence  of  enlarged  glands  in  the 
neighbourhood  of  some  of  the 
affected  joints.  Several  observers 
have  found  bacteria  within  the 
joints,  and  Bannatyne  and  others 
have  described  a  short  bacillus, 
the  ends  of  which  stain  deeply 
whilst  the  intervening  portion 
remains  unstained,  causing  it  to 
look  like  a  diplococcus.  This  was 
found  in  several  cases,  but  though 
injected  into  the  joints  of  animals, 
no  results  followed. 

Traumatism  plays  an  important 
part  in  the  production  of  certain 
types  of  osteo-arthritis,  and  Lane 
is  emphatic  in  maintaining  that 
these  cases  should  be  relegated  to 
a  different  category,  and  be  known 
as  chronic  traumatic  arthritis;  the 
changes,  however,  are  so  similar 
to  those  of  osteo-arthritis  that  we  prefer  to  consider  it  a  sub- 
division or  variety.  The  injury  may  be  slight  in  nature,  such  as 
a  sprain  or  strain,  or  more  severe,  such  as  a  fracture  or  disloca- 
tion involving  the  articular  surface ;  thus,  it  is  not  uncommon 
to  see  it  following  Colles's  fracture  or  one  of  the  cervix  femoris. 
Abnormal  pressure  maintained  for  a  long  time  also  causes 
changes  of  a  similar  type,  and  thus  many  of  the  joints  of  labouring 
men  are  deformed  in  a  peculiar  fashion,  according  to  the  special 
type  of  work  and  the  particular  joints  that  are  exposed  to  strain. 

Pathological  Anatomy. — The  disease  commences  in  the  articular 


Fig.  214.  —  Patella  from  Early 
Case  of  Osteo-arthritis,  show- 
ing Fibrillation  of  Cartilage. 
(Howard  Marsh.) 


598 


A   MANUAL  OF  SURGERY 


cartilage,  the  matrix  of  which  cracks  and  undergoes  fibrillar 
changes,  and  presents  a  villous  appearance,  resembling  the  pile  of 
velvet  (Fig.  214).  The  cartilage  cells  proliferate,  so  that  the 
capsules  contain  many  instead  of  one,  and  these,  giving  way,  dis- 
charge their  contents  into  the  joint.  The  cartilage  thus  softened 
is  readily  worn  away  by  the  movements  of  the  articulation,  and 
the  exposed  surface  of  bone  becomes  hard,  sclerosed,  and  polished 
like  ivory  (eburnated).  This  usually  occurs  in  certain  definite 
directions.  In  hinge  joints  the  surfaces  become  grooved  longi- 
tudinally, whereas  in  ball-and-socket  joints,  like  the  hip,  the  head 
is  eroded  in  a  circular  manner.  This  condensed  tissue  does  not 
extend  very  deeply,  and  immediately  beneath  it  the  cancellous 

bone  is  of  a  more  open 
texture  than  usual,  and 
filled  with  fatty  me- 
dulla. In  spite  of  the 
sclerosis,  the  articular 
end  of  the  bone  is  con- 
tinually being  worn 
away,  and  this  may 
go  on  to  such  an  ex- 
tent as  to  lead  to  actual 
shortening  of  the  limb. 
Concurrently  with  this 
destruction,  new  bone 
formation  is  taking 
place  at  the  margins 
of  the  articular  carti- 
lage, producing  irre- 
gular osteophytes, 
which  have  been 
likened  to  the  gutterings 
of  a  candle.  They  are 
\     ■  [\  preceded    by   an    over- 

k_ _^  -—-      .  :,  ;  growth  of  cartilage,  in 

which      ossification 
Fig.  215.— Late  Stage  of  Osteoarthritis  of   takes  place  secondarily. 
Knee,  showing  Destruction  of  the  Articu-    when  qnrh   nnrrrrnwrrU 
lar   Cartilage,    and    Eburnation    of    the    ^vnen  sucfl  outgrowths 
Exposed  Bone   in  Longitudinal   Grooves.    n&ve      been      produced 
(From  College  of  Surgeons'  Museum.)        more     or     less     evenly 
The  margins  of  the  surfaces  are  distinctly  lipped,  around    the   joint    mar- 
gin,  a  characteristic 
'lipping'  of  the  edge  of  the  cartilage  results  (Fig.  215).  %  Some- 
times these  osteophytes  attain  to  a  large  size,  and  by  interlocking 
may  lead  to  ankylosis  of  the  joint-     The  synovial  membrane  is 
usually  thickened,  and  the  villi  occasionally  proliferate,  and  may 
reach  such   dimensions  as  to  be   felt  through  the  skin,  rolling 
under  the  finger.     They  are  red,  vascular,  and  succulent  during 
life,    but    after   removal   and    preservation    in    spirit,    they   look 


DISEASES  OF  JOINTS  599 


shrunken  and  insignificant.  This  overgrowth  is  often  associated 
with  excessive  effusion,  though  usually  the  affection  is  of  a  dry 
type.  Occasionally  cartilaginous  nodules  develop  in  the  villi  of 
the  synovial  fringes,  later  on  becoming  ossified,  and  if  detached 
constitute  one  form  of  loose  cartilage. 

Clinical  History. — Several  distinct  types  of.  this  disease  may  be 
observed,  but  practically  they  may  be  subdivided  into  three  chief 
groups  :  A  chronic  type  involving  one  joint  only  ;  a  chronic  form 
affecting  many  joints  ;  and  an  acute  variety  which  is  also  poly- 
articular. 

i.  The  chronic  monarticular  variety  is  that  most  frequently  seen 
by  surgeons,  and  is  constantly  brought  about  by  injury.  Pain 
and  creaking  of  the  joint  on  movement  are  the  early  symptoms 
of  this  affection.  There  may  be  very  little  swelling,  unless 
effusion  is  present,  but  pain,  especially  at  night,  is  most  trouble- 
some, being  usually  increased  on  changes  of  weather,  particularly 
if  rain  is  threatening.  The  pain  and  stiffness  are  most  marked 
after  keeping  the  parts  at  rest,  and  diminish  when  the  limb  is  used. 
As  the  disease  progresses,  the  movements  become  more  and  more 
impaired,  and  the  crepitus  more  of  an  osseous  type ;  the  ends  of 
the  bones  are  felt  enlarged  and  lipped,  and  deformity  soon  becomes 
obvious.  Exacerbations  in  the  symptoms  occur  from  time  to  time, 
resulting  in  increased  crippling  of  the  articulation.  Finally,  the 
limb  may  become  absolutely  useless,  partly  from  the  pain  and  partly 
from  the  limitation  of  movement  produced  by  the  osteophytes. 
Wasting  of  the  adjacent  muscles  is  also  a  marked  feature. 

It  is  usually  seen  in  elderly  people,  and  may  supervene  very 
quickly  after  an  accident,  such  as  fracture  or  bruising  of  the 
cervix  femoris,  and  then  the  destructive  phenomena  may  progress 
at  a  rapid  rate.  When  it  appears  in  younger  people,  the  osseous 
lesions  are  much  less  evident. 

2.  The  chronic  polyarticular  variety  arises  independently  of  trau- 
matism, and  is  most  commonly  seen  in  females  of  middle  life. 
It  may  commence  in  one  joint  and  spread  to  others,  or  it  may 
appear  in  many  joints  simultaneously.  Most  frequently  one  or 
more  of  the  phalangeal  articulations  is  the  starting  point,  par- 
ticularly the  terminal  ones.  The  joints  become  stiff  and  swollen, 
are  tender,  and  small  nodular  bony  outgrowths  develop  at  the 
bases  of  the  phalanges,  which  are  known  as  Heberden's  nodosi- 
ties. The  trouble  gradually  spreads  to  other  joints,  and  although 
there  are  often  remissions,  yet  the  condition  progresses  steaddy 
until  the  patient  may  be  entirely  crippled  thereby.  Well  marked 
overgrowth  of  bone  and  eburnation  of  the  articular  ends  are 
characteristic  features  of  this  type.  Sometimes  there  is  consider- 
able effusion,  accompanied  by  overgrowth  of  the  synovial  villi, 
but  this  is  unusual. 

3.  The  acute  polyarticular  variety  does  not  often  come  to  the 
surgeon  for  treatment,  at  any  rate  in  the  early  stages.     It  usually 


6oo 


A   MANUAL  OF  SURGERY 


attacks  young  or  comparatively  young  people,  and  females  rather 
than  males,  frequently  following  some  infective  trouble,  such  as 
influenza,  scarlatina,  tonsillitis,  etc.  It  is  often  ushered  in  by  a 
distinct  febrile  attack  with  persistent  increase  in  the  rate  of  the 
heart-beat  ;  trophic  and  vasomotor  phenomena  are  often  co- 
existent, such  as  patches  of  pigmentation,  clammy  cold  hands, 
and  rapid  muscular  atrophy.  The  smaller  joints  of  the  hands 
and  feet  are  mainly  affected,  and  that  more  or  less  symmetrically, 
although  the  terminal  interphalangeal  articulations  often  escape. 
The  capsules  are  distended  with  a  certain  amount  of  effusion, 
and  at  first  there  is  but  little  osseous  mischief.  In  not  a  few 
cases  a  very  characteristic  deformity  in  the  shape  of  ulnar 
adduction  of  all  the  fingers  occurs.  Gradually  the  trouble 
spreads  to  other  and  larger  joints,  and  osseous  manifestations 
appear ;  but  the  progress  is  slow,  and  may  be  to  a  large  extent 
arrested  by  treatment.  Neighbouring  lymphatic  glands  may  be 
enlarged  in  the  early  stages. 

It  is  important  to  note  that  gouty  and  rheumatic  troubles  may 
be  associated  with  osteo-arthritis ;  the  rheumatic  affections  may 
precede,  the  gouty  usually  follow. 

The  Diagnosis  of  osteo-arthritis  per  se  is  not  often  difficult  in 
a  well-marked  case,  the  crepitus,  pain,  and  enlargement  of  the 
ends  of  the  bones,  together  with  the  slight  amount  of  effusion, 
constituting  a  tolerably  characteristic  picture.  From  simple 
chronic  synovitis  it  may  be  known  by  the  history  and  smaller 
amount  of  effusion,  and  by  the  pain  and  rigidity  being  frequently 
more  marked  after  rest,  and  diminishing  after  the  joint  has  been 
actively  used.  There  is  more  difficulty  in  distinguishing  the  form 
associated  with  increased  effusion  and  enlargement  of  the  synovial 
villi ;  careful  examination  may,  however,  enable  the  surgeon  to  make 
out  these  villi  moving  to  and  fro  in  the  joint  under  his  hand,  whilst 
possibly  the  ends  of  the  bone  may  be  lipped.  For  diagnosis  from 
chronic  rheumatism  and  Charcot's  disease,  see  pp.  583  and  604. 

The  diagnostic  points  between  polyarticular  osteo-arthritis  and 
gout  are  suggested  in  the  following  table : 


Osteo-arthritis. 

Gout. 

Sex  : 

Females  : 

Males : 

Type  of  patient. 

Poor,     ill  -  nourished,     de- 

Well -  to  -  do       and       well- 

pressed,  anxious;  often  ex- 

nourished people. 

posed  to  damp  and  cold. 

Onset. 

Insidious. 

Sudden  and  obvious. 

Locality  of  onset. 

Usually    in     hands,    espe- 

Feet, especially  metatarso- 

cially in  the  thumb. 

phalangeal  joint  of  great 
toe. 

Type  of  attack. 

No     obvious     swelling     or 

Red   and   painful    at    first, 

redness. 

with  skin  shiny  over  the 
joint. 

Pain. 

Slight  and  aching. 

Severe  and  acute. 

Symmetry. 

Well  marked. 

Not  usually  present. 

Deposit  of  urate  of 

Absent. 

Present. 

soda. 

DISEASES  OF  JOINTS  60 1 

The  Prognosis  is  usually  unfavourable.  The  fact  that  many 
joints  are  affected  is  an  indication  that  there  is  a  considerable 
constitutional  tendency  to  the  development  of  the  disease,  and 
although  it  may  be  temporarily  combated  with  success,  still, 
sooner  or  later,  the  patient  is  almost  certain  to  be  crippled  by  it. 
The  affection  of  only  one  joint  often  points  to  a  traumatic  origin, 
and  the  outlook  is  correspondingly  brighter ;  but  where  the 
disease  attacks  several  parts  of  the  body,  there  is  but  little  hope 
of  checking  it,  and  indeed  cases  are  known  in  which  every  joint 
has  successively  become  implicated,  the  patient  dragging  on  a 
weary  existence,  never  free  from  pain,  and  usually  in  a  cramped 
or  sitting  posture,  until  death  from  exhaustion  supervenes. 

Treatment. — For  this  troublesome  complaint  there  is,  unfor- 
tunately, little  that  can  be  effected  in  the  way  of  cure,  although 
much  can  be  done  to  alleviate.  Locally,  the  articulations  should 
be  protected  from  cold  and  injury  by  being  swathed  in  flannel, 
whilst  stimulating  embrocations  and  sedative  applications  may  be 
beneficially  employed.  It  is  not  advisable  to  maintain  the  joints 
absolutely  and  always  at  rest,  otherwise  they  tend  to  become 
fixed,  and  their  mobility  is  seriously  limited  at  an  unnecessarily 
early  date.  Moreover,  it  is  often  found  that  the  more  a  joint  is 
moved,  the  easier  and  less  painful  do  those  movements  become, 
and  hence  regular  massage  is  desirable.  As  to  general  treat- 
ment, the  individual  is  warned  against  exposing  himself  to  cold 
and  damp,  and,  since  the  disease  is  often  considered  to  be  due  to 
perverted  or  diminished  nervous  activity,  all  possible  sources  of 
irritation  and  wTorry  should  be  removed.  At  the  same  time  the 
nutrition  must  be  improved,  and  plenty  of  good  food,  cod-liver 
oil,  etc.,  administered.  A  large  number  of  different  drugs  have 
been  tried  for  this  complaint,  but  none  of  them  are  very  satis- 
factory. Perhaps  the  best  is  iodide  of  sodium  combined  with 
some  alkaline  purgative  and  hepatic  stimulant,  such  as  sulphate 
of  soda.  Natural  mineral  waters  and  baths  are  often  beneficial, 
those  of  Bath  and  Buxton  in  this  country  being  most  frequently 
recommended.  Arsenic  is  sometimes  useful  in  cases  where  the 
disease  is  probably  of  nervous  origin. 

Occasionally  operative  treatment  in  the  shape  of  excision  may 
be  useful  in  this  complaint,  but  only  when  the  disease  is  limited 
to  one  joint,  and  when  it  has  progressed  to  such  a  stage  as  to 
seriously  cripple  the  patient's  usefulness,  as  in  the  knee-joint, 
elbow  or  the  shoulder,  or  when  the  act  of  mastication  is  impaired, 
owing  to  an  affection  of  the  temporo-maxillary  articulation.  In 
suitable  cases  excellent  results  are  obtained. 

The  hip-joint  is  not  uncommonly  the  seat  of  osteo-arthritis  in 
old  people,  and  it  always  causes  a  considerable  amount  of  pain, 
especially  on  flexion  of  the  limb,  rendering  sitting  difficult  and 
walking  uncomfortable,  whilst  the  movements  are  steadily  more 


602  A   MANUAL  OF  SURGERY 

and  more  curtailed.  The  limb  appears  at  first  to  be  slightly- 
increased  in  length,  but  later  on  becomes  shortened  from  erosion 
of  the  head  and  atrophy  of  the  neck  of  the  bone  ;  the  trochanter  is 
also  much  thickened  and  more  prominent  than  usual,  on  account 
of  the  associated  atrophy  of  neighbouring  muscles.  Well-marked 
crepitus  is  obtained  on  moving  the  thigh.  The  acetabular  cavity 
is  increased  in  size  owing  to  the  formation  of  a  projecting  rim  or 
lip.  If  a  patient  falls  on  the  affected  hip,  some  difficulty  may  be 
experienced  in  making  a  diagnosis  from  fracture  of  the  neck  of  the 
thigh-bone.  The  previous  history  and  the  facts  that  the  trochanter 
rotates  around  its  normal  centre,  and  is  unduly  prominent  rather 
than  approximated  to  the  median  line,  and  that  the  ilio-tibial  band 
is  not  relaxed,  as  in  fractures,  should  suffice  to  prevent  mistakes. 

When  the  temporo -maxillary  joint  is  affected,  the  condyle  of  the 
jaw  becomes  larger  than  usual  and  somewhat  flattened,  whilst 
the  eminentia  articularis  is  partially  absorbed  and  the  glenoid 
cavity  increased  in  size,  so  that  there  is  a  tendency  for  the 
condyle  to  slip  forwards  owing  to  the  action  of  the  external 
pterygoid  muscles.  If  only  one  joint  is  affected,  the  bone  is 
carried  towards  the  sound  side,  but  when  both  are  involved  the 
chin  becomes  prominent  owing  to  a  forward  displacement  of  the 
whole  bone.  Pain  and  crepitus  are  experienced  on  opening  the 
mouth,  rendering  mastication  difficult,  and  even  impracticable. 
If  ordinary  treatment  fails  to  give  relief,  the  affected  condyle  of 
the  jaw  should  be  excised. 

For  osteo-arthritis  of  the  Spine,  see  Chapter  XXII. 

Neuropathic  Arthritis  (Syn. :  Charcot's  Disease). 

This  disease,  bearing  the  name  of  the  late  Professor  Charcot,  is 
a  peculiar  affection  of  joints  met  with  in  the  course  of  locomotor 
ataxy.  It  is  slightly  more  common  in  women  than  men,  and  is 
almost  always  an  early  manifestation,  occurring  usually  between 
the  lightning-like  pains  and  the  onset  of  the  ataxic  symptoms. 
The  most  typical  form  is  lighted  up  by  some  slight  injury — e.g.,  a 
strain  or  sprain — and  is  characterized  by  a  rapid  painless  dis- 
tension of  the  joint  with  a  light-coloured  serum,  which  may  also 
extend  into  the  communicating  bursa? ;  there  is  some  amount  of 
effusion  into  the  surrounding  cellular  tissue,  although  without 
oedema.  This  distension  may  be  so  rapid  that  abnormal  mobility 
or  even  dislocation  may  occur  at  the  end  of  a  few  hours.  The 
joints  most  frequently  affected  are  the  knee,  hip,  and  shoulder ; 
occasionally  more  than  one  articulation  is  involved.  The  course 
of  the  case  varies ;  in  some  few  instances  the  fluid  is  gradually 
absorbed  and  the  joint  returns  to  its  normal  size  and  shape, 
although  somewhat  weakened.  Sometimes  the  attacks  of  dis- 
tension recur,  and  after  each  the  joint  becomes  more  and  more 
crippled.     In  others,  however,  and  perhaps  most  frequently,  the 


DISEASES  OF  JOINTS 


b03 


bones  become  eroded  to  a  considerable  extent,  the  ligaments 
stretched,  and  a  weak,  flail-like  articulation  remains,  in  which 
the  ends  of  the  bones  are  atrophied  and  displaced  (Figs.  217 
and  218).  In  other  instances  new  osseous  formations  occur  here 
and  there  under  the  synovial  membrane,  especially  in  cases  where 
there  is  much  distension,  so  that  on  compressing  the  swelling 
between  the  hands  a  sensation  is  produced  similar  to  that  im- 
parted  by  grasping   a  bag  of  bo.ies.     Occasionally,  under  these 


Fig.  216. — Hypertrophic  Variety  of 
Charcot's  Disease  of  Knee  Joint. 
(From  College  of  Surgeons'  Mu- 
seum.) 

The  patella  (pat.)  can  be  seen  poised  on 
the  top  of  a  mass  of  new  bone  formed 
by  the  welding  together  of  a  number  of 
smaller  portions  formed  in  the  peri- 
synovial  tissues. 


Fig.  217. — Atrophic  Variety  of 
Charcot's  Disease  of  Knee 
Joint.  (From  College  of 
Surgeons'  Museum.) 

The  bones  are  cleanly  eroded,  and 
no  new  formation  is  present. 
The  patella  is  reduced  to  a  mere 
shell,  one  eighth  of  an  inch 
thick. 


circumstances,  the  osseous  masses  become  welded  together,  giving 
rise  to  large  overgrowths,  which  lead  subsequently  to  fixation  of 
the  joint  (Fig.  216).  The  disease  sometimes  runs  a  more  chronic 
course,  and  then  closely  resembles  osteo-arthritis,  since  there  is 
but  little  effusion,  whilst  the  ends  of  the  bones  become  eroded, 
and  osteophytes,  perhaps  of  great  size,  form  around  the  edges  of 
the  cartilages,  leading  to  defective  mobility  and  crepitus. 

The  Diagnosis  of  Charcot's  disease  from  osteo-arthritis  is,  as  a 
rule,  readily  made  if  one  remembers  the  following  points :  Charcot's 


604 


A   MANUAL  OF  SURGERY 


disease  is  usually  characterized  by  a  rapid  onset,  limitation  to  one 
joint,  considerable  effusion,  absence  of  pain,  atrophy  of  the  ends 
of  the  bones,  and  a  tendency  to  the  production  of  a  weak,  flail-like 
joint,  whilst  the  general  signs  of  tabes  are  also  observed.  Osteo- 
arthritis, on  the  other  hand,  comes  on  slowly,  often  affects  many 
joints,  has  but  little  effusion,  is  very  painful,  and  is  attended  with 
overgrowth  tending  to  produce  ankylosis.  In  the  more  chronic 
cases  the  distinguishing  features  are  much  less  evident. 

As  to  pathological  anatomy,  the  changes  observed  are  prac- 
tically identical  with  those  seen  in  osteo-arthritis,  except  that  the 
erosion  is  more  rapid,  the  effusion  greater,  and  the  formation  of 
osteophytes  less  constant. 

The  Treatment  of  Charcot's  disease  consists    in    keeping    the 


Fig.  218. — Charcot's  Disease  of  Left  Knee  and  Shoulder 

The  great  atrophy  of  the  ends  of  the  bones,  and  the  resulting  dislocations,  are 

clearly  evident. 

limb  at  rest  on  a  splint  and  applying  elastic  pressure.  The 
effusion,  when  considerable,  may  be  removed  by  an  aspirator,  but 
is  very  likely  to  re-collect.  In  the  later  stages,  where  the  joint 
is  entirely  disorganized,  some  form  of  fixed  apparatus  may  be 
applied  to  render  the  limb  more  useful,  or,  failing  that,  amputation 
may  be  required. 

The  same  type  of  articular  lesion  occurs  in  Syringomyelia,  a  disease  which 
consists  in  a  gliomatous  development  in  the  spinal  cord,  and  usually  in 
the  cervico-dorsal  region.  It  is  characterized  by  loss  of  the  senses  of  pain, 
and  of  heat  or  cold,  but  tactile  and  muscular  sensibility  persists.  Atrophy 
of  various  muscles  of  the  hand  or  forearm  also  occurs,  whilst  trophic  lesions, 
e.g.,  whitlow,  perforating  ulcer,  etc.,  are  common.  Joint  troubles  are  observed 
in  at  least  one-third  of  the  cases,  mainly  in  the  upper  extremity,  tabes 
generally  affecting  the  lower.  Either  atrophic  or  hypertrophic  phenomena 
are  developed,  and  the  course  is  identical  with  that  of  Charcot's  disease, 
except  that  suppuration  is  a  little  more  likely  to  follow,  owing  to  the  frequent 
presence  of  septic  sores. 

i  Somewhat  similar  in  nature  to  Charcot's  disease  is  the  chronic  arthritis  met 
with  in  many  conditions  where  the  nervous  supply  to  a  limb  is  impaired  as  a 
result  of  central  or  peripheral  disease  of  the  nervous  system.  Thus,  it  may 
follow  spina  bifida,  hemi-  or  para-plegia  of  cerebral  or  spinal  origin,  or  may 


DISEASES  OF  JOINTS  605 

be  secondary  to  a  peripheral  neuritis,  due  to  either  injury,  syphilis,  gout, 
diabetes,  leprosy,  etc  The  terminal  articulations  of  fingers  or  toes  are  those 
most  often  affected  (acro-arthritis),  although  larger  joints  may  be  involved. 
They  become  swollen  and  painful,  and  after  a  time  ankylosis  ensues. 

Haemophilic  Diseases  of  Joints. 

In  haemophilia  (p.  245)  any  injury  to  a  joint,  such  as  a  sprain 
or  wrench,  may  lead  to  a  copious  effusion  of  blood  into  the 
articular  cavity,  which  becomes  suddenly  swollen,  distended,  and 
evidently  full  of  fluid.  There  is  some  pain  on  movement,  the  part 
becoming  hot  and  tender,  whilst  when  coagulation  has  taken  place 
it  is  hard  and  firm.  Total  recovery  may  ensue,  or  the  joint  be  left 
weak  and  liable  to  recurrence  of  haemorrhage  and  inflammation. 
The  effects  on  the  articular  surfaces  are  curious :  the  cartilages 
usually  retain  their  normal  colour,  but  become  thin,  worn,  and 
rough,  especially  at  the  points  of  greatest  pressure ;  fibrillar 
degeneration  of  the  matrix  may  occur,  and  in  some  cases  the 
cartilage  has  been  found  totally  absent,  being  replaced  by  fibrous 
tissue.  Ecchondroses  subsequently  developing  into  bone  are 
formed  at  the  margins  of  the  joint  surfaces,  the  changes  thus 
produced  being  somewhat  akin  to  those  of  osteo-arthritis.  The 
ligaments  and  synovial  membranes  may  remain  of  a  normal 
texture,  or  are  slightly  thickened,  and  usually  of  a  russet-brown 
colour.  Adhesions  are  often  present,  causing  considerable  impair- 
ment of  mobility.  The  treatment  consists  in  keeping  the  part  at 
rest,  and  applying  ice  in  the  early  stages ;  whilst,  later  on, 
friction,  massage,  and  pressure  may  be  employed.  The  surgeon 
must  never  attempt  to  aspirate  the  joint,  even  with  a  fine  needle. 

Loose  Bodies  in  Joints. 

Several  varieties  of  loose  bodies  are  met  with  in  joints,  which 
may  be  described  as  follows  :  (1)  The  so-called  'melon-seed  bodies' 
consist  of  dense  fibroid  tissue  derived  from  altered  blood-clot,  or 
more  frequently  from  a  fibrinous  exudation  in  cases  of  very  chronic 
tuberculous  disease.  At  first  irregular  in  shape  and  laminated  in 
texture,  they  are  generally  transformed  into  round  pellets  or 
elongated  masses  by  the  movements  of  the  articulation.  Bursas 
and  tendon  sheaths  are  much  more  frequently  affected  than  joints. 
The  number  present  is  usually  considerable,  whilst  there  is  also 
some  glairy  effusion,  causing  distension  and  a  certain  amount  of 
creaking.  A  few  years  ago  we  operated  on  a  case  in  which  the 
knee-joint  was  occupied  by  a  number  of  rounded  yellowish-white 
foreign  bodies,  several  of  which  were  nearly  as  large  as  walnuts ; 
they  were  probably  of  haemorrhagic  origin.  (2)  Portions  of 
articular  or  interarticular  cartilage  may  be  broken  off  as  a  result  of 
mechanical  violence.  They  usually  consist  of  a  smooth  rounded 
mass  of  articular  cartilage  enclosing  a  central  bony  nucleus 
(Fig.  219).     (3)  They  are  sometimes  derived  from  the  develop- 


606  A  MANUAL  OF  SURGERY 

ment  of  cartilaginous  nodules  in  the  synovial  fringes  or  villi, 
which  may  either  remain  adherent  and  become  pedunculated,  then 
occasionally  wearing  a  bed  for  themselves  in  the  articular  surface, 
or  may  be  totally  detached.  Such  structures  are  usually  lobu- 
lated  and  irregular  in  shape,  and  consist  of  calcified  cartilage  or 
bone,  whilst  a  certain  amount  of  normal  cartilage  is  also  present 
(Fig.  220).  It  is  not  at  all  uncommon  for  this  condition  to  be  met 
with  in  osteo-arthritis,  but  sometimes  the  cartilaginous  cells  from 
which  they  are  derived  have  persisted  as  a  '  fcetal  residue'  owing 
to  some  modification  in  development.  (4)  Finally,  portions  of  bone 
may  become  separated  from  their  surroundings,  and  remain  loose 
in  the  cavity.  Thus,  ecchondroses  may  be  broken  off  in  cases  of 
osteo-arthritis,  or  portions  of  the  articular  surface  detached  by 
mechanical  means,  or  even  sclerosed  areas  isolated  by  a  process 


Fig.  219. — Foreign  Body  in  Joint,  probably  derived  from  a  Portion  of 
Articular  Cartilage.    (From  College  of  Surgeons'  Museum.) 

A,  cartilage  ;  B,  bone. 

of  rarefying  osteitis  without  suppuration,  constituting  what  Paget 
originally  described  as  '  quiet  necrosis.' 

Although  cut  off  from  all  vascular  supply,  the  growth  of  some 
of  these  loose  bodies  is  said  to  continue,  owing  to  the  highly 
nutritious  fluid  which  bathes  their  surfaces. 

The  Symptoms  caused  by  this  condition  are  produced  by  the 
loose  body  being  occasionally  caught  between  the  articular 
surfaces,  leading  to  a  temporary  locking  of  the  joint  and  severe 
pain,  owing  to  the  stretching  of  the  ligaments.  The  fixation  is 
but  momentary,  since  the  foreign  body  is  readily  displaced,  but 
an  attack  of  subacute  synovitis  follows.  When  this  has  happened 
several  times,  the  ligaments  are  likely  to  become  relaxed,  and 
the  joint  somewhat  loose  and  distended.  Under  such  circum- 
stances it  may  be  possible  to  feel  the  foreign  body  and  to  shift 
its  position,  but  frequently  the  surgeon,  owing  to  its  ready 
mobility,  is  unable  to  detect  the  intruder  as  it  slips  away  into  the 
interior  of  the  joint.  From  this  point  of  view,  the  German  term 
'Gelenkmaus'  (joint  mouse),  as  applied  to  this  affection,  is  most 


DISEASES  OF  JOINTS 


607 


happy.  The  knee-joint  is  that  most  frequently  affected,  but  the 
same  condition  occurs  in  the  elbow  and  temporo  -  maxillary 
articulation. 

The  Diagnosis  between  a  loose  body  and  a  displaced  semilunar 
cartilage  in  the  knee-joint  is  not  always  easy,  since  in  both  con- 
ditions painful  locking  of  the  joint  occurs.  The  fixation,  however, 
is  but  momentary  in  the  case  of  a  loose  body,  but  may  persist 
until  reduced  in  the  latter,  whilst  a  localized  spot  of  tenderness 
may  be  detected  corresponding  to  the  site  of  the  injury  to  the 
interarticular  cartilage.  Moreover,  the  history  of  the  case  is  very 
different,  since  the  dislocation  of  a  semilunar  cartilage  is  always 
primarily  referred  to  some  twist  or  sprain  of  the  joint,  whereas 
with  a  loose  body  no  such  traumatic  influence  need  be  present. 


Fig.  220. — Loose  Cartilage  in  Joint,  probably  developed  in  a  Fringe 
of  Synovial  Membrane.     (From  College  of  Surgeons'  Museum.) 

A,  cartilage  ;  B,  bone. 


The  Treatment  consists  in  the  removal  of  the  foreign  body.  In 
former  days  this  was  done  by  means  of  various  subcutaneous 
operations  which  it  is  unnecessary  to  describe  here,  since  at  the 
present  time  removal  by  the  open  method  is  always  practised.  In 
the  knee-joint  a  vertical  incision  should  be  made,  about  2  inches  in 
length,  extending  a  little  above  and  below  the  line  of  the  articula- 
tion. It  should  be  placed  about  1  inch  from  the  patella,  on  which- 
ever side  the  loose  cartilage  presents  most  frequently,  but  prefer- 
ably on  the  outer.  If  possible,  the  foreign  body  should  be  fixed  by 
the  finger  in  one  of  the  lateral  pouches  of  the  joint  before  making 
the  incision.  •¥  The  capsule  and  synovial  membrane  are  opened, 
the  loose  body  removed,  and  the  cavity  washed  out,  if  thought 
desirable,   with   sterilized    saline  solution.     The   wounds   in    the 


6o8  A   MANUAL  OF  SURGERY 


synovial  membrane,  capsule,  and  skin  are  then  carefully  sutured. 
The  joint  should  be  kept  at  rest  subsequently  for  two  or  three 
weeks,  and  an  elastic  knee-cap  worn  for  some  time. 

Neuralgic  Joints. 

In  neurotic  individuals,  especially  young  women,  a  neuralgic 
condition  of  the  joints  is  commonly  met  with,  simulating  disease 
of  the  articulation.  On  careful  examination  the  pain  is  found  to  be 
superficial,  not  increased  by  jarring  the  articular  surfaces  together, 
and  often  not  strictly  confined  to  the  joint.  The  movements 
are  apparently  limited,  but  if  the  attention  of  the  individual  is 
diverted,  or  anaesthesia  induced,  they  are  found  to  be  perfectly 
free.  There  are  no  signs  of  effusion  into  the  cavity,  and  no  starting 
pains  at  night.  Occasionally  a  similar  condition  is  met  with  in 
men,  where  there  is  no  suspicion  of  hysteria. 

The  treatment  is  constitutional  and  local.  The  former  is  directed 
towards  improving  the  general  health,  and  correcting  any  error 
in  the  uterine  functions.  The  latter  is  best  accomplished  by  the 
use  of  cold  douches  and  electricity,  although  counter-irritation  in 
the  shape  of  blisters,  or  even  the  actual  cautery,  has  an  excellent 
moral  effect. 

Ankylosis. 

By  ankylosis  is  meant  a  condition  of  immobility,  partial  or 
complete,  of  a  joint,  resulting  from  some  preceding  inflammation 
of  the  articular  structures. 

The  term  false  ankylosis  is  sometimes  applied  to  a  condition 
resulting  from  extra-articular  lesions.  Such  may  be  either 
fibrous  or  osseous,  and  is  due  to  cicatricial  contraction  of  the 
skin,  shortening  of  muscles,  or  even  to  the  development  of  bony 
tissue  within  them  (myositis  ossificans).  True  ankylosis  always 
involves  the  articular  structures,  and  is  either  fibrous  or  bony. 

Fibrous  or  incomplete  ankylosis  results  (a)  from  thickening  and 
contraction  of  the  ligaments,  such  as  often  occurs  after  gonorrhceal 
or  rheumatic  affections  ;  (b)  from  the  formation  of  cord-  or  band- 
like adhesions  within  the  joint,  after  acute  synovitis  ;  (c)  from 
erosion  of  the  cartilage  and  exposure  of  the  bone  ;  granulations 
sprout  up  on  each  side,  and  by  their  union  lead  to  dense  fibroid 
adhesions  between  the  articular  surfaces.  Some  amount  of  move- 
ment is  possible  in  most  of  these  cases. 

Complete  or  osseous  ankylosis  (synostosis)  arises  from  the  union 
of  either  the  whole  or  part  of  the  opposing  surfaces  left  by  the 
destruction  of  the  cartilage,  the  bond  of  union,  at  first  fibro- 
cicatricial,  being  subsequently  ossified  (Fig.  221)  ;  it  may  also  be 
due  to  the  interlocking  and  fusion  of  osteophytes,  formed  at  the 
margin  of  the  bone  in  osteo-arthritis  or  Charcot's  disease. 


DISEASES  OF  JOINTS 


609 


The  Causes  of  ankylosis  are  very  variable,  but  may  be  arranged 
as  follows  : 

1.  Injury  to  the  articular  surfaces,  as  from  fractures  which  run 
into  a  joint. 

2.  Non  -  suppurative  inflamma- 
tions of  joints,  involving  the  for- 
mation of  fibrous  adhesions  or  the 
contraction  of  ligaments,  as  in 
synovitis,  whether  traumatic,  rheu- 
matic, gouty,  gonorrhceal,  etc.,  and 
the  early  stages  of  acute  or  tuber- 
culous arthritis. 

3.  Destruction  of  bones,  asso- 
ciated or  not  with  articular  diseases, 
as  in  Pott's  disease  of  the  spine, 
and  the  later  suppurating  stages  of 
acute  or  tuberculous  arthritis. 

4.  Nervous  affections  are  occa- 
sionally the  cause  of  ankylosis, 
by  leading  to  a  chronic  form  of 
arthritis.  The  lesions  may  be 
central,  as  in  spina  bifida,  tabes 
and  syringomyelia ;  or  peripheral, 
as  in  neuritis,  Raynaud's  disease, 
diabetes,  leprosy,  or  division  of 
nerves. 

5.  Long  -  continued  abnormal 
pressure  of  contiguous  bones  may 
result  in  ankylosis,  as  in  scoliosis  or 

osteoarthritis  of  the  spine.  In  the  latter  affection  the  immobility 
may  be  due  either  to  ossification  of  ligaments  or  to  the  interlocking 
of  osteophytes. 

The  position  in  which  ankylosis  occurs  and  the  effects  thus  pro- 
duced differ  according  to  the  joint  affected. 

In  the  shoulder  there  is  but  little  displacement,  and  the  existence 
of  immobility  is  of  comparatively  little  importance,  owing  to  the 
free  movements  of  the  scapula  and  clavicle.  The  elbow-joint  is 
very  commonly  ankylosed  on  account  of  its  exposed  position,  and 
the  frequency  of  fracture-dislocations  in  its  neighbourhood.  The 
formation  of  callus,  and  the  adhesions  likely  to  form  within  the 
joint  in  these  cases,  readily  explain  its  frequency.  The  most 
favourable  position  for  ankylosis  is  when  the  arm  is  flexed  to  a 
little  more  than  a  right  angle,  with  the  hand  midway  between 
pronation  and  supination.  By  this  means  access  to  the  mouth  is 
possible,  and  the  patient  can  use  his  hand  for  feeding  purposes. 
The  -wrist  is  most  commonly  fixed  as  a  result  of  gonorrhceal  or 
rheumatic  synovitis.  In  the  hip-joint  (Fig.  221)  much  depends 
upon^the  treatment  as  to  whether  the  ankylosis  takes  place  in  a 

39 


Fig.  221. — Ankylosis  of  Hip- 
joint  in  Good  Position  after 
Early  Hip  Disease.  (Howard 
Marsh.) 


6io  A  MANUAL  OF  SURGERY 


good  or  bad  position.  In  neglected  cases  the  thigh  may  be  in  a 
position  of  adduction  and  internal  rotation,  crossing  in  front  of  the 
other  leg.  Occasionally  a  scissor-like  deformity  has  resulted  from 
inflammation  of  both  hip-joints,  one  leg  lying  in  front  of  the 
other ;  progression  is  accomplished  with  difficulty,  the  body 
twisting  at  each  step,  and  crutches  are  often  needed.  In  the  knee- 
joint  ankylosis  in  an  absolutely  straight  position  of  the  limb  should 
not  be  aimed  at,  since  slight  flexion  renders  the  leg  more  useful 
both  in  walking,  mounting  stairs,  and  sitting  down.  In  the  ankle- 
ioint  considerable  trouble  may  arise  from  immobility,  unless  the 
foot  is  at  right  angles  to  the  leg. 

Treatment.  —  Fibrous  ankylosis  may  be  treated  by  forcible, 
though  judicious,  manipulation  of  the  limb  under  an  anaes- 
thetic, thereby  rupturing  adhesions  ;  the  limb  is  kept  at  rest 
for  a  few  days,  and  then  massage  and  passive  movements  are 
employed.  If  massive  adhesions  are  present,  but  little  good 
as  regards  mobility  results  from  such  treatment,  since  even 
if  ruptured  by  the  manipulations,  they  are  almost  certain 
to  reunite ;  in  tuberculous  cases  it  is  unwise  to  attempt  this 
for  fear  of  diffusing  or  again  lighting  up  the  disease.  It  must 
not  be  forgotten  that  marked  atrophy  of  bone  is  often  associated 
with  this  condition,  and  therefore  a  fracture  can  easily  be  produced. 

For  osseous  ankylosis  various  operative  measures  may  be 
employed,  with  a  view  either  to  correct  the  deformity,  or  in  other 
cases  to  restore  movement  to  the  part.  At  the  shoulder,  wrist  and 
ankle  nothing  need  be  undertaken  unless  obvious  and  troublesome 
deformity  is  present.  At  the  elbow  excision  may  be  beneficially 
employed,  and  with  every  prospect  of  gaining  a  moveable  joint. 
If,  however,  ankylosis  is  present  in  a  child,  the  operation  should 
be  deferred  until  growth  has  come  to  an  end.  Ankylosis  of  the 
knee  in  a  false  position  needs  cuneiform  osteotomy,  or  the  resection 
of  a  wedge-shaped  portion  of  bone,  in  order  to  secure  a  straight, 
rigid  and  useful  limb. 

Ankylosis  of  the  hip-joint  in  a  bad  position  is  best  treated  by 
dividing  the  neck  or  the  upper  part  of  the  shaft  of  the  femur. 
Several  operations  have  been  devised  for  this  purpose  :  i.  Adams' 
subcutaneous  osteotomy  of  the  neck  of  the  bone  consists  in  passing 
a  sharp-pointed  bistoury  down  to  the  anterior  surface  of  the  cervix 
femoris,  from  a  point  midway  between  the  trochanter  and  the 
anterior  superior  spine  of  the  ilium.  A  track  is  thus  made, 
allowing  the  introduction  of  an  Adams'  osteotomy  saw,  by  means 
of  which  the  neck  of  the  femur  is  divided  subcutaneously.  The 
limb  is  put  up  in  a  straight  position,  and  the  bone  allowed  to 
reunite.  2.  The  same  result  may  be  obtained  by  an  open  method, 
making  the  same  incision  as  in  the  anterior  operation  for  excising 
the  joint  (p.  624).  Gant  suggested  division  below  the  lesser 
trochanter.  This  may  be  accomplished  by  cutting  down  on  the 
bone  from  the  outer  side  and  chiselling  it  across. 


DISEASES  OF  JOINTS 


611 


As  to  the  operation  to  select  in  any  particular  case,  the  surgeon's 
choice  must  be  guided  by  the  condition  of  affairs  present.  A 
skiagram  of  the  neck  of  the  femur  should  always  be  taken  so 
as  to  ascertain  its  condition.  Sometimes  it  is  stunted,  and  has 
practically  disappeared  ;  in  other  cases  it  is  much  thickened,  and 
forms  a  large  bony  mass  passing  from  the  trochanter  to  the  ilium, 
and  probably  containing  encapsuled  foci  of  tuberculous  material. 
In  both  these  conditions  subtrochanteric  osteotomy  must  be 
employed,  and  it  is  not  unusual  to  find  that  the  adductor  muscles 
are  so  contracted,  that  their  attachments  to  the  pubes  require 
section  before  the  limb  can  be  satisfactorily  straightened.  Division 
of  the  cervix  can  only  be  recommended  when  that  structure  is  of 
normal  length  and  size. 

Hip-joint  Disease. 

Although  the  term  '  hip-joint  disease '  is  usually  applied  to  a 
tuberculous  arthritis,  it  is  not  the  only  affection  involving  this 


Fig.  222. — Tuberculous  Disease  of  the  Head  and  Neck  of  the  Femur, 
showing  Sequestra  in  an  Abscess  Cavity,  and  Communication  on 
the  Under  Side  of  the  Neck  with  the  Joint.     (Tillmanns.) 

The  epiphysis  of  the  head  has  been  invaded,  and  the  articular  'cartilage 
entirely  stripped  off  by  the  disease;  the  continuous  black  line  "indicates 
the  amount  of  bone  which  it  would  be  necessary  to  remove. 

articulation.  Simple  synovitis  occurs  in  the  course  of  rheumatic, 
gonorrhoeal,  or  pyaemic  affections.  Acute  arthritis  is  also  met 
with  secondary  to  an  acute  infective  osteomyelitis  of  the  upper 
end  of  the  femur,  and  is  evidenced  by  all  the  ordinary  signs  of 
that  affection,  separation  and  necrosis  of  the  upper  epiphysis 
being  a  frequent  result.  Osteo-arthritis  is  not  uncommon  (p.  601), 
whilst  Charcot's  disease  may  also  occur ;  but  none  of  these  call 
for  special  mention  here. 

Tuberculous  Disease  of  the  Hip  (Syn. :  Morbus  Coxae,  Tuberculous 
Coxitis,  Coxalgia)  differs  in  no  respect  from  the  same  disease  as  it 

39—2 


6l2 


A  MANUAL  OF  SURGERY 


affects  other  joints,  and  hence  no  detailed  notice  of  the  pathological 
anatomy  is  required.  Suffice  it  to  say  that  it  may  originate  in  the 
synovial  membrane  or  bone,  more  frequently  in  the  latter,  and 
then  commencing  either  beneath  the  articular  cartilage  or  in 
connection  with  the  epiphyseal  cartilage  of  the  caput  femoris 
(Fig.  222).  Very  rarely  the  disease  becomes  circumscribed  in 
the  neck  of  the  bone,  forming  a  chronic  abscess,  the  diagnosis  of 
which  is  exceedingly  difficult.  More  usually  the  disease  spreads 
to  the  under  side  of  the  neck,  and  thus  involves  the  synovial 
membrane,  which  passes  into  a  state  of  pulpy  degeneration.    The 


■  .^  ':'*''- 


Fig.  223. — Femur  and  Acetabulum  in  Hip  Disease.     (King's  College 

Museum.) 

The  epiphysis  of  the  caput  femoris  has  been  practically  destroyed,  and  the 
acetabulum  is  enlarged  by  absorption  of  its  posterior  margin,  and  dis- 
placed upwards  [travelling  acetabulum).  The  rami  of  the  ischium  and 
pubes  have  been  removed. 

substance  of  the  epiphysis  is  invaded,  and  caries  of  the  head  is 
thereby  produced,  together  with  necrosis  or  ulceration  of  the 
cartilage.  The  acetabulum  undergoes  similar  changes ;  from 
the  contact  and  backward  pressure  of  the  diseased  head  the 
posterior  acetabular  margin  is  absorbed  and  the  cavity  extended, 
whilst  at  the  same  time  a  new  rim  of  bone  forms  beneath  the 
adjacent  periosteum  at  a  slightly  higher  level,  thus  giving  rise  to 
what  is  known  as  a  '  travelling  acetabulum'  (Fig/ 223).  In  this 
way  the  socket  is  increased  both  in  size  and  depth,   travelling 


DISEASES  OF  J 01 NTS 


6i3 


backwards  and  upwards  with  the  head  of  the  bone  towards  the 
dorsum  ilii.  Other  factors  assisting  in  the  displacement  of  the 
head  of  the  bone  are  :  the  tonic  action  of  the  muscles,  keeping  the 
limb  in  a  position  of  flexion,  adduction,  and  inversion,  thereby 
causing  a  considerable  portion  of  the  head  to  project  out  of  the 
acetabulum  ;  and  the  early  softening  and  destruction  of  the  pos- 
terior ligaments,  which  are  much  thinner  than  those  in  front  of  the 
joint.  Occasionally  a  mass  of  protuberant  granulations  sprouts  up 
from  the  centre  of  the  cavity,  and  may  also  assist  in  this  process. 
Should  the  acetabulum  be  perforated,  a  tuberculous  abscess  is 
likely  to  form  within  the  pelvis.     The  adjacent  pelvic  bones  may 


A  B  CD 

Fig.  224. — Diagram  to  Illustrate  the  Positions  assumed  by  the  Limb 

in  the  Early  and  Late  Stages  of  Hip  Disease. 

A  represents  the  position  of  abduction  taken  by  the  right  limb  in  the  early 
stage  of  hip  disease,  and  B,  Nature's  method  of  masking  this  by  tilting 
the  pelvis  down  on  the  affected  side,  whilst  the  other  leg  is  adducted;  the 
effect  of  this  on  the  spine,  in  causing  a  lateral  deflection,  is  also  indicated. 
C  shows  the  same  thing  in  the  later  stage,  when  adduction  is  present, 
and  the  pelvis  is  tilted  upwards  on  the  affected  side,  thus  producing 
apparent  shortening  (D). 

either  become  thickened  by  the  deposit  of  osteophytes,  or  carious  ; 
if  sepsis  is  present,  necrosis  may  also  supervene. 

Clinical  History. — The  patient,  usually  a  child,  is  observed  to 
limp,  and  may  complain  of  pain  either  in  the  hip  or  inner  side  of 
the  knee,  the  latter  being  due  to  the  fact  that  both  joints  are 
supplied  by  the  same  nerves,  viz.,  the  anterior  crural,  sciatic,  and 
obturator  trunks.  There  may  be  some  history  of  injury,  but  not 
necessarily.  On  examining  the  limb  in  the  early  stage,  it  is 
usually  found  to  be  apparently  lengthened,  whilst  the  thigh  is 
slightly  wasted.  The  nates  are  flattened,  and  the  gluteal  fold 
lost,  conditions  partly  due  to  atrophy  of  the  muscles,  partly  to 
the  flexion  of  the  limb.  The  joint  is  more  or  less  rigid,  and  pain 
is  produced  on  attempting  to  move  it,  or  on  jarring  the  leg,  as  by 
striking  the  heel  or  trochanter.      The  position  assumed  in  this 


614 


A   MANUAL  OF  SURGERY 


early  stage  is  one  of  slight  and  increasing  flexion,  abduction,  and 
eversion  (Fig.  224,  A),  the  reason  for  this  being  that  thereby  the 
ligaments,  and  especially  the  ilio-femoral,  are  most  relaxed,  and 
the  capacity  of  the  joint  is  at  its  greatest.  The  latter  fact  has 
been  demonstrated  in  the  healthy  cadaver  by  inserting  the  nozzle 
of  a  syringe  into  the  joint  through  the  acetabulum,  and  forcibly 
injecting  fluid,  when  this  position  is  at  once  assumed.  The 
flexion  and  abduction,  however,  are  not  always  evident,  since  the 
flexion  is  masked  by  lordosis  of  the  spine  (Figs.  225,  226),  and 
the  abduction  by  the  pelvis  being  tilted  down  on  the  affected 
side,  producing  thereby  apparent  lengthening  of  the  diseased 
limb  and  lateral  curvature  of  the  spine,  with  its  lumbar  convexity 


Fig.   225.  —  Hip  Disease,   with  Well-Marked  Compensatory  Lordosis, 
caused  by  Extending  the  Legs  Flat  on  the  Table. 


Fig.  226. — On  Flattening  the  Spine  against  the  Couch  by  raising  the 
Unaffected  Left  Leg  and  pressing  it  up  against  the  Abdomen,  the 
Degree  of  Flexion  of  the  Right  Thigh  at  once  becomes  Obvious. 

towards  the  affected  side  (Fig.  224,  B).  The  sound  leg  being 
brought  into  a  position  of  adduction,  the  parallelism  of  the  limbs 
is  maintained.  The  flexion  can  be  demonstrated  by  any  method 
which  obliterates  the  lumbar  curve  of  the  spine,  as  by  fully 
bending  up  the  sound  limb  on  the  abdomen,  the  affected  thigh 
rising  at  once  from  the  bed  and  forming  an  angle  which  indicates 
the  amount  of  flexion  (Fig.  226).  The  abduction  is  demonstrated 
by  laying  a  rod  across  the  two  anterior  superior  spines,  and 
placing  another  at  right  angles  to  its  centre.  This  will  not 
correspond  with  the  line  of  the  body  or  of  the  limb,  but  makes 
an  angle  with  it.  The  eversion  cannot  be  masked.  The  rigidity 
is  easily  demonstrable  in  that  all  movements  of  the  hip-joint  are 
greatly  limited  ;  thus  if  an  attempt  is  made  to  bend  the  affected 


DISEASES  OF  JOINTS  615 

thigh  on  the  abdomen,  the  corresponding  side  of  the  pelvis  is 
raised  with  it  from  the  bed. 

As  the  disease  progresses,  and  the  bones  become  more  exten- 
sively affected,  the  pain  increases,  with  nocturnal  startings,  whilst 
abscesses  form,  and  a  certain  amount  of  fever  and  constitutional 
disturbance  is  caused  thereby.  The  position  of  the  limb  also 
changes ;  for  although  the  flexion  is  maintained  and  even  in- 
creased, adduction  and  inversion  are  now  associated  with  it. 
The  pelvis  is  tilted  up  on  the  affected  side  (Fig.  224,  C  and  D), 
causing  appavcnt  shortening,  lateral  curvature  with  a  lumbar  con- 
vexity to  the  sound  side,  and  abduction  of  the  healthy  limb. 
No  satisfactory  cause  for  this  position  can  be  given,  but  it  is 
usually  attributed  to  the  yielding  of  the  posterior  and  outer  part 
of  the  capsule,  together  with  infiltration  and  weakening  of  the 
small  external  rotator  muscles,  allowing  the  adductors  and  internal 
rotators  unopposed  play. 

When  an  abscess  has  formed,  the  most  usual  situation  for  it  to 
point  is  a  little  in  front  of  and  internal  to  the  great  trochanter, 
close  to  the  insertion  of  the  tensor  fasciae  femoris.  It  may  reach 
that  spot  either  from  an  opening  in  the  anterior  part  of  the 
capsule,  coming  thus  to  the  surface  along  the  line  of  least 
resistance,  or  it  may  burrow  from  the  posterior  portion  of  the 
capsule  along  the  rotator  muscles  and  superior  gluteal  nerve. 
Less  frequently  abscesses  pass  directly  backwards  to  open  in  the 
gluteal  region,  or  forwards  along  the  pubo-femoral  ligament, 
pointing  on  the  inner  side  of  the  femoral  vessels  below  Poupart's 
ligament.  As  a  rare  complication,  the  tuberculous  process  may 
extend  to  the  bursa  under  the  psoas  tendon,  which  usually  com- 
municates with  the  joint,  leading  to  the  formation  of  an  abscess 
in  the  lower  part  of  Scarpa's  triangle,  and  occasionally  a  typical 
psoas  abscess  results  from  an  extension  upwards  within  the  sheath 
of  the  muscle  of  a  tuberculous  infection  from  this  bursa.  An  intra- 
pelvic  abscess  following  perforation  or  disease  of  the  acetabulum 
may  either  burrow  upwards,  and  come  to  the  surface  on  the  inner 
side  of  the  vessels  above  Poupart's  ligament ;  or  it  may  gravitate 
downwards,  and  burst  in  the  ischio-rectal  fossa,  close  to  the  tuber 
ischii. 

The  final  stage  of  the  disease  is  one  of  real  shortening  (Fig  227), 
due  to  erosion  of  the  head  of  the  bone  and  its  displacement  back- 
wards upon  the  dorsum  ilii.  The  position  assumed  is  one  of 
increased  flexion,  adduction,  and  inversion ;  whilst  if  septic 
sinuses  persist,  hectic  fever  and  amyloid  changes  in  the  viscera 
are  likely  to  follow. 

At  any  stage  cure  by  ankylosis  may  be  obtained  ;  but  unless 
the  abnormal  position  has  been  corrected  by  extension,  deformity 
is  almost  certain  to  be  present. 

The  Diagnosis  of  hip  disease  appears  to  be  a  matter  of  con- 
siderable difficulty  to  some,  if  we  may  argue  from  the  mistakes 


6i6 


A  MANUAL  OF  SURGERY 


which  commonly  occur.  The  pain  in  the  knee  present  in  the 
early  stages  leads  to  its  frequently  being  mistaken  for  disease  of 
that  articulation  ;  a  very  slight  amount  of  care  in  the  examination 
should  prevent  such  an  error.  From  disease  of  the  opposite  hip,  it 
is  recognised  by  the  relative  mobility  of  the  thigh  on  the  two 
sides.  The  diagnosis  from  sacw-iliac  disease  is  given  at  p.  619. 
Spinal  mischief  may  also  be  confounded  with  it,  if  a  psoas  abscess 
points  at  any  of  the  ordinary  situations  in  which  sinuses  form  in 
connection  with  the  hip-joint.  The  presence  of  spinal  deformity 
and    the   ability  to   perform   the   test   movement   for   hip  disease 


A  B 

Fig.  227.— Position-  of  the  Limb  in  the  Later  Stages  of  Hip  Disease. 
A  shows  more  especially  the  adduction  and  inversion ;  B,  the  flexion  and 
compensatory  lordosis. 

should  readily  enable  the  surgeon  to  make  a  correct  diagnosis, 
but  it  must  not  be  forgotten  that  the  two  conditions  may  co-exist. 
If  the  limb  can  be  put  into  what  is  known  as  the  tailor's  position 
— that  is,  flexion  to  a  right  angle  with  marked  abduction  and 
aversion — one  may  be  practically  certain  that  hip  disease  is  not 
present. 

An  encapsuled  abscess  in  the  neck  of  the  femur  is  a  condition  which 
it  is  very  difficult  to  distinguish  from  true  hip  disease.  A  constant 
deep  boring  pain  is  complained  of,  which  is  increased  by  pressure 
over  the  neck,  or  by  jarring  the  trochanter ;  but  if  the  limb  is 
manipulated  gently,  it  can  be  proved  that  the  movements  of  the 
joint  are  not  really  impaired. 

The  Prognosis  of  hip  disease  is  by  no  means  unfavourable  if  the 


PLATE  XXIX. 


5    3 


w    c 


-    3 


-    » 


DISEASES  OF  JOINTS 


617 


condition  is  properly  treated.  Of  course,  the  patient  is  liable  to 
develop  acute  tuberculosis  or  tuberculous  disease  elsewhere  ;  or, 
if  abscesses  are  allowed  to  become  septic,  serious  complications — 
such  as  pyaemia,  sapraemia,  hectic  and  amyloid  disease — may 
ensue.  Apart  from  these,  however,  no  serious  consequences 
affecting  life  need  be  feared,  although  the  usefulness  of  the  limb 
may  be  seriously  crippled  from  shortening  or  ankylosis,  especially 
if  the  latter  occurs  in  a  faulty  position. 

The  Treatment  ot  hip  disease  must  be  conducted  along  the 
same  lines  as  for  tuberculous  lesions  generally.  In  the  early  stages 
the  limb  is  kept  at  rest  by  the  application  of  a  Liston's  splint,  or  it 
may  be  placed  between  sandbags,  and  a  weight  and  pulley  attached. 
By  this  means  not  only  is  rest  assured,  but  deformity  is  prevented. 
If  the  amount  of  flexion  is  slight,  the  limb  may  be  allowed  to  lie 
on  the  bed  in  the  horizontal  posture  ;  this  will  possibly  induce 
some  compensatory  lordosis,  but  as 
the  muscular  spasm  relaxes,  the 
curvature  of  the  spine  disappears. 
When,  however,  a  considerable  de- 
gree of  flexion  is  present,  extension 
must  be  made  along  the  axis  of  the 
flexed  limb,  which  is  supported  on 
pillows.  It  will  be  found  that  after 
a  few  days  the  flexion  diminishes, 
and  the  limb  will  then  gradually 
assume  the  horizontal  position. 
Should  this  precaution  not  be 
adopted,  the  extension  merely  pro- 
duces lordosis,  and  the  pain  from 
intra-articular  tension  is  increased 
thereby.  The  general  health  of  the 
patient  must  at  the  same  time  be 
attended  to,  and  cod-liver  oil  and 
syrup  of  the  iodide  of  iron  may  be 
administered  with  benefit.  When 
the  more  urgent  symptoms  have  dis- 
appeared, a  Thomas's  hip-splint  is 
applied,  so  as  to  enable  the  patient 
to  get  about  (Fig.  228).  This  con- 
sists of  a  flat  bar  of  malleable  iron, 
about  an  inch  and  a  half  wide,  ex- 
tending from  the  axilla  to  below  the  knee  ;  it  is  shaped  so  as  to 
fit  the  varying  curves  of  the  body,  and  cross-pieces  embrace  the 
trunk  at  the  level  of  the  nipples,  as  also  the  thigh  and  the  calf ; 
it  is  firmly  bandaged  to  the  body  and  limb.  A  patten  is  placed 
under  the  boot  of  the  sound  leg,  and  the  patient  allowed  to  get 
about  on  crutches.  This  apparatus  should  be  worn  for  six 
months  after  all   signs  of  active  disease   have   disappeared.     It 


Fig.  228. — Thomas's  Hip- 
splint   APPLIED. 


6i8  A  MANUAL  OF  SURGERY 

may  also  be  employed  in  the  earlier  and  more  painful  stages  if 
it  is  at  first  bent  so  as  to  accommodate  itself  to  the  flexed  position 
of  the  limb  ;  as  the  effect  of  the  rest  becomes  evident  in  a 
diminution  of  muscular  spasm,  the  splint  can  gradually  be 
straightened  out,  so  that  at  length  the  limb  is  fully  extended. 

When  abscesses  form,  they  may  be  opened  antiseptically  and 
drained,  or  preferably  tapped  and  injected  with  iodoform,  the 
former  precautions  as  to  rest  and  constitutional  treatment  being 
still  maintained.  More  extensive  operative  measures  —  such  as 
excision  of  the  head  by  the  anterior  method  (p.  624) — are  sometimes 
undertaken  in  the  early  stages  to  cut  short  the  disease,  especially 
when  prolonged  treatment  is  impracticable,  as  amongst  the  poor, 
or  when  the  general  health  and  constitutional  powers  are  defective. 
The  removal  of  the  whole  head  necessarily  involves  the  upper 
epiphysis,  and  hence  defective  growth  of  the  femur  results,  as  well 
as  immediate  shortening.  For  these  reasons,  as  also  because 
repair  is  possible  in  most  cases  without  operation  (when  there  is  a 
certain  amount  of  recuperative  power  and  prolonged  treatment  is 
feasible),  this  proceeding,  at  one  time  so  common,  is  being  dis- 
carded more  and  more  in  favour  of  conservative  measures. 

It  is  sometimes  possible,  however,  to  save  some  portion  of  the 
head,  and  if  so,  this  should  always  be  attempted.  A  very  success- 
ful series  of  cases  has  recently  been  published,  in  which  the  joint 
was  opened  from  the  front,  the  interior  freely  curetted  (in  one  case 
after  a  temporary  dislocation  of  the  head),  the  bone  scraped,  and 
in  more  than  one  case  a  channel  gouged  along  its  anterior  wall  to 
expose  and  remove  a  deep  focus.  Indeed,  when  one  attempts  to 
save  the  head  of  the  femur  in  this  way,  it  is  always  well  to  remove 
the  compact  tissue  from  the  front  of  the  neck  so  as  to  expose  and 
explore  the  epiphyseal  line.  By  this  plan,  shortening  and  defective 
growth  can  to  a  large  extent  be  avoided. 

In  the  later  stages,  and  especially  where  sinuses  have  formed  in 
the  gluteal  region  or  behind  the  trochanter,  excision  by  the  posterior 
method  (p.  625)  is  preferable ;  this  is  usually  an  easy  matter 
since  the  head  is  probably  eroded  and  displaced.  The  sinuses 
should,  if  possible,  be  included  in  the  incision,  but  under  any  cir- 
cumstances must  be  opened  up  and  scraped.  When  the  aceta- 
bulum is  extensively  implicated,  the  disease  can  only  be  satisfac- 
torily dealt  with  by  removing  the  head  of  the  bone,  and  the  posterior 
method  affords  the  best  means  of  subsequent  drainage  ;  of  course 
this  presumes  that  the  general  condition  of  the  patient  has 
not  been  seriously  undermined,  and  that  there  is  a  good  pros- 
pect of  gaining  a  useful  limb.  Otherwise  amputation  through  the 
hip-joint  is  required,  especially  when  the  mischief  has  extended 
into  the  pelvis,  or  when,  after  excision,  a  weak,  flail-like  limb 
results  or  osteomyelitis  supervenes.  It  is  also  needed  when  after 
excision  sinuses  persist  and  lead  down  into  the  acetabular  cavity, 
from  which   there  is  a   plentiful   secretion  of   pus,  and  over  the 


DISEASES  OF  JOINTS  619 


entrance  to  which  the  upper  end  of  the  femur  is  drawn,  thereby 
obstructing  the  escape  of  the  discharge,  and  rendering  dressing 
both  difficult  and  painful.  The  operation  often  gives  most  excellent 
results,  the  patient's  condition  rapidly  improving.  Removal  by 
the  anterior  racquet  method  is  perhaps  the  most  convenient. 

Disease  of  the  Sacro-iliac  Joint. 

Tuberculous  disease  of  this  joint  is  most  commonly  met  with  in 
adults,  but  rarely  in  children.  It  may  commence  in  the  synovial 
membrane,  but  is  frequently  the  result  of  mischief  starting  in  the 
pelvic  bones,  especially  the  ilium.  The  Pathological  Anatomy 
calls  for  no  description,  inasmuch  as  it  follows  the  ordinary 
course  of  tuberculous  disease. 

The  Clinical  Signs  consist  of  pain  and  a  sense  of  weakness  in 
the  lower  part  of  the  back,  increased  by  standing,  walking,  or 
any  movement — such  as  coughing,  sneezing,  and  the  like — which 
calls  the  flat  abdominal  muscles  into  sudden  action  and  drags  on 
the  ilium.  It  is  of  a  very  unpleasant  character,  a  sensation  as  if 
the  pelvis  were  coming  to  pieces  being  experienced  by  the  un- 
fortunate individual.  Owing  to  the  fact  that  the  lumbo-sacral 
cord  passes  in  front  of  the  articulation,  pain  is  often  referred  to  the 
gluteal  region  or  down  the  leg.  Movements  of  the  limb  cause 
pain  if  the  pelvis  is  not  supported,  but  can  be  freely  performed  if 
the  pelvis  is  steadied.  Compression  together  of  the  innominate 
bones,  or  their  forcible  separation,  is  the  means  of  most  effectually 
demonstrating  the  existence  and  situation  of  the  pain.  The 
patient  is  unable  to  stand  or  to  put  any  weight  on  the  affected 
limb,  and  hence  limps  during  walking,  allowing  his  body  to  lean 
forwards,  and  making  use  of  a  stick.  There  is  apparent  lengthen- 
ing on  the  affected  side,  but  on  measurement  from  the  anterior 
superior  spine  to  the  internal  malleolus  the  leg  is  found  to  be  of 
the  same  length  as  its  fellow.  This  appearance  is  due  to  the  fact 
that  the  whole  innominate  bone  is  tilted  downwards  and  forwards, 
so  that  the  anterior  superior  spine  is  at  a  lower  level  and  more 
prominent  than  that  on  the  opposite  side.  The  region  of  the 
synchondrosis  is  often  swollen,  puffy,  and  tender ;  whilst  after  a 
time  abscesses  form,  which  may  either  point  immediately  over 
the  articulation,  or  burrow  upwards  into  the  lumbar  region,  or 
forwards  into  the  groin,  or  downwards  into  the  pelvis,  opening  in 
the  ischio-rectal  fossa.  The  last  is  a  most  serious  complication, 
since  it  necessarily  introduces  the  septic  element. 

The  Diagnosis  needs  to  be  made  from  sciatica,  hip  disease,  and 
spinal  disease.  Sciatica  is  known  by  the  character  of  the  pain, 
which  shoots  down  the  back  of  the  thigh  in  the  course  of  the  great 
sciatic  nerve,  which  may  be  distinctly  tender  on  pressure.  There 
is  no  apparent  elongation  of  the  limb,  and  compression  together 
of  the  pelvic  crests  is  painless.     From  affections  of  the  hip-joint, 


6ao  A  MANUAL  OF  SURGERY 

sacro-iliac  disease  is  recognised  by  the  fact  that,  if  the  pelvis  is 
supported,  the  thigh  may  be  moved  in  all  directions  without  great 
discomfort ;  whilst  compression  of  the  pelvis  in  hip  disease  causes 
no  pain.  Moreover,  in  the  advanced  stages  of  hip  disease,  there 
is  apparent  or  real  shortening,  a  condition  never  noticed  in  the 
sacro-iliac  affection.  From  spinal  disease,  the  diagnosis  should  not 
be  difficult  if  a  careful  examination  of  the  spine  and  pelvis  is 
made. 

The  Prognosis  of  sacro-iliac  disease,  though  usually  stated  to 
be  unfavourable,  is  not  necessarily  so  if  asepsis  is  maintained  ;  it 
is  the  admission  of  the  septic  element  that  constitutes  the  main 
danger.  When  affecting  girls,  it  may  lead  to  subsequent  deformity 
of  the  pelvis  and  trouble  in  parturition. 

Treatment  in  the  early  stages  consists  in  absolute  rest,  with 
the  application  of  a  pelvic  support,  and  attention  to  the  general 
health,  combined  possibly  with  local  counter-irritation.  When 
abscesses  form,  they  should  be  freely  opened,  and  if  diseased  bone 
can  be  felt  with  a  probe,  it  should  be  scraped  or  cut  away,  and 
the  parts  swabbed  over  with  pure  carbolic  acid.  Occasionally  it 
is  necessary  to  remove  the  posterior  part  of  the  iliac  crest  in  the 
neighbourhood  of  the  posterior  superior  spine  in  order  to  gain 
access  to  the  diseased  area  ;  this  may  be  accomplished  by  the 
chisel  or  trephine  through  a  vertical  incision,  and  we  have  had  a 
number  of  excellent  results  from  this  proceeding. 

Excision  of  Joints. 

Excision  of  joints  is  an  operation  which,  though  formerly 
undertaken  in  a  few  isolated  instances  for  compound  fractures 
and  dislocations,  has  only  during  the  past  fifty  years  been  estab- 
lished on  a  scientific  basis,  or  utilized  to  any  great  extent.  The 
late  Sir  William  Fergusson  was  one  of  the  chief  pioneers  in  this 
branch  of  operative  surgery,  and  to  his  skill  and  insight  we  owe 
much  of  what  has  thus  been  gained.  Since  the  introduction  of 
antisepsis,  however,  the  operations  have  been  still  further  elabo- 
rated, and  excision  is  now  undertaken  for  many  conditions  that 
formerly  would  not  have  been  so  treated.  The  chief  articular 
lesions  for  which  excision,  partial  or  complete,  is  now  recom- 
mended are  as  follow  :  i,  For  compound  dislocations  or  fracture- 
dislocations  ;  2,  for  various  forms  of  simple  or  comminuted 
fracture  in  the  neighbourhood  of  joints  where  ankylosis  is  likely 
to  follow,  and  either  interfere  seriously  with  the  utility  of  the 
joint  or  fix  it  in  a  bad  position  ;  the  shoulder  and  elbow  are  the 
joints  most  frequently  dealt  with  in  this  way;  3,  for  some  forms 
of  congenital  or  old-standing  dislocation  which  cannot  be  other- 
wise remedied  ;  4,  in  the  later  stages  of  acute  arthritis,  where 
the  ends  of  the  bones  are  carious,  the  joint  disorganized,  and 
chronic  suppuration  is  present  ;  5,  in  tuberculous  arthritis,  where 


DISEASES  OF  JOINTS  621 

palliative  treatment  has  failed  to  cut  short  the  disease,  or  where 
disorganization  of  the  joint  has  occurred  with  erosion  of  the  ends 
of  the  bones ;  6,  for  ankylosis  of  certain  joints,  consecutive  to 
arthritis,  either  acute,  tuberculous,  or  syphilitic,  especially  if  in  a 
bad  position  ;  7,  for  osteo-arthritis  in  special  regions. 

The  results  to  be  attained  necessarily  vary  in  the  different 
joints,  and  according  to  the  particular  causes.  Sometimes  anky- 
losis in  a  good  position  is  all  that  can  be  expected,  in  others  a 
freely  moveable  pseudarthrosis  ;  in  some  cases  the  removal  of 
certain  diseased  tissues  is  the  primary  object  of  the  operation, 
whilst  in  others  no  disease  is  present.  All  these  varying  con- 
ditions must  be  taken  into  consideration  in  determining  the  nature 
and  extent  of  any  excision. 

The  late  Professor  Oilier  of  Lyons  emphasized  and  established 
the  benefits  to  be  derived  from  subperiosteal  resections  in 
certain  cases.  Necessarily,  every  excision  must  lead  to  consider- 
able interference  with  the  peri-articular  structures  ;  muscles  and 
tendons  have  to  be  detached  from  their  insertions,  and  portions 
of  the  bones  removed.  If,  however,  the  periosteum  is  raised, 
together  with  the  attached  muscles  and  tendons,  prior  to  sawing 
or  cutting  the  bones  away,  a  more  satisfactory  reproduction  of  the 
articular  structures  follows,  and  the  movements  of  the  joint  suffer 
less  interference  than  if  one  cuts  away  the  periosteal  envelope 
with  the  bone.  Of  course,  where  the  periosteum  is  invaded  with 
tubercle,  this  should  not  be  attempted,  whilst  in  some  joints — 
such  as  the  elbow — there  is  no  advantage  to  be  derived  from  it, 
since  there  is  always  a  tendency  to  too  great  a  formation  of  bone, 
and  this  would  possibly  be.  exaggerated  by  a  subperiosteal  resec- 
tion. It  is  rather  in  the  operations  undertaken  for  traumatic 
lesions  that  this  plan  is  to  be  recommended. 

In  a  small  text-book  like  this  we  must  perforce  limit  ourselves 
to  a  description  of  the  methods  most  commonly  adopted,  and 
refer  students  to  special  works  on  Operative  Surgery  for  further 
details. 

Shoulder-joint. — Excision  of  the  shoulder-joint  may  be  needed  for  tuber- 
culous disease,  for  the  later  stages  of  acute  arthritis,  occasionally  for  osteo- 
arthritis if  the  disease  is  limited  to  this  articulation,  for  compound  or  com- 
minuted fractures,  and  possibly  for  simple  fractures  of  the  anatomical  neck 
when  associated  with  dislocation  of  the  small  detached  head  of  the  bone.  In 
old  unreduced  dislocations  where  passive  movement  is  impracticable,  and 
there  is  little  hope  of  improvement,  excision  may  give  excellent  results. 

Operation. — The  patient  lies  on  the  back,  the  shoulder  projecting  somewhat 
over  the  edge  of  the  table,  and  with  a  sandbag  beneath  the  scapula  to  steady 
it.  The  arm  being  slightly  rotated  inwards,  an  incision  is  made  from  a  point 
midway  between  the  coracoid  process  and  the  acromion,  extending  downwards 
and  outwards  for  3  or  4  inches  through  the  fibres  of  the  deltoid  muscle 
(Fig.  229,  D).  It  is  better  to  incise  the  deltoid  than  to  pass  between  it  and 
the  pectoralis  major,  the  cephalic  vein  and  accompanying  artery  being  thus 
uninjured.  The  wound  is  thoroughly  opened  up  by  means  of  retractors,  and 
the  bicipital  groove  looked  for  ;  an  incision  is  made  along  its  outer  border, 


622 


A  MANUAL  OF  SURGERY 


and  the  long  tendon  of  the  biceps,  if  still  present,  turned  out,  and  held  to  the 
inner  side  by  a  blunt  hook.  A  twig  of  the  anterior  circumflex  artery  will  here 
be  divided,  and  need  a  ligature.  The  arm  is  now  thoroughly  everted,  and  the 
tendon  of  the  subscapularis  and  the  anterior  part  of  the  capsule,  with  which 
it  is  incorporated,  freely  divided ;  where  practicable,  the  attachments  of  the 
muscle  to  the  bone  should  be  separated  subperiosteally,  a  proceeding  pre- 
senting no  difficulty  where  inflammation  has  previously  existed.  The  arm  is 
now  inverted  and  held  downwards  by  the  side  of  the  table,  so  as  to  bring  the 
great  tuberosity  into  view ;  the  muscles  attached  to  this  process  are  dealt  with 
in  a  similar  way,  and  the  upper  part  of  the  capsule  freely  opened.  The  head 
of  the  bone  is  then  protruded  into  the  wound,  and  removed  by  the  saw.  It 
will  often  suffice  to  apply  the  saw  obliquely  through  the  substance  of  the 
tuberosity  ;  this  is  to  be  preferred  to  removal  of  the  whole  tuberosity  by  a 
horizontal  incision  at  a  lower  level.  The  synovial  membrane  and  glenoid 
cavity  are  dealt  with  as  circumstances  may  dictate,  and  it  is  often  advisable 
to  make  a  counter-opening  through  ths  posterior  axillary  fold  for  the  insertion 


Fig.  229. — Incision  for  Excision  of  Shoulder. 

A,  coracoid  process  ;    B,  tip  of  acromion ;    C,  intermuscular  line  between 
deltoid  and  pectoralis  major;  D,  incision. 


of  a  drainage-tube ;  the  anterior  wound  can  then  be  entirely  closed.  In 
applying  the  dressing,  care  must  be  taken  to  put  a  good  pad  in  the  axilla,  so 
as  to  keep  the  arm  from  being  drawn  forcibly  inwards  by  the  muscles  attached 
to  the  bicipital  groove.  There  is  no  need  to  commence  passive  movements 
before  the  end  of  the  first  week.  Fibrous  union  usually  results,  and  the  move- 
ments of  the  shoulder  are  generally  very  good. 

Excision  of  the  Elbow  may  be  required  for  simple  or  compound  fracture-dis- 
location, or  for  subsequent  ankylosis,  especially  if  the  limb  is  in  a  bad  position, 
for  tuberculous  arthritis,  and  possibly  in  the  later  stages  of  acute  arthritis. 
The  best  plan  of  operating  is  as  follows :  A  single  longitudinal  incision, 
5  inches  in  length,  is  made  in  the  middle  line  of  the  posterior  aspect  of  the 
joint,  extending  for  equal  distances  above  and  below  the  tip  of  the  olecranon, 
and  a  little  to  the  inner  side  The  limb  is  held  across  the  patient's  body,  the 
surgeon  standing  on  the  affected  side.     The   incision  extends   through    the 


DISEASES  OF  JOINTS  623 


substance  of  the  triceps  down  to  the  bone.  The  origin  of  the  flexor  carpi 
ulnaris  and  the  inner  half  of  the  triceps  tendon  are  detached,  and  the  hollow- 
between  the  olecranon  and  the  internal  condyle  cleared,  the  knife  being  kept 
close  to  the  bone,  and  the  soft  parts  retracted  by  a  vigorous  use  of  the  thumb- 
nail. By  this  means  the  ulnar  nerve  escapes  injury,  and,  indeed,  is  often  not 
seen  at  all.  The  internal  lateral  ligament  should  be  divided,  and  the  common 
origin  of  the  flexors  from  the  front  of  the  inner  condyle.  The  outer  half  of 
the  joint  is  then  dealt  with  in  a  similar  way,  the  anconeus  being  divided  close 
to  its  insertion  to  the  ulna,  the  continuity  of  the  triceps  with  the  deep  fascia 
covering  it  being  also  maintained.  The  origin  of  the  extensor  muscles  is 
separated  from  the  back  of  the  outer  condyle,  and  the  external  lateral  ligament 
severed.  The  joint  can  now  be  freely  opened  by  dividing  any  of  the  fibres 
of  the  posterior  ligament  which  remain  intact,  and  the  denuded  ends  of  the 
bones  protruded  from  the  wound.  The  lower  end  of  the  humerus  is  now 
thoroughly  cleared,  and  the  articular  surface  removed,  the  section  passing 
through  the  centre  of  the  olecranon  fossa.  The  olecranon,  together  with  the 
upper  articular  surface  of  the  coronoid  process  and  the  head  of  the  radius, 
are  next  sawn  off,  care  being  taken  to  draw  aside  and  protect  the  soft  parts  by 
retractors,  especially  those  covering  the  ulnar  nerve.  The  synovial  membrane 
can  be  dealt  with  as  may  be  necessary.  Even  if  the  head  of  the  radius  is  free 
from  disease,  nothing  is  gained  by  leaving  it  intact,  since  ankylosis  is  very 
likely  to  follow  unless  plenty  of  bone  is  removed.  For  a  similar  reason  sub- 
periosteal resection  is  needless,  and,  indeed,  is  an  undesirable  refinement. 
The  wound  is  carefully  sutured,  and  a  drainage-tube  inserted  for  a  few  hours. 
The  limb  is  kept  on  a  hinged  angular  splint  for  a  week,  by  which  time  union 
of  the  external  wound  should  be  complete,  but  the  position  is  altered  each  day. 
After  a  week,  the  splint  may  be  dispensed  with,  and  the  limb  kept  at  rest  on 
a  pillow,  free  passive  movement,  both  angular  and  rotatory,  being  daily 
practised.  Considerable  attention  is  needed  in  order  to  obtain  a  good  result, 
but  in  a  successful  case  every  movement  of  the  joint  is  perfectly  restored. 
As  a  rule,  the  lower  end  of  the  humerus  develops  two  lateral  bony  processes, 
like  malleoli,  within  the  grasp  of  which  the  upper  rounded  ends  of  the  radius 
and  ulna  are  able  to  move. 

The  Wrist-joint  is  only  excised  for  extensive  tuberculous  disease  when 
abscesses  and  sinuses  are  present.  Ankylosis  of  the  articulation,  though  a 
troublesome  condition,  is  not  sufficiently  so  to  require  such  treatment.  The 
best  method  to  employ  is  that  known  as  Lister's  operation,  a  somewhat  com- 
plicated proceeding,  but  which  in  suitable  cases  gives  excellent  results.  Prior 
to  operating  the  fingers  are  well  bent,  so  as  to  break  down  any  adhesions  which 
are  present.  Two  incisions  are  made,  one  on  the  radial  side  of  the  dorsum, 
and  the  other  on  the  inner  or  ulnar  aspect  of  the  wrist.  The  dorsal  incision  is 
angular  (Fig.  230,  L,  L),  commencing  at  a  point  on  the  back  of  the  radius 
between  the  tendons  of  the  extensor  secundi  internodii  pollicis  (B)  and  the  ex- 
tensor communis  digitorum  (D) ;  it  is  at  first  parallel  to  the  former  tendon,  and 
on  its  ulnar  side,  till  it  reaches  the  base  of  the  second  metacarpal  bone,  when 
its  direction  is  changed,  and  it  courses  downwards  along  that  bone  for  an 
inch  or  two.  It  should  extend  to  the  bone,  and  in  doing  so  the  tendons  of 
the  extensor  carpi  radialis  longior  and  brevior  (H  and  I)  are  divided  as  close 
to  their  attachments  as  possible.  The  tendinous  structures  are  then  stripped 
off  the  back  of  the  dorsum  on  either  side  of  the  incision,  and  on  the  outer 
side  a  pair  of  cutting  pliers  is  insinuated  so  as  to  detach  the  trapezium 
from  the  rest  of  the  carpus.  The  synovial  sheaths  of  these  tendons  should,  if 
possible,  not  be  opened.  The  hand  is  then  rolled  over,  and  the  ulnar  incision 
made  well  on  the  inner  side  of  the  limb,  extending  for  at  least  3  inches 
between  the  extensor  and  flexor  carpi  ulnaris  tendons.  The  separation  of  the 
extensor  tendons  from  the  back  of  the  carpus  is  now  completed,  and  the 
attachment  of  the  extensor  carpi  ulnaris  (K)  divided.  The  tissues  on  the 
palmar  aspect  of  the  joint  are  detached,  the  pisiform  being  severed  from 
the  rest  of  the  carpus,  and  where  possible  left,  and  the  hook  of  the  unciform 
clipped  off  with  cutting  pliers.     The  carpus  is  now  free  front  and  back,  and 


624 


A  MANUAL  OF  SURGERY 


the  bones  are  either  removed  piecemeal  or  taken  away  en  bloc  by  inserting  a 
pair  of  cutting  pliers  above  and  below,  and  dividing  their  upper  and  lower 
connections ;  more  usually  the  carpal  bones  are  picked  out  in  fragments. 
Attention  is  then  directed  to  the  lower  ends  of  the  radius  and  ulna,  and  to  the 
articular  ends  of  the  metacarpal  bones,  all  the  cartilage  and  the  intervening 
synovial  tissue  being  cleared  away.  Finally,  the  remaining  fragments  of  the 
carpus  are  dealt  with  as  the  case  may  require.  The  radial  incision  may  often 
be  entirely  closed,  whilst  a  drainage-tube  is  inserted  through  the  ulnar  wound. 
The  hand  is  placed  on  a  special  splint,  with  a  thick  convex  cork  support  for 
the  palm,  which  keeps  the  wrist  slightly  extended,  and  with  a  short  lateral 
projection  upon  which  the  thumb  can  rest.  The  fingers  must  be  thoroughly 
flexed  and  extended  daily,  beginning  on  the  second  or  third  day,  but  the  wrist 
should  be  kept  at  rest  until  it  is  quite  firm.  There  is  a  much  greater  tendency 
to  a  flail-like  joint  than  to  undue  fixity,  owing  to  the  amount  of  bone  removed, 


Fig.  230.— Excision  of  the  Wrist.     (Lister.) 

A,  Radial  artery ;  B,  extensor  secundi  internodii  pollicis  ;  C,  ext.  indicis  ; 
D,  ext.  communis  digitorum  ;  E,  ext.  minimi  digiti  ;  F,  ext.  primi  inter- 
nodii pollicis ;  G,  ext.  ossis  metacarpi  pollicis  ;  H,  ext.  carpi  radialis 
longior  ;  I,  ext.  carpi  radialis  brevior ;  K,  ext.  carpi  ulnaris  ;  L,L,  line  of 
radial  incision. 


and  the  necessary  divisions  cf  all  the  extensors  of  the  carpus  ;  if  such  occurs,  a 
leather  support  must  be  worn,  either  as  a  temporary  or  permanent  appliance. 

The  Hip-joint  is  rarely  excised  for  conditions  other  than  tuberculous  disease, 
and  even  for  this  it  is  performed  much  less  frequently  than  formerly.  There 
are  two  chief  methods  of  operating,  the  anterior  and  the  posterior. 

1.  Excision  by  the  anterior  method  is  carried  out  as  follows:  The  incision 
(Fig.  75  D  ;  p.  292)  extends  from  immediately  below  the  anterior  superior  spine 
vertically  downwards  for  3  or  4  inches.  It  passes  between  the  tensor  fasciae 
femoris  and  sartorius  muscles  superficially,  and  between  the  glutei  and  rectus 
deeply,  a  small  arterial  twig  from  the  external  circumflex  being  divided  at 
this  stage.  The  neck  of  the  bone  and  capsule  of  the  joint  are  exposed,  and 
the  latter  is  freely  incised  along  its  attachment  to  the  anterior  intertrochanteric 
line,  so  as  to  allow  of  the  admission  of  the  finger,  whereby  the  joint  can  be 
fully  explored.  The  neck  of  the  bone  is  cut  through  in  situ  by  means  of  an 
Adams'  osteotomy  saw,  the  incision  through  the  bone  being  placed  obliquely 


DISEASES  OF  JOINTS 


M 


downwards  and  inwards.  The  head  of  the  bone  is  now  either  prised  out  of 
the  acetabulum  by  an  elevator,  or  grasped  by  lion  forceps  and  twisted  out,  a 
matter  easily  accomplished  where  the  articular  structures  are  diseased,  but 
a  proceeding  of  some  difficulty  in  the  normal  joint  of  a  cadaver.  As  much  of 
the  infected  synovial  membrane  as  possible  is  clipped  away  with  scissors, 
and  the  acetabulum  scraped,  if  necessary.  The  external  wound  is  either 
closed,  with  the  exception  of  an  opening  for  a  drainage-tube,  or  stuffed  with 
gauze  soaked  in  iodoform  emulsion.  There  may  be  comparatively  little 
shortening  of  the  limb  as  the  result  of  this  proceeding,  but  the  movements 
are  considerably  limited. 

2.  Excision  by  the  posterior  method,  as  we  have  already  said,  is  usually 
undertaken  in  the  later  stages  of  the  disease.  Any  sinuses  which  exist  pos- 
teriorly may  be  utilized,  but  if  the  skin  is  unbroken,  an  incision  known  as 
Langenbeck's  may  be  employed  (Fig.  231).  The  patient  lies  on  the  sound 
limb,  whilst  the  affected  thigh  is  flexed.  The  incision  is  made  in  the  line  of 
the  femur,  extending  2  inches  above  the  top  of  the  great  trochanter,  and  about 
3  inches  below  it.  It  is  carried  at  once  down  to  the  bone,  and  the  muscles 
attached  to  the  summit  and  posterior  border  of  the  great  trochanter  freely 
divided,  as  close  to  the  bone  as  possible.  The  capsule  is  opened  to  a  sufficient 
extent  to  allow  of  the  exploration  of  the  joint  by  the  finger.  If  the  disease 
is  very  extensive,  the  femur  is  now  chiselled  across,  immediately  below  the 
great  trochanter,  but  above  the  lesser.  The  upper  end  of  the  bone  is 
grasped  by  lion  forceps,  and  twisted  out  of  the  acetabulum,  after  division 
of  the  remaining  structures,  which  are  attached  chiefly  along  its  anterior 
border.  The  ligamentum  teres  has  almost  always  been  previously  destroyed, 
and  hence  this  stage  of  the  operation  is  not  especially  difficult.  The  synovial 
membrane  and  acetabulum  are  easily  reached,  and  the  diseased  portions 
removed.  In  favourable  cases  a  drainage-tube  may  be  inserted,  and  the  wound 
closed,  but  not  uncommonly  it  is  wiser  to 
partially  stuff  it  with  gauze  infiltrated  with 
iodoform,  and  allow  it  to  heal  by  granulation. 
Slight  extension  of  the  limb  should  be  sub- 
sequently made,  so  as  to  prevent  undue  shorten- 
ing from  the  traction  of  the  long  thigh  muscles. 
The  leg  is  placed  between  sandbags,  or  a  Liston's 
long  splint  applied.  Fibrous  ankylosis,  with  a 
certain  limited  amount  of  movement,  is  the 
usual  result. 

It  is  not  always  necessary  to  include  the 
trochanter  in  this  operation.  If  the  disease  is 
limited  to  the  head  of  the  bone,  it  alone  should 
be  removed,  with  as  little  disturbance  as 
possible  to  the  muscles  passing  to  the  trochanter. 
If  such  can  be  effected,  the  subsequent  mobility 
and  usefulness  of  the  limb  are  considerably  in- 
creased. 

The  advantages  claimed  for  the  anterior 
method  are  :  that  it  is  a  less  severe  operation, 
that  fewer  muscles  and  tendons  are  interfered 
cision  for  Excision  of  the  with,  that  no  vessels  of  importance  are  divided, 
Hip  from  Behind.  (Till-  and  that  only  the  head  of  the  bone  is  excised. 
manns.)  The  objections  to  it  are  :  that  the  drainage  pro- 

vided is  very  unsatisfactory,  that  the  trochantei 
cannot  be  readily  dealt  with,  whilst  it  is  also  difficult  to  remove  all  the 
synovial  membrane. 

The  great  advantages  of  the  posterior  operation  are  that,  in  spite  of  a  free 
division  of  the  muscular  and  tendinous  attachments,  excellent  drainage  is 
provided,  and  both  trochanter  and  acetabulum  are  readily  accessible.  On 
the  whole,  the  anterior  method  should  be  employed  in  the  early  stages  of  the 

40 


Fig.  231. — Langenbeck's  In- 


626  A   MANUAL  OF  SURGERY 

disease,  the  posterior  in  the  later.     The  situation  of  abscesses  or  sinuses  may, 
however,  determine  the  choice  of  the  surgeon. 

The  Knee-joint  is  excised  for  tuberculous  disease,  osteo-arthritis,  or  deformity 
due  to  osseous  or  fibrous  ankylosis  in  a  bad  position.  A  horseshoe-shaped 
incision  is  made,  extending  from  the  back  of  one  condyle  to  the  other,  reaching 
downwards  nearly  as  far  as  the  tubercle  of  the  tibia.  The  limb  is  well  flexed,  the 
ligamentum  patella?  divided,  and  the  joint  opened.  The  skin  and  subcutaneous 
tissues  are  then  separated  from  the  anterior  surface  of  the  patella,  which  may 
be  at  once  removed  by  a  curved  incision  above  it,  communicating  on  either 
side  with  that  already  made  below.  The  flexion  is  now  increased,  and  the 
lateral  ligaments  divided  ;  by  this  means  the  interior  of  the  joint  is  freely 
exposed,  so  that  the  attachments  of  the  crucial  ligaments  to  the  tibia  can  also 
be  severed.  The  lower  end  of  the  femur  is  then  cleared  of  diseased  synovial 
membrane,  so  as  to  allow  of  the  application  of  a  broad  excision  saw.  The 
usual  rule  given  as  to  the  direction  of  the  saw-cut  in  the  bone  is  that  the 
exposed  bony  surface  left  after  removing  its  articular  end  should  be  absolutely 
horizontal,  supposing  the  patient  to  be  standing  upright ;  personally,  we 
prefer  to  make  the  sections  so  that  the  limb  shall  be  left  very  slightly  flexed 
and  in-kneed,  a  position  which  greatly  adds  to  the  subsequent  comfort  of  the 
patient.  To  accomplish  this,  the  saw  must  be  applied  parallel  to  the  articular 
surface,  i.e.,  at  right  angles  to  the  axis  of  the  body,  not  of  the  femur,  and  with 
a  slight  upward  slant  from  before  backwards.  The  bone  should  be  partially 
sawn  through  by  a  side-to-side  movement,  but  the  posterior  surface  of  the 
condyles  should  be  divided  by  raising  or  depressing  the  handle  of  the 
instrument,  so  that  the  structures  lying  behind  in  the  intercondyloid  notch  are 
not  encroached  upon.  Sufficient  bone  should  be  sawn  off  in  the  adult  to 
include  the  greater  part  of  the  articular  cartilage,  but  as  little  as  possible  con- 
sistent with  removing  all  the  disease,  otherwise  the  limb  is  shortened  to  such 
an  extent  as  to  interfere  with  its  subsequent  usefulness.  The  head  of  the  tibia 
is  then  protruded,  and  cleared  from  the  neighbouring  soft  parts;  it  is  held 
absolutely  vertical,  and  a  saw  applied  in  a  horizontal  position,  the  bone  being 
divided  from  before  backwards.  Any  diseased  synovial  membrane  is  now 
dissected  away,  special  attention  being  directed  to  the  subcrureal  pouch.  All 
bleeding-points  having  been  secured  by  ligature,  the  bones  are  fitted  together, 
and,  if  considered  advisable,  secured  in  position  by  thick  silver  wire,  or  silver- 
plated  nails  or  screws.  The  external  incision  is  closed,  drainage-tubes  being 
inserted  at  each  angle  of  the  wound.  A  Gooch's  splint  is  applied  to  the  limb, 
and  in  this  it  remains  until  sound  healing  has  occurred,  after  which  an  im- 
moveable case  either  of  plaster  of  Paris  or  water-glass  is  kept  on  until  eight  or 
ten  weeks  have  elapsed  since  the  operation. 

The  Ankle-joint  is  excised  for  tuberculous  disease.  Two  incisions  are  made, 
an  inner  and  an  outer.  The  outer  incision  runs  along  the  anterior  border  of  the 
fibula  and  curves  round  the  outer  malleolus,  being  about  3  inches  in  length. 
The  lower  end  of  the  fibula  is  exposed,  and  by  preference  subperiosteally. 
The  external  lateral  ligament  is  split  vertically,  and  separated  from  its  attach- 
ments to  the  fibula,  its  continuity  with  the  periosteum  being,  however,  main- 
tained. The  fibula  is  then  divided  about  1  inch  above  the  tip  of  the  malleolus, 
and  the  latter  process  of  bone  removed.  The  periosteum  and  ligaments  are 
separated  as  far  as  possible  from  the  front  and  back  of  the  bones.  The 
inner  incision  is  T-shaped,  and  is  made  along  the  inner  surface  of  the  tibia, 
with  a  short  transverse  cut  at  its  lower  end,  which  reaches  just  below  the 
inner  malleolus.  The  periosteum  and  internal  lateral  ligament  are  dealt  with 
as  on  the  outer  side,  and  the  front  and  back  of  the  tibia  are  easily  denuded. 
The  inner  malleolus  is  projected  from  the  wound,  and  the  lower  end  of  the 
tibia  removed  by  a  keyhole  saw,  the  dorsal  structures  being  held  aside  by  a 
retractor.  The  articular  surface  of  the  astragalus  is  sawn  off  from  the  outer 
wound,  or,  if  advisable,  the  whole  of  the  bone  may  be  removed. 

The  above  subperiosteal  method  of  excision  is  one  of  the  best  that  have 
been  suggested.     The  greatest  care  should  be  taken  not  to  open  the  sheaths  of 


DISEASES  OF  JOINTS  627 


the  tendons,  and  in  dressing  the  wound  the  foot  must  be  kept  at  right  angles 
to  the  leg,  and  no  lateral  deviation  permitted.  As  soon  as  possible  it  is 
encased  in  plaster  of  Paris,  windows  being  left  for  the  dressing  of  the  wounds, 
if  necessary. 

In  non-tuberculous  cases  a  transverse  incision  extending  from  one  malleolus 
to  the  other  may  be  employed.  Sutures  are  placed  through  the  tendons  above 
and  below,  and  they  are  then  divided  ;  the  anterior  tibial  nerve  is  similarly 
secured  above  and  below  before  division,  and  the  vessels  are  divided  between 
ligatures.  By  opening  the  capsule  a  very  free  exposure  of  the  joint  surfaces 
is  provided,  permitting  a  very  thorough  excision.  The  tendons  and  nerve  are 
carefully  sutured  together  before  closing  the  wound. 

Excision  of  the  Astragalus  is  sometimes  required  in  the  treatment  of  tuber- 
culous disease  of  contiguous  joints,  as  also  in  some  cases  of  talipes  and  of 
fractures  or  dislocations  of  the  bone.  Many  methods  of  operating  have  been 
described,  but  we  think  it  is  best  accomplished  through  a  single  vertical 
incision  over  the  front  of  the  ankle,  running  parallel  to  the  vessels  and  tendons, 
which  are  carefully  avoided  and  stripped  back  from  the  dorsum  by  means  of 
periosteal  detachers,  so  that  the  upper  surface  of  the  astragalus  can  readily  be 
reached.  The  astragalo-scaphoid  and  ankle-joint  are  then  freely  opened,  and 
the  ligamentous  and  fascial  connections  on  either  side  severed.  The  neck  of 
the  bone  may  with  advantage  be  divided  at  this  stage,  and  its  head  removed, 
so  as  to  give  access  to  the  under  surface  and  allow  of  the  division  of  the  strong 
interosseous  ligament  extending  between  the  adjacent  surfaces  of  the  astragalus 
and  os  calcis.  It  may  be  possible  to  remove  the  rest  of  the  bone  in  one  frag- 
ment, but  it  is  certainly  wiser  to  break  it  up  with  chisel  or  gouge,  and  take  it 
away  piecemeal. 


40- 


CHAPTER  XXI. 

INJURIES  OF  THE  SPINE. 

The  spinal  cord  is  protected  from  injury  in  a  most  complete  and 
efficacious  manner,  (a)  Its  position  between  the  bodies  and  the 
laminae  with  the  spinous  processes  arising  therefrom  is  itself 
mechanically  advantageous,  since,  whether  the  spine  is  forcibly 
flexed  or  extended,  the  cord  remains  midway  between  the  points 
of  chief  compression  or  extension,  and  hence  in  a  position  of  rest. 
(b)  The  buffer-like  action  of  the  intervertebral  discs,  and  the 
varying  curves  of  the  column,  serve  to  distribute  some  part  of 
any  force  that  reaches  it.  (c)  There  is  ample  space  in  the 
medullary  canal,  in  which  the  cord  with  its  membranes  is  slung 
by  prolongations  of  dura  mater  around  the  issuing  nerves,  whilst 
the  cord  itself  hangs  loosely  within  the  dura  mater,  suspended  by 
the  ligamenta  denticulata,  and  surrounded  by  cerebro-spinal  fluid. 
(d)  The  cord  terminates,  in  an  adult,  at  the  lower  border  of  the 
first  lumbar  vertebra,  a  spot  well  above  the  junction  of  the  fixed 
base  and  the  moveable  upper  part,  a  point  where  the  effect  of  jars 
and  wrenches  is  mainly  felt,  (e)  Nature  has,  moreover,  intro- 
duced a  whole  series  of  buffers  and  other  means  of  preventing 
shock  to  the  spine  when  a  person  falls  on  his  feet,  e.g.,  the  arches 
and  elasticity  of  the  foot,  the  changes  in  direction  of  the  bones  at 
each  joint,  the  interarticular  cartilages  of  the  knee,  etc. 

The  parts  of  the  spine  most  exposed  to  injury  are  those  where 
a  fixed  and  moveable  portion  meet,  e.g.,  the  dorsi-lumbar  and  the 
cervico-dorsal  regions.  The  upper  part  of  the  dorsal  curve,  which 
is  relatively  weak  and  projects  backwards,  is  thereby  exposed  to 
injury,  so  that  fractures  are  not  at  all  uncommon  about  the  fourth 
dorsal  vertebra.  The  close  proximity  of  the  head  explains  the 
frequency  of  lesions  about  the  upper  cervical  region. 

Sprains. 

Sprains  and  strains  of  the  spine  are  very  common  accidents,  a 
fact  not  to  be  wondered  at,   when  we  consider  the  complicated 


INJURIES  OF  THE  SPINE  629 

muscular  and  ligamentous  arrangements  present.  They  are 
produced  by  any  sudden  or  unexpected  movements,  such  as  falls, 
especially  from  horseback,  railway  accidents,  and  the  like.  The 
injury  is  most  likely  to  affect  mobile  parts  of  the  spine,  e.g.,  the 
cervical  and  lumbar  regions,  and  may  be  limited  to  the  liga- 
mentous or  muscular  structures,  or  may  involve  both.  The 
resulting  Signs  are  simply  those  of  a  severe  but  localized  trauma, 
viz.,  pain,  tenderness,  bruising,  and  perhaps  a  little  swelling ;  the 
subjective  phenomena  are  much  increased  by  movement,  so  that 
the  spine  is  always  kept  rigidly  quiet.  If  only  the  muscles  or 
interspinous  ligaments  are  involved,  no  further  consequences 
are  likely  to  arise  ;  but  when  the  ligamenta  subfiava  are  lacerated 
and  the  spinal  canal  is  thus  opened,  the  gravest  symptoms  may 
ensue  from  blood  finding  its  way  into  the  canal  outside  the  dura 
mater,  leading  possibly  to  paraplegia,  which  may  be  of  a  tempo- 
rary or  permanent  nature.  Inflammation  of  the  damaged  fibrous 
tissues  may  also  extend  to  the  meninges  and  cord,  and  cause 
compression  of  the  latter  or  even  organic  disease.  Moreover,  in 
patients  of  a  tuberculous  temperament,  spinal  caries  may  be  set 
up  as  a  result  of  such  injuries,  whilst  syphilitic  or  malignant 
disease  has  also  been  known  to  follow. 

In  the  cervical  region,  sprains  are  very  liable  to  occur  as  a  result 
of  severe  blows  on  the  head,  causing  rupture  of  the  inter-transverse 
ligaments,  and  the  displacement  may  be  so  great  as  to  simulate 
dislocation.  The  head  and  neck  are  held  immoveable  and  rigid, 
and  there  is  often  considerable  loss  of  power,  the  patient  being 
sometimes  unable  to  lift  the  head  spontaneously  from  the  pillow. 
Sprains  in  the  lumbar  region  are  very  common,  both  as  a  result 
of  railway  injuries,  when  they  are  often  associated  with  nervous 
symptoms  (p.  640),  and  as  a  consequence  of  overlifting,  when  the 
quadratus  lumborum  is  most  likely  to  be  affected.  The  back  is 
kept  fixed  and  rigid,  the  patient  being  unable  to  turn  or  stoop 
without  pain.  Sometimes  hematuria  results  from  injuries  in  the 
lumbar  region,  arising  from  an  associated  contusion  of  the  kidneys. 

Treatment. — The  patient  should  be  kept  at  rest,  and  fomenta- 
tions applied  to  the  injured  part.  When  the  painful  or  inflam- 
matory symptoms  have  disappeared,  massage  with  stimulating 
liniments  is  needed.  In  the  severer  cases  the  individual  should  be 
kept  in  bed  for  six  or  eight  weeks,  and  in  the  cervical  region  some 
form  of  mechanical  support  may  be  subsequently  necessary.  The 
appearance  of  inflammatory  symptoms  involving  the  meninges 
calls  for  greater  care  ;  the  patient  should  then  be  kept  as  much  as 
possible  in  the  prone  position,  and  a  spinal  icebag  applied.  The 
onset  of  paraplegia,  due  either  to  haemorrhage  or  inflammatory 
exudation,  would  raise  the  question  of  laminectomy  (p.  644). 


6.30  A   MANUAL  OF  SURGERY 


Penetrating  Wounds  of  the  Spine. 

These  lesions  are,  fortunately,  uncommon  in  civil  practice, 
being  generally  due  to  stabs  with  pointed  instruments,  such  as 
bayonets,  or  to  gunshot  wounds.  They  occasionally  result  from 
falls,  the  unfortunate  individual  becoming  impaled  on  area 
railings,    branches   of  trees,  etc.      The  Symptoms   produced  are 

(a)  those  due  to  the  wound  in  the  soft  parts,  which  may  also 
involve  the  peritoneal  and  pleural  cavities,  or  damage  some  of 
the  viscera  ;  in  the  neck,  the  vertebral  artery  is  exposed  to  injury 
from    this   type   of    accident,    leading    to   serious    haemorrhage ; 

(b)  various  forms  of  fracture,  the  cord  being  compressed  by 
fragments  of  bone  which  have  been  driven  inwards,  or  by 
extravasated  blood  ;  (c)  those  due  to  laying  open  the  spinal  mem- 
branes, e.g.,  loss  of  cerebro-spinal  fluid,  which  in  itself  might 
prove  fatal  by  draining  the  cerebral  cavity,  and  so  causing  pressure 
on  the  base  of  the  brain,  or  at  a  later  date  may  determine  the 
patient's  death  by  setting  up  diffuse  septic  meningitis  (p.  638) ; 
and  (d)  those  due  to  wounds  of  the  spinal  cord.  The  effects  of  a 
total  transverse  lesion  at  different  levels  of  the  spine  are  given  at 
p.  643  ;  even  if  the  patient  escapes  the  dangers  of  diffuse  septic 
meningitis,  he  will  later  on  develop  acute  myelitis.  Of  course, 
the  division  of  the  cord  may  be  only  partial,  or  it  may  escape 
entirely,  whilst  nerve  roots  or  trunks  may  be  involved,  and  in  the 
lumbar  or  sacral  regions  the  cauda  equina  may  be  divided. 

Treatment  consists  in  thoroughly  exploring  the  wound  under 
an  anaesthetic,  removing  foreign  bodies  or  displaced  fragments  of 
bone,  and  attempting  to  render  it  aseptic.  Wounds  of  the  vertebral 
artery  or  other  structures  are  dealt  with  secundum  artem,  and  special 
attention  is  naturally  given  to  the  cord  and  its  membranes.  Should 
the  dura  mater  have  been  opened,  and  the  cord  have  escaped 
injury,  an  attempt  may  be  made  to  close  the  wound  in  the 
meninges,  and  the  patient  should  subsequently  be  kept  in  the 
prone  position  and  with  the  head  low,  so  as  to  prevent,  as  far  as 
possible,  the  escape  of  cerebro-spinal  fluid.  If  the  cord  itself  is 
divided  or  lacerated,  it  is  useless  trying  to  unite  it,  since  its  function 
in  conducting  impulses  from  the  brain  downwards  is  inevitably 
destroyed.  Where,  however,  the  cauda  equina  has  been  injured, 
it  is  perfectly  justifiable  to  lay  open  the  spinal  canal  to  a  sufficient 
extent  to  expose  the  divided  nerve  trunks,  and  then  to  suture  them. 

Fractures  of  the  Spine. 

Causes. — The  spine  may  be  broken  as  the  result  of  (a)  direct 
violence,  e.g.,  a  fall  on  the  back  over  some  projecting  body, 
such  as  a  carpenter's  bench  or  a  railing,  or  a  blow  on  the  back 
with  a  heavy  stone  or  with  a  swinging  baulk  of  wood,  or  a  gun- 
shot wound.  This  type  of  accident  may  involve  any  part  of  the 
spine,  and,  excluding  those  arising  from  gunshot,  is  less  frequent 


INJURIES  OF  THE  SPINE  631 


than  the  class  next  to  be  described.  Of  necessity,  the  spine  breaks 
at  the  point  struck ;  the  posterior  parts  of  the  vertebra?  are  most 
likely  to  be  damaged  in  this  form  of  injury,  (b)  Fractures  are 
also  due  to  indirect  violence,  then  usually  occurring  in  the  lower 
cervical  or  upper  dorsal  regions.  They  are  caused  by  forcible 
flexion  of  the  spine,  as  by  a  fall  downstairs  with  the  head  doubled 
up,  or  by  taking  a  '  header  '  into  shallow  water,  or  when  a  man, 
being  driven  under  a  bridge,  omits  to  stoop,  and  so  is  caught 
between  the  arch  and  the  cart,  or  sometimes  by  the  fall  of  a  heavy 
weight  on  the  back  of  the  neck,  the  spine  bending  and  breaking 
at  the  weakest  spot. 

Fractures  of  the  spine  may  be  divided  into  two  main  classes, 
according  to  whether  or  not  they  are  complete — that  is,  according 
to  whether  the  continuity  of  the  column  is  destroyed  or  not. 

(A)  Incomplete  Fractures  may  be  met  with  in  various  forms, 
and  are  most  frequently  due  to  direct  violence. 

(i.)  Fractures  of  the  Spinous  Processes  rarely  occur  except  in  the 
lower  cervical  or  dorsal  regions.  In  the  upper  cervical  region  the 
spines  are  short  and  retracted  to  allow  of  extension  of  the  head, 
whilst  in  the  lumbar  they  are  also  short,  but  very  strong.  The 
fracture  is  almost  always  due  to  direct  violence,  and  is  charac- 
terized by  the  signs  of  a  local  trauma,  together  with  great 
mobility,  perhaps  crepitus,  and  irregularity  in  the  line  of  the 
spines.  The  process  is  occasionally  much  depressed,  and  may 
even  cause  paraplegia  by  being  driven  into  the  spinal  canal. 

(ii.)  Fracture  of  the  Lamina  is  a  not  uncommon  accident,  always 
resulting  from  direct  violence.  If  only  one  lamina  is  broken,  the 
signs  are  not  very  distinct,  and  cord  symptoms  are  rare.  When 
both  laminae  yield,  the  posterior  part  of  the  neural  arch,  carrying 
with  it  the  spinous  process,  is  very  likely  to  be  depressed  to  a 
sufficient  extent  to  compress  the  cord  and  give  rise  to  paraplegia. 
Crepitus  is  often  obtainable,  and  a  gap  in  the  line  of  the  spinous 
processes  can  usually  be  felt. 

(iii.)  Fracture  of  the  Transverse  Processes  is  but  rarely  met  with 
apart  from  other  lesions  of  the  spine. . 

(iv.)  Partial  Fracture  through  the  bodies  may  occur  in  the  form 
of  fissures,  which  produce  but  little  effect,  except  pain  and 
rigidity,  and  cannot  be  diagnosed  with  certainty. 

Even  in  fractures  where  displacement  is  not  present,  paraplegic 
symptoms  may  arise,  either  immediately  from  concussion  of  the 
spinal  cord,  or  later  on  from  the  pressure  of  haemorrhagic  or 
inflammatory  effusions. 

The  Treatment  merely  consists  in  keeping  the  patient  at  rest 
for  a  time.  The  question  of  laminectomy  for  paraplegia,  due 
either  to  displacement  of  the  laminae  or  to  haemorrhage,  will  be 
discussed  later  (p.  644). 

(B)  Complete  Fractures  are  usually  associated  with  displace- 
ment,  and    loss   of  continuity  of  the   spinal   column,   and   hence 


632 


A   MANUAL  OF  SURGERY 


are  often  termed  Fracture-Dislocations.  They  result  either  from 
direct  or  indirect  violence.  There  is  always  a  tolerably  extensive 
lesion  (Fig.  232) ;  thus,  the  spinous  processes  and  laminae  may  or 
may  not  be  fractured,  the  ligamenta  interspinosa,  snpraspinosa, 
and  subnava  torn,  the  articular  processes  fractured  in  the  lumbar 
and  dorsal  regions,  or  displaced  without  fracture  in  the  cervical, 
and  either  the  intervertebral  substance  torn  across,  or  the  bodies 

broken,  thus  severing 
the  spine  into  two 
halves.  The  upper  or 
moveable  portion  is 
usually  driven  forwards 
over  the  lower  or  more 
fixed  fragment,  and  im- 
paction or  comminution 
is  often  present.  The 
spinal  cord  is  com- 
pressed between  the 
upper  end  of  the  lower 
fragment  and  the  la- 
minae of  the  upper 
fragment,  and  although 
the  displacement  may 
be  naturally  remedied 
by  the  falling  back  of 
the  bones  into  position 
('  recoil '),  yet  the  effects 
of  the  crush  on  the  cord 
are  usually  irremedi- 
able. In  slighter  cases 
the  spinal  membranes 
may  be  merely  punctured  by  a  splinter  of  bone,  or  haemorrhage 
may  occur  either  within  the  membranes,  or  outside  them  in  the 
fatty  theca  vertebralis.  Excessive  indirect  violence  may  lead  to 
an  associated  fracture  of  the  sternum. 

The  Signs  of  a  complete  fracture  are  usually  very  evident,  con- 
sisting of  local  pain,  swelling,  and  bruising,  and  a  certain  amount 
of  angular  deformity,  more  or  less  according  to  circumstances.  It 
may  be  possible  to  elicit  crepitus,  if  the  parts  are  not  impacted, 
but  all  unnecessary  movement  should  be  avoided  for  fear  of 
adding  to  the  injury  of  the  cord.  Paraplegia  below  the  part 
injured  is  present  in  most  cases,  and  with  it  some  amount  of 
general  shock.  When  the  cord  is  disintegrated  or  divided, 
symptoms  of  spinal  myelitis  rapidly  follow,  and  a  fatal  issue 
often  occurs  at  an  early  date  from  toxaemia  following  septic 
cystitis  or  sloughing  of  the  nates.  The  special  phenomena  of 
paraplegia  are  dealt  with  at  p.  641. 

The  Prognosis  of  these  cases  turns  largely  on  the  situation  of 


Fig.  232. — Complete  Fracture -Dislocation 
of  the  Spine  in  the  Lower  Dorsal  Region 
with  Displacement,  and  Compression  of 
the  Cord.     (After  Keen  and  White.) 


INJURIES  OF  THE  SPINE  633 


the  injury  and  the  amount  of  mischief  sustained  by  the  cord. 
The  higher  the  lesion,  the  greater  the  danger,  although  patients 
with  paraplegia  from  cervical  fracture  may  live  for  years,  and  even 
partially  recover,  if  the  cord  has  not  been  totally  disintegrated. 

The  Treatment  naturally  varies  with  the  character  of  the  case. 
The  patient  is  carefully  placed  on  a  prepared  bed,  the  greatest 
gentleness  being  used  in  handling  and  lifting  him,  for  fear  of 
increasing  the  damage  to  the  cord.  The  bed  must  be  firm,  though 
not  hard  ;  perhaps  the  best  type  to  employ  is  a  horsehair  mattress 
placed  over  fracture-boards ;  nothing  more  soft  or  yielding  is  per- 
missible. Spring  beds  and  wire-wove  mattresses  are  most  undesir- 
able. A  water-bed  is  required  in  the  later  stages,  but  should  not 
be  used  at  first,  as  it  is  scarcely  firm  enough.  The  shock  resulting 
from  the  accident  is  treated  in  the  usual  way  by  warmth  and,  if 
need  be,  by  stimulants;  but  it  must  be  remembered  that  anaesthetic 
regions  of  the  body  can  be  easily  blistered  or  burnt  by  hot-water 
bottles,  unless  carefully  guarded  by  flannels.  When  reaction  has 
occurred,  a  more  thorough  examination  of  the  patient  can  be 
made,  and  the  subsequent  course  of  action  decided  on. 

(a)  In  a  small  minority  of  the  cases  operative  treatment  is  justifiable. 
We  shall  discuss  later  on  (p.  644)  the  indications  for  laminectomy. 

(b)  When  the  displacement  persists  owing  to  impaction  of  the 
fragments,  reduction  under  an  anaesthetic  may  possibly  be  under- 
taken, provided  that  the  lesion  is  not  in  the  cervical  region,  and 
the  paraplegia  not  complete.  Of  course,  if  other  internal  injuries 
are  present  which  render  the  case  hopeless,  nothing  should  be 
done.  Great  care  must  be  used  in  attempting  reduction,  since 
the  object  is  to  relieve  pressure  on  the  cord,  and  any  undue 
violence  may  readily  increase  the  mischief;  in  the  lumbar  region, 
however,  considerable  force  may  be  employed  without  much 
danger.  Whether  reduction  is  accomplished  or  not,  the  further 
treatment  must  be  directed  in  accordance  with  the  indications 
given  in  the  next  paragraph.  Where  the  surgeon  fails  to  reduce 
the  deformity,  it  may  sometimes  be  advisable  to  make  gradual 
extension  from  the  feet  or  neck  by  the  use  of  weight  and  pulley. 

(c)  In  many  cases,  as  soon  as  the  patient  is  laid  flat  on  a  bed, 
the  displacement  remedies  itself,  especially  if  the  spine  has  been 
comminuted,  and  then  the  treatment  must  be  symptomatic,  as  also 
after  reduction  or  operation,  where  the  paraplegia  persists  or  is 
only  slowly  recovered  from.  He  is  kept  in  bed,  absolutely  flat, 
and  with  the  head  low ;  perhaps  some  form  of  mechanical  sup- 
port, e.g.,  a  plaster  of  Paris  or  leather  jacket,  may  be  considered 
advisable ;  but  its  application  is  always  a  matter  of  difficulty, 
and  in  the  early  stages  it  does  but  little  good.  Food  is  regularly 
administered,  and  at  first  must  be  light  and  readily  assimilable. 

The  chief  care  of  the  attendants  must  be  directed  to  the  skin, 
bladder,  and  bowels.  Bedsores  are  extremely  liable  to  form  on  all 
points  of  pressure,  and  hence  the  nates  and  heels  must  be  care- 


634  A   MANUAL  OF  SURGERY 

fully  guarded  (p.  80).  In  turning  the  patient  to  attend  to  the 
nates,  the  body  must  be  rolled  over  as  a  whole,  and  not  merely 
the  pelvis  twisted.  It  will  often  be  found  advisable  to  have  a 
divided  mattress  placed  beneath  the  pelvis,  so  that  one  lateral 
segment  may  be  removed  at  a  time,  and  thus  rotation  of  the 
body  will  not  be  needed.  A  bedpan  can  also  be  used  in  this  way 
without  disturbing  the  spine.  When  the  bladder  is  paralyzed,  the 
urine  must  be  withdrawn  by  a  catheter.  One  of  the  greatest 
dangers  that  the  patient  runs  is  from  the  supervention  of  septic 
cystitis,  and  the  extension  of  the  inflammation  upwards  to  the 
kidneys.  This  is  always  due  to  infection  from  without,  and  the 
greatest  care  must  be  taken  to  prevent  it.  The  penis  should  be 
thoroughly  purified,  and  the  urethra  well  flushed  out  before 
passing  an  instrument  in  these  cases  ;  in  the  intervals  between 
instrumentation  the  penis  is  wrapped  in  a  dry  antiseptic  or  sterilized 
dressing.  Only  soft  rubber  catheters  are  employed,  and  these 
must  be  kept  absolutely  aseptic  by  immersion  in  5  per  cent, 
carbolic  lotion,  or  1-1000  sublimate,  which  is  subsequently  re- 
moved before  use  by  washing  with  a  solution  of  boric  acid. 
Should  sepsis  occur,  the  bladder  is  irrigated  twice  daily  with 
some  mild  antiseptic,  such  as  Condy's  fluid,  boric  acid,  boro- 
glyceride  (1  in  20),  or  sanitas  (1  in  20),  whilst  urotropine,  salol  or 
boric  acid  in  10  grain  doses  may  be  administered  by  the  mouth 
thrice  daily.  Probably,  in  spite  of  all  precautions,  the  condition 
will  persist,  and  prove  fatal  from  extension  to  the  kidneys.  The 
bowels  are  always  obstinately  constipated,  and  must  be  opened 
either  by  purgatives  or  simple  enemata. 

Under  such  a  regime  the  patient  may  gradually  recover,  but 
more  often  succumbs  to  septic  poisoning  or  exhaustion.  Occa- 
sionally he  may  live  for  a  long  time,  although  paralyzed,  possibly 
developing  some  amount  of  reflex  micturition,  if  the  lumbar 
centres  are  not  involved.  Varying  degress  of  restoration  of 
power  in  the  lower  limbs  are  also  met  with. 

Dislocations  of  the  Spine. 

By  dislocation  of  the  spine  is  meant  a  displacement  forwards, 
either  partial  or  complete,  of  the  upper  part  of  the  spine,  with 
separation  of  the  articular  processes,  and  tearing  of  the  inter- 
vertebral substance.  A  pure  dislocation  can  only  occur  in  the 
cervical  region,  and  even  then  it  is  not  uncommonly  associated 
with  a  fracture.  The  reason  for  this  depends  partly  on  the 
immobility  of  the  dorsal  and  lumbar  vertebrae  in  the  latter  regions, 
and  partly  on  the  direction  of  their  articular  processes.  In  the 
cervical  region  these  look  mainly  upwards  and  downwards,  with  a 
slight  slope  forwards  and  backwards,  so  that  it  is  not  difficult  for 
one  to  slip  over  the  other ;  in  the  dorsal  region  they  are  placed 
nearly  vertical,  looking  forwards  and  backwards,  whilst  in  the 
lumbar  they  are  also  vertical,  but  look  inwards  and  outwards,  the 


INJURIES  OF  THE  SPINE  635 

lower  enclosing  the  upper  as  in  a  sheath,  so  that  in  the  last  two 
regions  of  the  spine  dislocation  is  impossible  without  concurrent 
fracture  of  the  articular  processes  and  probably  of  the  lamina?. 

Any  part  of  the  cervical  region  may  be  the  seat  of  a  dislocation. 
The  occiput  has  been  displaced  from  the  atlas  in  a  few  cases, 
resulting  in  sudden  death  ;  but  if  incomplete,  life  has  been  pro- 
longed for  a  few  hours  or  days.  Dislocation  of  the  atlas  from  the 
axis  has  followed  blows  on  the  neck,  or  has  been  the  cause  of 
death  in  hanging,  whilst  the  attempt  to  lift  a  struggling  child  by 
the  head  has  sometimes  led  to  this  calamity.  In  almost  all  cases 
the  odontoid  process  has  been  fractured  or  the  transverse  liga- 
ment torn,  causing  instant  death  from  compression  of  the  cord, 
owing  to  the  head  and  atlas  slipping  forwards.  Lateral  displace- 
ment from  rotation  has  also  been  observed,  the  cord  symptoms 
then  being  of  a  milder  type. 

Dislocation  may  occur  between  any  two  of  the  lower  five  cervical 
vertebra,  but  perhaps  most  frequently  between  the  fifth  and  sixth. 
It  is  almost  invariably  the  result  of  forcible  flexion  of  the  head 
and  neck,  perhaps  combined  with  rotation,  and  as  a  rule  the 
intervertebral  articulations  are  torn  open,  whilst  the  supraspinous 
and  interspinous  ligaments,  the  ligamenta  subflava,  and  the 
anterior  and  posterior  common  ligaments,  are  lacerated,  and  the 
intervertebral  substance  torn  across,  or  a  scale  of  the  articular 
surface  detached.  The  head  and  upper  portion  of  the  spine  are 
displaced  forwards,  so  that  the  cartilaginous  surfaces  of  the 
articular  processes  of  the  lower  vertebra  project  behind  the 
lamina?  and  transverse  processes  of  the  upper,  and  the  lower 
articular  processes  of  the  upper  vertebra  lie  within  the  inter- 
vertebral notch  of  the  lower  bone  (Fig.  233,  A  and  B,  a).  Two 
forms  of  dislocation  are  met  wTith — the  unilateral  and  bilateral. 

(a)  Unilateral  Dislocations  of  the  cervical  spine  is  due  to  force 
applied  from  the  back  and  side  of  the  neck.  The  head  is  turned 
towards  the  opposite  side,  and  more  or  less  fixed,  whilst  there  is 
no  evidence  of  compression  of  the  cord,  although  a  tingling  and 
neuralgic  pain  along  the  course  of  the  nerves  may  arise  from 
pressure  upon  and  stretching  of  the  nerve  trunks  in  the  inter- 
vertebral notch.  The  spinous  processes  may  be  irregular  and 
displaced  laterally,  whilst  the  line  of  the  transverse  processes  is 
similarly  altered  ;  such  signs  are,  however,  very  difficult  to  make 
out  in  thick  necks.  If  left  unreduced,  the  vertebra  becomes  fixed 
in  its  new  position,  the  head  and  neck  displaced,  and  permanent 
neuralgia  may  result.  In  such  cases,  if  seen  early,  replacement 
may  be  attempted.  The  patient  is  anaesthetized,  the  body  fixed, 
the  head  and  neck  flexed,  and  traction  made  in  that  position,  so 
as  to  unlock  the  edges  of  the  articular  processes.  Reduction  may 
be  accomplished  with  a  definite  snap  or  catch.  In  old-standing 
cases  an  operation  may  sometimes  be  attempted  to  relieve  pressure 
on  the  nerves,  but  it  is  impossible  to  replace  the  bones. 


636 


A   MANUAL  OF  SURGERY 


(b)  Bilateral  Dislocation  (Fig.  233,  A  and  B),  if  complete,  is 
always  accompanied  with  pressure  upon  the  cord  and  paraplegia ; 
occasionally,  however,  it  is  only  partial,  and  then  the  cord  may 
escape  without  immediate  injury,  owing  to  the  large  size  of  the 
canal  in  this  region  ;  haemorrhage  and  inflammation  may  subse- 
quently cause  grave  symptoms.  Treatment  is  of  but  little  avail  in 
most  of  the  cases  of  complete  double  dislocation,  since  probably 
the  cord  is  irretrievably  damaged ;  but  where  paraplegia  is  incom- 


Fig.  233. — Dislocation  of  the  Cervical  Spine.  (After  Keen  and  White.) 
A,  As  seen  from  in  front ;   B,  side-view  ;  aa  indicate  the  lower  articular  facets 

of  the  upper  or  displaced  vertebra,  which  are  thus  seen  to  lie  in  front  of 

the  upper  articular  processes  of  the  lower  vertebra. 

plete  it  is  possible  that  benefit  may  arise  from  early  interference. 
Replacement  by  traction  on  the  head  with  the  neck  flexed  may 
be  first  carefully  tried,  and  failing  that  laminectomy  should  be 
performed.  After  stripping  the  muscles  from  the  bones,  the 
surgeon  will  see  the  two  cartilage-covered  surfaces  of  the  upper 
articular  processes  of  the  lower  vertebra  standing  out  clearly 
behind  the  laminae  of  the  displaced  bone.  Upward  traction  on  the 
head  may  now  again  be  made,  and  reduction  thus  attempted ;  but 
if  this  does  not  succeed,  as  small  a  portion  as  possible  of  the  upper 
margins  of  the  exposed  articular  processes  is  excised  in  order  to 


INyURIES  OF  THE  SPINE  637 


allow  of  the  unlocking  of  the  bones  ;  if  the  whole  processes  are 
removed,  reduction  is  much  easier,  but  Nature's  barrier  to  prevent 
a  recurrence  of  the  trouble  has  been  taken  away,  and  fixation 
of  the  spinal  column  in  its  natural  position  becomes  impossible. 
The  sudden  relief  of  pressure  not  uncommonly  causes  such  an 
interference  with  the  intravascular  tension  in  the  cervical  cord 
as  to  lead  to  a  temporary  cessation  of  the  breathing,  for  which 
artificial  respiration  is  required.  It  is  usually  advisable  not  only 
to  replace  the  bones,  but  also  to  open  the  spinal  canal  and  mem- 
branes, so  as  to  remove  any  pressure  of  blood  or  inflammatory 
exudation  which  may  exist.  The  results  of  such  operations  are 
not  particularly  satisfactory. 

Secondary  Effects  following  Spinal  Injuries. 

Injuries  of  the  spinal  column  are  frequently  associated  with,  or  followed 
by,  conditions  affecting  the  cord  and  its  membranes  which  may  lead  to  the 
gravest  results,  even  when  the  local  lesion  to  the  spine  has  been  comparatively 
slight.  These  are  frequently  combined  with  one  another  in  the  most  puzzling 
fashion,  so  that  it  is  often  difficult  to  state  the  exact  nature  of  a  certain  group 
of  symptoms  ;  for  simplicity's  sake  we  shall  discuss  them  here  without  attempt- 
ing to  describe  the  various  combinations  which  may  present  themselves. 

The  following  secondary  effects  may  be  met  with  after  spinal  injuries : 
(a)  Direct  spinal  concussion  ;  (b)  spinal  haemorrhage  ;  (c)  spinal  meningitis ; 
(d)  spinal  myelitis;  and  (e)  spinal  neurasthenia  (or  railway  spine). 

Direct  Concussion. — This  condition  may  be  due  to  severe  blows  in  the  back, 
which  do  but  little  damage  to  the  spinal  column,  or  may  be  caused  by  accidents 
which  lead  to  the  infliction  of  greater  mischief,  but  without  an)'  serious  dis- 
placement of  parts.  The  term  '  concussion  '  should  be  limited  to  those  cases 
where  energetic  traumatic  influences  (falls,  bloics,  collisions,  etc.)  have  given  rise  to 
severe  disturbance  of  the  functions  of  the  cord  without  any  considerable  visible  anatomical 
changes  in  the  latter  (Erb).  In  fact,  the  term  is  really  only  applicable  to  those 
cases  which  recover  more  or  less  completely ;  if  recovery  does  not  ensue, 
minute  extravasations  or  other  lesions  have  been  present,  constituting  a  con- 
dition of  contusion  rather  than  concussion.  It  is  somewhat  doubtful,  however, 
whether  all  these  cases  are  not  due  to  minute  haemorrhages. 

The  Symptoms  produced  are  those  of  a  more  or  less  complete  and  immediate 
loss  of  function  of  that  portion  of  the  cord  situated  below  the  point  struck. 
Thus,  a  varying  degree  of  paraplegia  is  produced,  the  signs  of  which  differ  with 
the  region  affected  (see  p.  643).  In  addition,  the  patient  is  usually  prostrate 
from  general  shock  to  the  system,  and  the  reflexes  are  often  totally  lost — 
at  any  rate,  for  a  time — as  a  result  of  the  shock  to  the  cord.  Death  may  be 
caused  at  once  by  a  blow  in  the  upper  cervical  region,  or  varying  degrees  of 
loss  of  power  and  sensation  may  be  produced  in  any  or  all  of  the  limbs.  In 
the  lower  cervical  region  the  arms  are  mainly  affected,  and  perhaps  some  par- 
ticular nerve  may  be  picked  out  and  paralyzed.  In  the  lumbar  and  dorsal 
regions  a  more  typical  paraplegia  is  produced,  with  loss  of  power  over  the 
sphincters,  and  loss  of  reflexes.  Priapism  never  occurs  in  simple  concussion. 
The  temperature  of  the  body  may  be  depressed,  and  the  extremities  pallid  and 
cold  ;  the  pulse  is  rapid  and  weak,  and  the  respirations  shallow. 

The  Prognosis  is  always  uncertain,  as  in  cases  where  there  is  no  displace- 
ment it  is  impossible  to  gauge  the  extent  of  the  mischief.  If  merely  con- 
cussion is  present,  the  patient  is  likely  to  recover  ;  if  the  cord  is  contused,  or 
haemorrhage  has  occurred  into  it,  a  perfect  recovery  can  scarcely  be  expected. 

In  the  Treatment  absolute  rest  to  the  spine  is  of  the  greatest  importance,  and 


£38  A   MANUAL  OF  SURGERY 

this  should  be  maintained  if  possible  in  the  prone  position,  so  as  not  only  to 
diminish  static  congestion,  but  also  to  remove  any  pressure  on  the  spine,  and 
to  allow  topical  applications  to  be  made.  A  spinal  icebag  may  be  applied,  or 
the  back  may  be  dry-cupped,  whilst  the  patient  is  kept  absolutely  still,  and  on 
a  low  diet.  The  bladder  and  bowels  need  attention,  but  no  special  drugs  are 
necessary.     Of  course,  local  injuries  require  suitable  treatment. 

Spinal  Haemorrhage. — We  can  here  only  discuss  the  subject  of  spinal  haemor- 
rhage as  resulting  from  injuries.  It  also  occurs  apart  from  traumatism,  and 
it  is  interesting  to  note  that  such  happens  more  frequently  in  young  persons 
between  the  ages  of  ten  and  twenty  than  in  old  people,  as  with  cerebral 
haemorrhage.  The  bleeding  may  take  place  either  into  the  cord  itself,  or  out- 
side it,  and  hence  the  two  following  varieties  are  described  : 

(a)  Intramedullary  Haemorrhage,  or  spinal  apoplexy  (hcematomyelia) ,  is  met 
with  as  a  result  of  injury,  which  need  not  necessarily  involve  the  spinal 
column  ;  the  lower  cervical  region  is  the  part  usually  affected.  Extravasation 
into  the  cord  is  rarely  extensive,  and  may  occur  in  the  form  of  one  clot,  usually 
not  larger  than  an  almond,  or  more  commonly  in  many  spots,  the  gray  matter 
being  more  or  less  ploughed  up.  The  white  matter  is  compressed,  and  some- 
times the  blood  bursts  through  it  into  the  membranes.  Should  the  patient 
survive  the  injury  for  any  length  of  time,  secondary  degenerations  are  estab- 
lished, and  run  the  usual  course.  The  patient  is  suddenly  struck  down  with 
a  more  or  less  complete  paraplegia,  and  with  perhaps  pain  in  the  back,  the 
phenomena  being  very  similar  to  those  of  a  transverse  myelitis.  Some  degree 
of  recovery  follows,  but  the  parts  supplied  from  the  damaged  portion  of  gray 
matter  are  likely  to  remain  paralyzed.  The  Diagnosis  of  haemorrhage  turns 
on  the  rapid  onset  of  paraplegia,  which  may  be  incomplete,  without  spinal 
irritation  ;  fever  may  ensue  for  a  few  days,  and  if  the  cervical  region  is 
affected,  extreme  contraction  of  the  pupil  (myosis)  may  result  from  destruction 
of  the  cilio-spinal  centre.  The  Prognosis  depends  on  the  size  and  situation  of 
the  clot,  a  large  clot  producing  more  injury  than  a  small  one  ;  haemorrhage  in 
the  cervical  region  may  be  immediately  fatal  by  interference  with  the  respira- 
tion, whilst  in  the  lumbar  region  it  is  unfavourable  on  account  of  the  effect 
upon  the  sphincter  centres.  The  outlook  is  best  when  the  dorsal  portion  of 
the  cord  is  affected.  The  Treatment  is  the  same  as  was  indicated  for  direct 
concussion,  whilst  the  administration  of  ergot  may  be  beneficial. 

(b)  Extrameduilary  Haemorrhage  (iiamatoraehis)  is  a  more  frequent  complica- 
tion of  spinal  injuries,  such  as  sprains  or  limited  fractures,  than  the  former. 
The  blood  is  usually  extravasated  between  the  bones  and  the  dura  mater, 
especially  in  the  cervical  region,  but  may  occasionally  be  found  within  the 
dura  having  trickled  down  from  the  upper  part  of  the  column.  The 
symptoms  are,  in  brief,  those  of  spinal  irritation,  e.g.,  pain,  hyperaesthesia, 
spasms,  cramps,  etc.,  rapidly  followed  by  loss  of  power  in  the  muscles 
supplied  from  the  damaged  area,  or  by  '  gravitation  paraplegia'  (Thorburn), 
which  gradually  extends  from  below  upwards,  causing  death  by  asphyxia, 
the  whole  series  of  phenomena  being  afebrile.  In  intramedullary  haemorrhage 
the  symptoms  of  paralysis  are  more  evident,  and  those  of  spinal  irritation  less 
marked.  If  a  diagnosis  can  be  made,  ergotin  may  be  injected,  and  ice 
applied  to  the  spine,  or  even  laminectomy  performed  to  relieve  pressure ; 
later  on,  prolonged  rest  may  cause  the  absorption  of  the  clot,  and  even  total 
restoration  to  health. 

Spinal  Meningitis. — Inflammatory  conditions  of  the  spinal  membranes  may 
spread  downwards  from  the  head,  or  commence  as  a  local  affection.  Two 
forms  are  met  with  resulting  from  injury  : 

(a)  In  Acute  Spinal  Meningitis  the  inflammation  mainly  affects  the  arachnoid 
and  pia  mater  (leptomeningitis).  It  is  usually  generalized  in  distribution,  and 
not  unfrequently  extends  to  the  cerebral  membranes.     It  occasionally  follows 


INJURY  OF  THE  SPINE  639 


simple  injuries,  but  is  always  infective  in  origin,  being  due  to  a  diplococcus 
(?  pneumococcus)  in  subcutaneous  injuries,  or  to  the  ordinary  pyogenic  cocci 
in  open  wounds.  Pathologically ,  it  is  evidenced  by  hyperaemia  and  loss  of 
polish  of  all  the  membranes,  with  an  abundant  exudation ;  later  on,  lymph  or 
even  pus  may  collect,  especially  about  the  posterior  surface  of  the  cord ; 
should  the  patient  live,  organization  of  the  effused  lymph  may  lead  to  ex- 
tensive adhesions.  Clinically,  the  disease  is  usually  ushered  in  by  a  rigor, 
especially  in  the  septic  cases,  and  then  runs  a  marked  pyrexial  course 
The  symptoms  are  :  pain  in  the  back,  deep-seated,  boring,  and  severe,  in- 
creased on  all  movements,  and  often  extending  down  the  limbs  or  around  the 
body  ;  rigidity  of  the  spine  and  limbs,  accompanied  by  painful  cramps  and 
muscular  spasms,  almost  simulating  tetanic  convulsions ;  extreme  hyper- 
aesthesia,  especially  of  the  legs,  and  increased  reflex  excitability;  whilst  rapid 
emaciation  from  pain  and  sleeplessness  is  soon  produced.  If  the  condition 
is  limited  to  the  spine,  it  is  probably  followed  by  signs  of  myelitis,  viz.,  para- 
plegia, together  with  bedsores  and  vesical  troubles,  and  these  may  lead  to  a 
fatal  issue  ;  cases,  however,  are  met  with  which  pass  into  a  chronic  state,  and 
may  more  or  less  recover.  If  the  process  also  involves  the  cerebral  mem- 
branes, as  in  septic  cases,  the  symptoms  of  diffuse  cerebral  meningitis  are  also 
present,  and  the  patient  dies  of  coma.  Treatment  in  the  cases  due  to  a 
penetrating  injury  is  of  no  avail  if  prevention  of  the  disease  by  asepsis  fails. 
In  simple  cases  an  icebag  should  be  applied  to  the  spine,  the  patient  remaining 
in  the  prone  position.  Ergot  and  belladonna  may  be  given  internally,  and 
general  measures  to  allay  inflammation  adopted.  The  bladder  and  rectum 
must  be  attended  to,  and  bromides  and  chloral  administered  to  gain  sleep. 

(b)  Chronic  Meningitis  is  usually  localized,  and  may  occur  either  as  an 
inflammation  of  the  arachnoid  and  pia  mater  (leptomeningitis),  or  be  mainly 
limited  to  the  dura  mater  (pachymeningitis).  It  either  originates  as  a  chronic 
affection,  or  is  the  sequela  of  an  acute  attack,  and  is  more  likely  to  supervene 
in  syphilitic  individuals.  The  membranes  become  hyperaemic  and  thickened, 
and  adhesions  between  the  cord  and  its  membranes  may  occur.  The  extensions 
of  pia  mater  into  the  cord  readily  explain  the  fact  that  a  chronic  sclerosing 
myelitis  is  frequently  associated  with  this  affection.  The  Symptoms  are  those 
of  localized  pain  and  rigidity  in  the  back,  increased  on  all  movements,  and 
accompanied  by  shooting  pains  and  hyperaesthesia,  and  perhaps  muscular 
pains  and  cramps.  The  reflexes  are  usually  exaggerated,  and  vesical  com- 
plications may  follow.  Treatment  consists  in  prolonged  rest,  with  counter- 
irritation  in  the*  form  of  blisters  or  the  button  cautery  applied  to  the  back, 
whilst  mercury  is  administered  internally. 


Spinal  Myelitis. — Inflammation  of  the  spinal  cord  may  follow  injuries  of  the 
spine,  either  as  a  direct  consequence  of  depressed  or  displaced  bone,  or  from 
simple  concussion  or  contusion  with  haemorrhage  ;  it  may  also  be  caused  at  a 
later  date  by  extension  of  inflammation  from  the  meninges,  or  result  from  com- 
pression by  lymph,  pus,  granulation  or  cicatricial  tissue,  or  callus.  It  may  be 
acute  or  chronic.  In  the  former  the  cord  becomes  red  and  softened;  the 
nerve  elements  are  destroyed,  and  finally  replaced  by  cicatricial  tissue  if  the 
patient  live  long  enough.  In  chronic  cases  the  connective  tissue  becomes 
thickened,  and  the  nerve  structures  compressed  and  disintegrated,  whilst  the 
meninges  are  always  adherent  and  thickened. 

Symptoms. — Acute  Myelitis  is  evidenced  by  the  presence  of  pain  in  the  back 
and  along  the  course  of  the  nerves  arising  from  the  inflamed  area,  hyper- 
aesthesia, and  muscular  cramps  in  the  earlier  stages,  soon  followed  by  paralytic 
symptoms,  if  these  are  not  already  present  as  the  result  of  the  injury.  The 
irritative  symptoms  are,  however,  much  less  marked  than  in  acute  meningitis 
The  reflexes  vary  according  to  the  amount  of  destruction  of  the  cord  substance, 
whilst  muscular  atrophy  is  not  especially  rapid,  except  in  those  muscles 
formerly  supplied  from  the  affected  area.     The  sphincters  of  both  bladder  and 


640  A  MANUAL  OF  SURGERY 

rectum  are  paralyzed,  causing  retention  of  urine  and  incontinence  of  faeces; 
the  former  is  almost  invariably  followed  by  septic  cystitis,  especially  when  the 
trophic  centres  in  the  lumbar  enlargement  are  involved.  Bedsores  are  very 
liable  to  be  produced,  and  may  become  very  extensive  and  serious.  Priapism 
and  hyperpyrexia  are  often  present  when  the  cervical  region  is  affected.  The 
fatal  issue  is  usually  due  to  septic  poisoning  from  the  urinary  tract,  or  perhaps 
from  the  bedsores. 

Chronic  Myelitis  gives  rise  to  a  great  variety  of  symptoms,  but  those  most 
marked  are  a  gradually  increasing  motor  weakness,  going  on  to  paralysis, 
together  with  various  sensory  phenomena  ending  in  anaesthesia,  whilst  there  is 
trouble  with  the  bladder  and  rectum. 

The  treatment  of  each  of  these  conditions  is  mainly  symptomatic. 

Spinal,  or  Traumatic,  Neurasthenia  (Syn.  :  Railway  Spine,  Indirect  Concus- 
sion of  the  Spine). — Cases  are  not  uncommonly  met  with  in  which,  although 
there  has  been  no  direct  injury  to  the  spinal  column  or  cord,  and  no  immediate 
symptoms  of  importance,  the  fact  is  manifestly  demonstrated  in  various  ways 
that  considerable  commotion  and  disturbance  have  been  produced  in  the 
nervous  system.  Railway  accidents  are  the  most  common  cause  of  this  con- 
dition, but  it  may  arise  from  any  jar  to  the  spinal  column.  The  reason  why 
railway  accidents  are  so  often  responsible  for  this  state  is  that  the  forces 
employed  are  very  great,  and  the  collision  unexpected,  so  that  the  muscles  and 
ligaments  are  taken  at  a  disadvantage,  being  off  their  guard,  whilst  the  shock, 
terror,  and  mental  disturbance  are  also  important  factors.  Ligamentous  and 
muscular  lesions — i.e.,  sprains  and  strains — are  the  usual  local  phenomena 
produced  by  such  accidents. 

In  the  majority  of  cases  the  symptoms  are  mainly  due  to  excessive  irrit- 
ability and  weakness  of  the  spinal  and  cerebral  centres,  constituting  a  condi- 
tion of  nerve  prostration,  or  Neurasthenia,  and  the  history  will  usually  be  some- 
what of  this  type  :  The  individual  at  the  time  of  the  accident  is  thrown  from 
side  to  side,  or  severely  shaken,  but  does  not  lose  consciousness,  and,  although 
feeling  somewhat  dazed,  is  able  to  alight  without  help,  and  may  even  assist 
others.  He  perhaps  continues  his  journey,  and  goes  to  his  business,  but  finds 
in  the  course  of  a  few  hours  that  his  back  is  painful,  his  head  aching,  and  that 
he  cannot  apply  himself  to  his  work.  He  returns  home  and  goes  to  bed, 
sending  for  his  doctor,  who  will  probably  prescribe  rest  and  bromides.  His 
condition  remains  for  a  time  unaltered  ;  he  complains  of  pain  and  tenderness 
over  certain  regions  of  the  spine,  especially  the  lumbar,  and  is  unable  to 
walk,  or  to  undertake  any  serious  mental  or  physical  effort,  whilst  all  exces- 
sive sensory  stimuli,  such  as  a  bright  light  or  noise,  are  unusually  disturbing. 
Neuralgia  is  often  present,  whilst  the  pulse  is  weak  ;  the  urine  may  be  retained 
or  may  dribble  away,  and  the  temperature  be  for  a  time  subnormal.  Accom- 
modative asthenopia  (or  the  inability  to  accommodate  for  near  objects),  result- 
ing in  a  temporary  condition  of  presbyopia,  is  also  a  marked  feature  in  many 
of  these  cases.  All  the  symptoms  are  aggravated  by  mental  excitement  and 
exertion,  such  as  are  often  produced  by  the  necessary  interviews  with  doctors 
and  solicitors  pending  the  financial  compensation  by  the  railway  company. 
The  immediate  improvement  which  often  follows  the  satisfactory  settlement  of 
his  claim  for  damages  is  not  necessarily  due  to  imposture,  but  may  result  from 
the  removal  of  mental  tension  and  anxiety. 

This  condition  of  neurasthenia  may  develop  immediately  after  the  accident, 
as  an  acute  condition,  the  patient  lying  helpless  and  prostrate,  or  more 
often  chronically,  as  in  the  more  common  type  of  cases  described  above.  To 
it,  however,  is  frequently  added  a  considerable  element  of  Hysteria,  in  the  form 
either  of  acute  attacks  of  hysterics,  or  of  a  chronic  unconscious  exaggeration 
of  the  sensory  symptoms.  If  the  patient  is  examined  in  the  supposed  hyper- 
aesthetic  area  whilst  his  attention  is  distracted,  possibly  no  pain  will  be  com- 
plained of. 

The  Prognosis  is  generally  favourable,  the  patient  recovering  in  time,  but 
in  a  few  instances  permanent  effects  may  be  produced. 


INJURY  OF  THE  SPINE  641 

In  the  Treatment,  a  good  deal  of  care  is  needed  to  judge  rightly  when  the 
period  has  arrived  for  encouraging  movement  rather  than  rest,  and  thus  to 
prevent  the  patient  from  developing  a  condition  of  chronic  invalidism.  Re.U 
in  bed  is  to  be  recommended  at  first,  bromides  given  in  moderation,  and  fomen- 
tations applied  locally.  Later  on,  friction  with  liniments  and  massage  should 
be  employed,  and  when  all  chance  of  secondary  inflammatory  disturbance  is  at 
an  end,  movement  should  be  encouraged,  and  change  of  air  advised,  whilst  a 
course  of  strychnine  and  iron  may  be  administered. 

In  a  few  cases,  however,  fortunately  much  rarer,  the  symptoms  run  on 
into  those  of  a  chronic  inflammatory  condition  of  the  spinal  cord  and  its 
membranes,  and  these,  to  which  Erichsen  formerly  applied  the  term  Indirect 
Concussion,  are  of  the  gravest  import.  In  others,  nothing  may  be  noticed 
by  the  patient  for  some  weeks  or  months  beyond  the  fact  that  he  feels  a 
little  shaken,  and  not  so  capable  of  doing  his  work  as  formerly  ;  but,  at  the 
same  time,  he  loses  flesh,  and  looks  worn  and  fagged.  Gradually  other 
phenomena  develop.  His  brain  power  is  diminished,  and  any  mental  effort 
causes  him  to  be  muddled ;  memory  fails,  the  temper  is  irritable,  and  his 
sleep  disturbed ;  the  head  is  often  hot.  The  vision  is  usually  defective, 
and  he  complains  of  noises  in  the  ears.  The  sense  of  touch  is  impaired, 
so  that  all  delicate  movements  are  hindered.  The  spine  is  kept  rigidly 
stiff,  the  head  fixed,  and  the  gait  is  somewhat  unsteady  and  shambling ;  the 
walking  powers  are  much  diminished,  and  going  up  and  down  stairs  is  espe- 
cially difficult.  Motor  power  in  all  regions  of  the  body  is  partly  lost ;  any  or 
every  modification  of  sensation  may  be  met  with,  whilst  the  reflexes  are 
increased  The  bladder  may  lose  its  power  of  retaining  urine  for  a  time,  but 
this  is  not  always  a  marked  symptom  ;  there  is  great  impairment  of  both  sexual 
desire  and  power.  On  examining  the  back,  distinct  tenderness  is  felt  over  one 
or  more  spots,  especially  in  the  lower  cervical,  mid-dorsal,  and  lumbar  regions. 
In  such  cases,  where  the  symptoms  develop  slowly,  and  remain  unaltered  by 
treatment,  the  Prognosis  is  most  unfavourable,  since  they  are  probably  due  to 
inflammatory  changes  in  the  cord  and  brain,  and  although  the  patient  may 
live  for  years,  yet  he  is  permanently  crirpled,  and  becomes  a  confirmed  invalid. 
Treatment  in  the  earlier  stages  consists  of  rest,  preferably  on  a  prone  couch, 
with  counter-irritation,  such  as  blisters,  or  even  the  actual  cautery,  over  the 
spine,  whilst  mercury  or  iodide  of  potash,  and  bark,  are  administered.  Careful 
nursing  and  massage  of  the  limbs,  or  galvanism,  are  needed,  and  warm  sea- 
water  douches  may  be  most  useful.  If,  however,  no  improvement  follows,  the 
patient  must  be  encouraged  to  get  about  as  best  he  can,  and  to  go  out  in  an 
invalid  chair,  so  as  to  maintain  the  general  health,  whilst  careful  attention  is 
directed  to  the  personal  hygiene. 

Paraplegia. 

Paraplegia  arises  in  the  course  of  spinal  injuries  from  a  variety 
of  causes,  which  may  be  classified  as  follows : 

1 .  Paraplegia  arising  immediately  after  the  accident,  from  : 

(a)  Direct  concussion   without  evident  lesion,   if   such   a 

condition  be  possible  ; 

(b)  Disintegration  of  the  cord  from  intramedullary  haemor- 

rhage, or   from   contusion   without  displacement  of 
bone  ; 

(c)  Displacement  of  bones,  with  or  without  recoil,  crushing 

the  cord  ; 

(d)  Penetrating  wounds  dividing  the  cord. 

However  produced,  the  same  symptoms  manifest  themselves  if 
the  lesion  is  complete  ;  recovery  is  alone  possible  in  the  first  and 

4i 


642  A  MANUAL  OF  SURGERY 

perhaps  in  the  second  group,  whilst  in  the  other  forms  the  para- 
plegia is  maintained  by  a  subsequent  acute  transverse  myelitis. 
2.  Paraplegia  arising  after  an  interval,  from  : 

(a)  Extramedullary  spinal  haemorrhage,  if  the  symptoms 

show  themselves  without  pyrexia  in  twenty-four  or 
forty-eight  hours ; 

(b)  The  pressure  of  inflammatory  exudations,  as  in  spinal 

meningitis,  when  the  symptoms  are  preceded  by 
inflammatory  phenomena,  and  do  not  appear  before 
seventy-two  hours  at  the  earliest ; 

(c)  The  pressure  of  callus  or  of  cicatricial  adhesions  around 

the  cord  and  membranes  (i.e.,  peri-pachymeningitis). 

It  is  unnecessary  to  discuss  further  the  special  signs  and 
symptoms  accompanying  each  form ;  they  have  been  already 
mentioned.  We  merely  propose  to  indicate  briefly  the  effects  of 
a  total  transverse  lesion,  and  then  to  describe  the  results  of 
paraplegia  as  they  vary  with  the  situation  of  the  injury.  It  must 
be  remembered  that  the  nerves  are  derived  from  spinal  segments 
which  are  always  at  a  higher  level  than  the  exit  of  the  nerves  from 
the  canal — i.e.,  the  nerves  travel  downwards  within  the  spinal  canal 
for  a  variable  distance,  less  in  the  cervical  region,  more  in  the 
lumbar,  before  escaping  through  the  inter-vertebral  foramina. 

A  Total  Transverse  Lesion,  destroying  absolutely  one  segment 
of  the  cord,  will  result  in  the  following  symptoms  : 

i.  Paralysis  of  the  muscular  area  supplied  by  the  destroyed 
segment,  followed  by  rapid  atrophy,  reaction  of  degeneration,  and 
loss  of  reflexes  in  this  particular  group  of  muscles. 

2.  Paralysis  of  all  the  muscles  supplied  by  the  segments  below 
that  which  has  been  destroyed.  The  trophic  condition  remains 
normal,  at  any  rate,  for  a  time,  but  when  secondary  descending 
degeneration  in  the  antero-lateral  columns  has  occurred,  the 
muscles  become  contracted,  tense,  and  rigid  (late  rigidity).  The 
condition  of  the  reflexes  after  a  total  transverse  lesion  has  been 
a  fertile  source  of  discussion,  but  it  is  now  maintained  that  the  deep 
reflexes  are  entirely  and  permanently  lost,  whilst  the  superficial 
reflexes,  though  absent  for  a  time,  may  reappear.  If,  however,  a 
portion  of  the  cord  remains  intact,  both  superficial  and  deep 
reflexes  may  persist  or  reappear,  and  even  be  exaggerated. 

3.  Complete  anaesthesia  of  the  sensitive  area  supplied  by  the 
destroyed  segment,  and  of  all  the  sensitive  areas  below. 

4.  A  narrow  zone  of  hyperesthesia  is  found  at  the  upper  level 
of  the  anaesthetic  area,  due  to  the  irritation  of  the  nerve  roots  at 
the  site  of  injury. 

5.  Vasomotor  paralysis  combined  with  trophic  disturbances  in 
the  parts  which  are  paralyzed. 

6.  Visceral  changes,  especially  in  the  bladder  and  rectum. 


INJURY  OF  THE  SPINE  643 


Phenomena  of  Paraplegia  at  Different  Levels. 

1.  At  the  Upper  End  of  the  Sacrum. — Total  transverse  lesions 
at  this  spot  are  exceedingly  rare ;  they  only  involve  the  cauda 
equina  and  cause  paralysis  of  the  sacral  plexus.  The  effects 
produced  are :  (i.)  Paralysis  of  all  the  muscles  of  the  legs,  except 
those  supplied  by  the  anterior  crural  nerve,  the  obturator,  and 
the  superior  gluteal,  whilst  the  perineal  and  penile  muscles  are 
also  affected,  (ii.)  Anaesthesia  of  the  penis,  scrotum,  perineum, 
lower  half  of  the  gluteal  region,  and  the  whole  of  the  legs 
except  the  front  and  outer  part  of  the  thigh,  supplied  by  the 
cutaneous  branches  of  the  anterior  crural,  and  the  region  supplied 
by  the  long  saphena.  (iii.)  The  bladder  and  rectum  are  both 
shut  off  from  their  spinal  centres,  and  hence  there  will  be  tem- 
porary retention  of  urine,  followed  by  distension  with  overflow, 
and  incontinence  of  faeces.  The  bladder,  however,  gradually 
contracts,  its  walls  become  thickened,  and  its  capacity  steadily 
diminishes,  so  that  incontinence  becomes  more  and  more  absolute. 

2.  If  the  lesion  is  situated  in  the  Dorsi-lumbar  region,  or 
passes  through  the  lumbar  enlargement,  which  corresponds  to 
the  twelfth  dorsal  and  first  lumbar  vertebrae,  there  is  complete 
paralysis  of  the  muscles  of  both  limbs,  including  those  passing  to 
them  from  the  trunk  ;  total  anaesthesia  of  the  legs,  gluteal  and 
perineal  regions,  and  possibly  the  lower  part  of  the  abdomen  ; 
whilst,  if  the  vesical  centres  are  destroyed,  there  is  total  paralysis 
of  the  bladder,  with  relaxation  of  the  sphincter,  dribbling  of 
urine,  which  early  becomes  ammoniacal,  and  cystitis,  due  to 
trophic  changes ;  if  the  centres  escape,  retention  with  overflow  is 
the  usual  result :  the  rectum  and  sphincter  ani  are  paralyzed, 
causing  incontinence  of  faeces,  the  passage  of  which  is  unrecognised 
from  the  anaesthetic  condition  of  the  anus. 

3.  In  the  Mid-dorsal  region  the  same  phenomena  are  met  with, 
but  to  them  are  added  a  more  extensive  region  of  anaesthesia, 
limited  above  by  a  hyperaesthetic  zone,  which  feels  like  a  tight 
painful  girdle  round  the  waist  ;  paralysis  of  the  flat  abdominal 
muscles ;  retention  of  urine,  followed  by  distension  with  over- 
flow, which,  however,  when  asepsis  is  maintained,  may  occa- 
sionally be  followed  by  a  state  of  reflex  micturition  in  which  the 
patient  passes  water  unconsciously  and  involuntarily,  whenever 
there  is  sufficient  present  to  cause  sensory  stimuli  to  ascend  to 
the  undamaged  centres.  The  abdominal  paralysis  is  a  most 
important  addition  to  the  gravity  of  the  case,  for  all  straining 
movements  are  thereby  prevented,  and  thus  coughing  is  em- 
barrassed and  defaecation  hindered.  The  gases  developing  from  the 
stagnant  faeces  accumulate  and  cause  distension  of  the  belly 
(meteorism),  and  thereby  respiration  may  be  seriously  impaired. 
The  diaphragm,  moreover,  is  hampered  in  its  action,  since  the 
lower  ribs  cannot  be  fixed  or  steadied,  and  hence  its  contractions 

41—2 


644  A   MANUAL  OF  SURGERY 


tend  to  pull  them  inwards,  instead  of  increasing  the  dimensions 
of  the  thoracic  cavity. 

4.  In  the  Cervico  -  dorsal  region  all  these  phenomena  are 
present,  but  the  anaesthesia  extends  over  nearly  the  whole  trunk, 
and  the  hyperesthesia  may  involve  the  arms,  whilst  the  inter- 
costal and  spinal  muscles  are  also  paralyzed.  Respiration  has 
therefore  to  be  carried  on  by  the  hampered  diaphragm,  with  the 
assistance  of  a  few  of  the  accessory  respiratory  muscles  in  the 
neck,  and  hence  is  much  impeded  ;  if  bronchitis  is  present,  it 
will  prove  fatal  by  asphyxia  in  a  few  days  from  the  inability  to 
expectorate.    Priapism  is  a  marked  feature  of  cervical  paraplegia. 

5.  In  the  Lower  Cervical  region  the  arms  also  become  involved 
in  both  the  paralysis  and  anaesthesia,  and  if  the  lesion  is  situated 
at  or  above  the  fourth  cervical  vertebra,  instant  death  results 
from  paralysis  of  the  phrenics  and  consequent  stoppage  of  the 
respiration. 

Death  from  Paraplegia,  therefore,  may  arise  from  a  variety  of 
causes  and  at  various  periods.  It  may  be  immediate,  from 
respiratory  failure  in  lesions  above  the  fourth  cervical  vertebra ; 
or  it  may  occur  from  accumulation  of  mucus  or  pus  in  the 
air-passages,  when  the  lesion  is  in  the  upper  dorsal  region  ;  or 
it  may  be  delayed  for  weeks,  or  even  months,  and  then  is  due 
to  sloughing  of  the  nates,  or  septic  absorption  from  an  inflamed 
or  ulcerated  bladder,  which  is  often  associated  with  suppurative 
pyelonephritis. 

The  Prognosis  and  Treatment  both  depend  on  the  position  and 
character  of  the  lesion  causing  the  paraplegia,  and  on  the  previous 
habits  and  condition  of  health  of  the  individual. 

Laminectomy. 

By  laminectomy,  or,  as  it  used  to  be  badly  termed,  trephining 
the  spine,  is  meant  an  operation  for  the  removal  of  the  lamina? 
and  spinous  processes  of  one  or  more  vertebrae,  in  order  to  relieve 
pressure  on  the  cord,  whether  due  to  depressed  bone,  abscess, 
granulation  tissue,  excessive  callus,  cicatrices,  or  tumours.  The 
operation  consists  in  making  a  longitudinal  incision  in  the  middle 
line  of  the  back,  extending  to  the  spinous  processes ;  the  muscular 
and  tendinous  structures  are  then  cleared  from  the  posterior  aspect 
of  the  vertebrae  as  far  as  the  transverse  processes,  a  proceeding 
usually  attended  with  considerable  haemorrhage,  which  can  be 
checked,  perhaps,  better  by  hot  sponge  pressure  than  by  attempt- 
ing to  secure  the  individual  vessels.  The  neural  arches  are  then 
examined  for  injury,  etc.,  and  those  which  seem  to  be  most 
affected  removed  by  cutting  pliers,  Hey's  saw,  or  laminectomy 
forceps.  The  posterior  aspect  of  the  membranes  of  the  spinal 
cord  is  thus  exposed,  and  the  various  conditions  which  may  be 
present  are  dealt  with  according  to  circumstances.     In  this  place 


INJURY  OF  THE  SPINE  645 

we  have  merely  to  consider  the  use  of  this  operation  after  injury 
to  the  spine.  For  its  employment  in  other  conditions,  see 
Chapter  XXII. 

Much  controversy  has  arisen  as  to  the  value  of  this  operation 
and  the  circumstances  under  which  it  may  be  justifiable.  It 
must  be  remembered  as  a  fundamental  guiding  principle  that 
repair  is  impossible  after  the  spinal  cord  has  been  divided,  or 
any  one  segment  totally  disintegrated,  and  hence,  if  it  is  certain 
that  a  total  transverse  lesion  of  the  cord  has  been  caused  by  an 
accident,  it  is  absolutely  useless  to  operate.  Early  and  complete 
disappearance  of  all  the  reflexes  is  a  suggestive  phenomenon,  but 
cannot  be  looked  on  as  absolute  evidence  of  a  total  transverse 
lesion ;  if,  however,  the  deep  reflexes  remain  absent  for  an) 
length  of  time,  even  though  some  of  the  superficial  ones  have 
reappeared,  operation  is  useless.  The  presence  of  the  deep 
reflexes  is  always  an  evidence  that  at  any  rate  a  portion  of  the 
cord  remains  uninjured,  and  would  encourage  one  to  operate, 
This  question  cannot,  however,  be  absolutely  settled  in  the  early 
stages  of  the  case,  when  an  exploration  is  likely  to  be  of  most 
service,  and  therefore  there  will  always  be  a  certain  number  of 
cases  in  which  it  will  be  a  matter  of  doubt  as  to  whether  or  not 
any  benefit  will  accrue  from  operation.  The  final  decision  undei 
such  circumstances  will  depend  on  the  special  predilections  and 
opinions  of  the  surgeon  who  is  in  charge  of  the  case,  and  the 
general  state  of  the  patient. 

Apart  from  these  doubtful  cases,  the  following  are  generally 
admitted  as  being  suitable  for  operation  :  (1)  Penetrating  wounds 
or  fractures  with  displacement  which  involve  the  spine  below  the 
first  lumbar  vertebra  ;  the  cauda  equina  is  present  below  that  level, 
and  not  the  spinal  cord,  and  it  is  reasonable  to  treat  it  in  the  same 
way  as  one  would  treat  a  single  peripheral  nerve  ;  (2)  when  the 
injury  is  mainly  limited  to  the  neural  arch,  which  has  been  driven 
in  by  direct  violence  ;  (3)  in  all  cases  of  bilateral  dislocation  of 
the  cervical  spine  where  the  patient  is  not  moribund ;  (4)  if 
paraplegia  arises  with  or  without  inflammatory  symptoms,  when 
an  interval  has  elapsed  since  the  accident ;  the  pressure  in  such 
cases  may  be  produced  by  blood  or  inflammatory  exudations,  and 
benefit  may  possibly  arise  from  the  operation  ;  if,  however,  it  is 
due  to  a  total  transverse  myelitis,  no  good  can  follow.  (5)  When 
symptoms  of  irritation  or  paralysis  supervene  at  a  later  date, 
from  contraction  of  cicatrices  around  the  cord  or  its  membranes 
(peri-pachymeningitis),  or  from  excessive  callus  formation,  lamin- 
ectomy may  be  performed  with  good  hopes  of  a  successful  result. 


CHAPTER   XXII. 
DISEASES    OF    THE    SPINE. 

Spina  Bifida. 

By  Spina  Bifida  is  meant  a  condition  of  imperfect  development  of 
some  portion  of  the  posterior  aspect  of  the  spine,  with  or  without 
a  similar  affection  of  the  spinal  cord  and  membranes. 

It  must  be  remembered  that  the  spinal  cord  is  developed  as 
a  linear  involution  of  the  epiblast,  the  edges  of  this  medullary 
groove  growing  up  and  uniting,  so  as  to  include  a  passage  lined 
with  epithelium,  and  subsequently  known  as  the  central  canal. 
The  cord  is  gradually  separated  from  the  overlying  skin  by  an 
intrusion  of  mesoblastic  elements,  from  which  the  vertebrae, 
together  with  the  spinal  muscles  and  ligaments,  are  developed. 
The  ossification  of  each  vertebra  originates  in  three  main  centres 
— one  for  the  body,  and  one  for  each  half  of  the  neural  arch, 
whilst  epiphyses  are  developed  as  plates  above  and  below  the 
body,  as  also  for  the  transverse  and  spinous  processes. 
The  following  are  the  chief  forms  of  spina  bifida  : 
i.  A  Myelocele  results  from  non-closure  of  the  primitive 
medullary  groove.  It  is  characterized  by  the  appearance  in  the 
lumbo-sacral  region  of  a  raw  surface,  which  consists  of  the  spread- 
out  structures  of  the  spinal  cord,  at  the  upper  part  of  which  opens 
the  central  canal.  The  condition  is  evidently  incompatible  with 
life,  and  the  children,  if  they  are  not  stillborn,  as  is  usually  the 
case,  do  not  live  beyond  a  day  or  two. 

2.  A  Syringo-myelocele  (Fig.  234)  arises  from  a  distension  of 
the  central  canal  of  the  cord,  the  posterior  portion  of  which 
usually  remains  adherent  to  the  skin,  from  which  it  has  never 
been  separated,  owing  to  defective  development  of  the  meso- 
blastic tissues.  The  spinal  nerves  travel  round  the  walls  of  the 
cyst  in  order  to  find  their  way  to  the  intervertebral  foramina. 
Trophic  phenomena  are  nearly  always  a  prominent  feature  of 
these  cases. 

3.  A  Meningomyelocele  (Fig.  235)  is  due  to  a  development  of 
fluid  within  the  membranes  which  remain  adherent  to  the  skin, 


DISEASES  OF  THE  SPINE 


647 


the  spinal  cord  or  nerves  of  the  cauda  equina  passing  down  the 
posterior  aspect  of  the  cavity  as  a  strap,  and  the  nerves  traversing 
and  perforating  the  sac  to  reach  the  intervertebral  foramina. 

4.  A  Meningocele  (Fig.  236)  is  characterized  by  a  protrusion  of 
the  membranes,  containing  cerebro-spinal  fluid,  through  a  defect 
in  the  posterior  walls  of  the  vertebrae,  the  spinal  cord  and  nerves 
being  in  their  normal  position.     This  variety  is  uncommon. 

Of  these  forms,  the  meningo-myelocele  is  that  most  frequently 
seen  in  living  children,  although,  according  to  Bland  Sutton,  from 
whose  book  on  Tumours  the  above  description  is  mainly  derived, 
the  first  is  really  the  most  common. 

Clinical  Characters. — A  spina  bifida  is  recognised  by  the  appear- 
ance of  a  tumour  in  the  middle  line  of  the  back  (Fig.  237),  most 
commonly  involving  the  lower  part  of  the  spine ;  it  may  be 
covered  by  normal  skin,  but  usually  that  over  the  apex  is  thin 
and  translucent,  and  not  unfrequently  a  number  of  small  dilated 
vessels  are  seen  coursing  over  it.     On  compressing  the  tumour, 


Fig.  234. — Diagram  of     Fig.    235. — Diagram    of     Fig.    236. — Diagram 

Svringo-Myelocele.         Meningo-Myelocele.         of  Meningocele. 

S  C,  spinal  cord ;  CSF,  cerebro-spinal  fluid  in  sac  ;  N,  nerves. 


its  size  can  be  diminished,  and  in  infants  distension  of  the  anterior 
fontanelle  can  be  felt,  showing  that  the  sac  is  filled  with  cerebro- 
spinal fluid,  and  there  is  always  a  distinct  impulse  on  coughing 
or  crying.  The  defect  in  the  posterior  portion  of  the  vertebras  is 
very  evident,  the  edges  of  the  bones  being  felt  at  the  margins  of 
the  tumour.  Various  other  deformities  may  be  associated  with 
spina  bifida,  especially  hydrocephalus  and  talipes,  which  are 
perhaps  most  common  in  cases  of  syringo-myelocele,  whilst  per- 
forating ulcer,  ankylosis  of  the  terminal  phalanges  of  the  toes, 
and  other  trophic  phenomena,  are  also  developed,  perhaps  at  a 
much  later  date. 

The  Prognosis  of  the  case  depends  mainly  on  the  thickness  and 
character  of  the  overlying  skin.  If  it  is  thin,  and  the  cord 
evidently  adherent  to  it,  as  sometimes  indicated  by  a  cicatricial 
depression  or  dimple,  the  sac  is  very  likely  to  give  way,  causing 
either  death  from  sudden  escape  of  cerebro-spinal  fluid,  or  a  fatal 
issue  in  a  few  days  from  septic  meningitis.  If  the  spina  bifida  is 
small,  and  covered  with  healthy  skin  and  subcutaneous  tissue,  the 


64S 


A   MANUAL  OF  SURGERY 


patient  may  reach  adult  life,  but  even  then  trophic  phenomena 
may  supervene.  Occasionally  a  meningocele,  with  only  a  small 
aperture  of  communication  with  the  spinal  canal,  is  cured 
spontaneously  by  the  gradual  development  of  the  bones  con- 
stricting the  neck  of  the  sac. 

Treatment. — The  majority  of  these  cases  are  best  left  alone,  the 
tumour  being  merely] guarded  from  injury  by  the  application  of 

a  suitable  cap.  If  the  sac  is 
gradually  increasing  in  size,  and 
threatening  to  give  way,  operative 
interference  is  absolutely  necessary 
if  life  is  to  be  saved.  Acupuncture 
through  the  thinned  integument,  the 
cerebro  -  spinal  fluid  being  allowed 
to  drain  away  subsequently  into 
an  antiseptic  dressing,  or  tapping 
through  the  healthier  integument 
around  the  base,  repeated  several 
times,  and  followed  by  compres- 
sion, may  lead  to  a  cure  in  favour- 
able cases.  Statistics,  however,  go 
to  prove  that  the  best  results  are 
obtained  by  tapping,  followed  by 
the  injection  of  Morton's  fluid 
(R :  iodi,  grs.  x. ;  pot.  iod.,  grs.  xxx. ; 
glycerinum,  ad  ^i.).  A  small 
quantity  of  the  cerebro-spinal  fluid 
is  withdrawn,  and  then  from  half  a 
drachm  to  a  drachm  of  the  iodine 
solution  is  introduced.  It  diffuses 
itself  slowly,  and  tends  to  act 
locally,  so  that  if  the  child  is  kept 
quiet,  and  only  semi-recumbent,  its 
effect  will  be  limited  to  the  sac  of 
the  spina  bifida  and  its  neighbour- 
hood. In  some  cases  persistent 
leakage  may  follow  this  treatment, 


Fig.  237.  —  Spina  Bifida  in 
Lad  aged  Sixteen,  probably 
of  the  meningo-myelocele 
Type.    (From  a  Photograph.) 

The  swelling  had  not  increased 
much  in  size  since  he  was  a 
child,  but  distinct  trophic 
phenomena  were  being  de- 
veloped in  the  shape  of  talipes  and  such  is  dealt  with  by  means 
of  both  feet.  of  a   firm  antiseptic  compress;    in 

many  the  injection  needs  to  be  re- 
peated more  than  once. 

Of  late  years  treatment  by  operation  has  been  coming  more 
and  more  into  vogue.  Naturally,  it  is  chiefly  applicable  in  the 
meningocele  type,  and  infants  or  those  suffering  from  trophic 
phenomena  do  not  stand  it  well.  An  incision  is  made  over 
the  sac,  either  in  the  middle  line  if  it  is  certain  that  the  cord  is 
not  there,  or  to  one  side,  if  it  is.  The  child  should  be  kept  with 
the  head  low  when  the  sac  is  opened,  so  as  to  limit,  as  far  as 


DISEASES  OF  THE  SPINE  649 

possible,  the  loss  of  cerebro-spinal  fluid.  In  a  meningocele,  the 
protruding  membranes  are  cut  away,  the  wound  in  them  is  very 
carefully  sutured,  and  the  spinal  muscles  drawn  together  by  deep 
stitches,  so  as  to  create  an  extra  protective  barrier,  in  addition  to 
the  skin  and  subcutaneous  tissues.  When  the  cord  runs  down 
the  back  of  the  sac,  it  is  freed  by  incisions  on  either  side,  and  if 
it  cannot  be  separated  from  the  skin,  the  whole  strip  is  replaced  in 
the  vertebral  canal,  the  membranes  are  closed  over  it,  and  finally 
the  muscles  and  skin  are  united  by  rows  of  sutures.  The  results 
obtained  by  this  means  have  been  encouraging,  and  in  suitable 
cases  operation  may  be  recommended  with  some  prospect  of 
success. 

Spina  Bifida  Occulta  is  the  term  applied  to  a  condition  in  which 
the  posterior  portion  of  the  vertebras  is  absent,  but  without  any 
protrusion  of  the  cord  or  its  membranes.  The  overlying  skin 
may  be  cicatricial  in  character,  or  a  large  growth  of  hair  may 
arise  from  it ;  occasionally  a  lipoma  develops  in  this  situation, 
and  by  its  downward  growth  compresses  the  spinal  cord,  causing 
paraplegia.  Unless  such  a  condition  is  present,  spina  bifida 
occulta  calls  for  no  treatment,  but  an  exploratory  operation 
should  always  be  undertaken  when  nervous  phenomena  supervene. 

Congenital  Sacral  Tumours. 

Other  congenital  conditions  of  the  lower  end  of  the  spine  are 
described  as  congenital  sacral  or  coccygeal  tumours.  The  majority 
of  these  arise  from  what  is  known  to  embryologists  as  the  neurentevic 
canal.  In  early  fcetal  life  it  is  supposed  that  the  neural  and 
alimentary  canals  are  continuous,  the  passage  of  communication 
being  known  by  the  above  name.  Ordinarily,  it  entirely  dis- 
appears after  the  union  of  the  proctodeum  with  the  intestine,  but 
evidences  of  its  existence  are  occasionally  met  with,  either  in  the 
form  of  a  cicatricial  dimple  adherent  to  the  tip  of  the  coccyx  [post- 
anal dimple),  or  as  one  of  the  following  conditions  : 

(i.)  A  dermoid  cyst,  containing  the  usual  mixture  of  sebaceous 
material  and  epithelial  cells,  and  often  a  tuft  of  hair  ;  it  develops 
in  the  space  between  the  rectum  and  coccyx,  and  may  either 
project  posteriorly,  below  the  coccyx,  or  open  into  the  rectum  ; 
the  tuft  of  hair  may  thus  find  its  way  out  of  the  anus.  In  a  case 
under  the  care  of  Mr.  W.  Turner,  at  Westminster  Hospital, 
it  was  actually  connected  with  the  spinal  meninges,  removal 
involving  the  loss  of  cerebro-spinal  fluid. 

(ii.)  A  tumour  of  a  glandular  or  adenomatous  nature  is  occa- 
sionally found  in  the  same  region.  It  is  characterized  micro- 
scopically by  the  existence  of  alveoli,  lined  by  cuboidal  epithelium, 
held  together  by  connective  tissue  ;  it  may  attain  a  large  size, 
but  is  quite  innocent.    Such  growths  are  termed  by  Bland  Sutton 


650  A  MANUAL  OF  SURGERY 

thyroid-dcrmoids,  but  a  better  name  would  be  a  congenital  adenoma  of 
the  post-anal  gut. 

Various  other  tumours  are  met  with  in  infants  in  this  region, 
and  the  same  title  of  congenital  sacral  or  coccygeal  tumour  has 
sometimes  been  applied  to  them  : 

(a)  A  spina  bifida  of  the  meningocele  type,  which  may  com- 
municate with  the  subdural  space,  or  may  have  been  shut  off  by 
a  natural  process  of  cure. 

(b)  A  lipoma  may  also  form  here,  and  in  some  cases  has  simu- 
lated by  its  shape  a  caudal  appendage. 

(c)  A  partially  developed  foetus  may  be  met  with,  enclosed 
within  the  subcutaneous  tissues  of  the  sacral  region,  and  is  known 
as  a  teratoma. 

(d)  Sarcoma  and  cystic  hygroma  have  also  been  observed. 

The  conditions  are  so  exceedingly  rare  that  it  is  unnecessary  to 
enter  into  details  of  treatment,  which  is  conducted  in  accordance 
with  general  principles. 

Inflammatory  Affections  of  the  Spine. 

I.  Acute  Osteomyelitis  of  the  Spine  is  an  uncommon  affection, 
which  has  only  recently  been  recognised.  It  is  due  to  the  same 
causes  as  similar  disease  elsewhere,  viz.,  infection  with  pyogenic 
organisms  in  an  individual  of  low  germicidal  power.  It  is  charac- 
terized by  severe  pain  in  a  localized  portion  of  the  back,  and  fever  ; 
deformity  is  not  a  marked  feature,  since  massive  necrosis  occurs 
and  not  a  gradually  destructive  caries.  Abscesses  form  early,  and 
there  is  great  danger  of  an  extension  of  the  inflammation  to  the 
spinal  meninges,  leading  to  a  fatal  issue.  The  prognosis  is  ex- 
tremely bad,  owing  to  this  latter  complication,  and  the  only 
possible  treatment  consists  in  early  incisions  to  give  exit  to  the 
pus.  Sequestra  can  easily  be  removed  from  the  back  of  vertebrae, 
but  from  the  front  only  in  the  lumbar  and  cervical  regions. 

II.  Tuberculous  Disease  of  the  Spine  or  Spinal  Caries  (Syn.:  Pott's 
Disease,  Angular  Curvature). — The  above  names  are  applied  to  a 
condition  due  to  tuberculous  disease  of  the  vertebras,  originating 
almost  invariably  in  their  bodies,  which  are  more  or  less  destroyed, 
leading  to  the  so-called  '  angular  curvature.'  This  latter  title  is 
misleading  and  inaccurate,  since  the  deformity,  though  sometimes 
angular  in  character,  can  scarcely  partake  of  the  nature  of  an 
angle  and  a  curve  at  the  same  time.  The  term  '  Pott's  disease ' 
is  derived  from  Percival  Pott,  who  first  described  it  accurately 
in  1779. 

Etiology. — The  causes  of  tuberculous  disease  of  the  spine  are 
much  the  same  as  those  of  tuberculous  affections  elsewhere,  viz.  : 
it  affects  an  individual  predisposed  to  the  development  of  tuber- 
culous  disease   either  by   inherited   tendency,   or  by  impairment 


DISEASES  OF  THE  SPINE 


651 


of  the  general  health,  as  from  some  preceding  illness,  or  expo- 
sure to  defective  sanitary  conditions.  The  actual  deposit  of 
tubercle  is  probably  determined  by  some  injury  which,  though 
slight  and  perhaps  not  noticed  at  the  time,  is  sufficient  to  cause 
local  diminution  of  vitality,  thereby  constituting  a  favourable 
nidus  in  which  the  Bac.  tuberculosis  can  develop.  It  is  most  fre- 
quently met  with  in  children,  but  may  arise  at  any  age,  and 
equally  in  either  sex.  Sprains  and  strains  of  the  vertebral  column, 
or  of  the  soft  parts  attached 
thereto,  are  the  local  lesions 
mainly  responsible  for  it. 
Any  part  of  the  spinal 
column  may  be  involved, 
but  the  lower  dorsal  is  by 
far  the  commonest.  The 
cervical  region  is  rarely 
attacked, except  in  children, 
whilst  in  adults  the  dorsi- 
lumbar  vertebrae  are  the 
favourite  seat. 

Pathological  History.  — 
The  actual  changes  in  the 
bones  in  Pott's  disease  are 
exactly  similar  in  nature 
to  those  we  have  already 
described  as  occurring 
generally  in  cancellous 
bone  (p.  514),  and  no  special 
description  need  be  given 
here.  The  disease  starts 
in  one  of  two  places,  either 
under  the  periosteum 
covering  the  anterior  sur- 
face of   the  vertebrae   (this 

most  often  in  adults),  or  at  Fig. 238.— TuberculousDiseaseofSimne 
the  line  of  junction  of  the 
upper  or  lower  plate-like 
epiphyses  with  the  body, 
the  usual  situation  in 
children.       In    the    former 

case  the  subperiosteal  tuberculous  deposit  early  extends  to  the 
subjacent  bone,  and  spreads  to  neighbouring  vertebrae,  either 
along  the  under  surface  of  the  anterior  common  ligament,  or 
through^the  intervertebral  discs,  which  are  disintegrated  by  the 
process.  When  it  spreads  along  the  anterior  common  ligament 
(Fig.  238),  the  disease  may  be  very  extensive,  body  after  body 
being  eroded,  and  the  intervertebral  discs  suffering  even  more 
than  the  bones.     In  such  a  case  the  deformity  produced  is  not 


f(4L 


/  ! 


showing  Destruction  of  the  Bodies 
of  the  Vertebr.e,  and  Abscess  For- 
mation BENEATH  THE  ANTERIOR  COMMON 

Ligament.  (Modified  from  Specimen 
in  College  of  Surgeons'  Museum.) 


652 


A  MANUAL  OF  SURGERY 


strictly  angular,  but  rather  of  a  general  kyphotic  nature.  Occa- 
sionally, however,  the  disease  starts  simultaneously  in  many  foci, 
so  that  the  bodies  of  several  vertebrae  become  pitted  and  carious, 
without  producing  general  destruction.  In  other  cases  the  process 
is  limited  to  the  bodies  and  intervertebral  discs  of  two  adjacent 
vertebrae,  the  periosteum  being  but  little  affected.  This  variety 
is,  perhaps,  most  common  in  the  lumbar  region,  where  the  bodies 
of  the  vertebrae  are  large  and  permit  a  limiting  zone  of  sclerosed 
tissue  to  form  ;  it  is  also  not  uncommon  in  this  situation  to  find 
definite  sequestra  (Fig.  239). 

The  terms  already  described  as  characteristic  of  the  different 
forms  of  caries  may  be  applied  to  the  varying  conditions  met  with 
in  this  disease.  Thus,  when  it  runs  its  course  without  suppura- 
tion, caries  sicca  is  said  to  be  present  ;  if  pus  develops,  as  is  so 


% 


:v 


-snaba*"-"* 


Fig.  239. — Tuberculous  Disease  of  Two  Lumbar  Vertebra,  showing 
Sequestrum  on  the  Anterior  Aspect,  and  Lateral  Thickening 
preventing  Angular  Deformity.     (College  of  Surgeons'  Museum.) 

frequently  the  case,  caries  suppurativa  ;  and  when  sequestra  occur, 
caries  necrotica. 

Cure  is  effected  by  the  bodies  of  the  vertebrae  falling  together 
and  becoming  ankylosed,  so  that  a  deformed  and  immobile  condi- 
tion of  the  affected  portion  of  the  spine  is  often  the  best  result  that 
can  be  anticipated.  The  new  bone  thus  formed  becomes  in 
time  sclerosed  and  very  dense,  and  the  synostosis  also  involves 
the  spines  and  laminae.  Occasionally,  the  tuberculous  process 
extends  backwards  through  the  body  of  the  bone  so  as  to  im- 
plicate the  posterior  common  ligament,  and  paralytic  or  other 
symptoms  may  then  arise  from  pressure  on  the  cord. 

Rare  cases  have  been  described  in  which  the  disease  mainly 
affected  the  sides  of  the  vertebrae,  as  a  result  of  which  lateral 
deformity  occurred  ;  and  still  more  uncommon  are  those  in  which 
the  posterior  portion  of  the  neural  arches  is  primarily  involved. 

In  the  upper  cervical  region  the  disease  usually  starts  in  the 


DISEASES  OF  THE  SPINE  653 


large  joints,  either  between  the  occiput  and  atlas,  or  between  the 
atlas  and  axis.  For  a  time  it  may  be  limited  to  one  side,  but 
usually  the  bone  is  attacked  at  an  early  stage,  and  the  trouble  then 
spreads  to  other  joints.  A  special  complication  of  this  variety  will 
be  mentioned  hereafter  (p.  658). 

The  Signs  and  Symptoms  produced  by  tuberculous  caries  of  the 
vertebrae  vary  considerably  in  different  situations,  but  for  practical 
purposes  may  be  described  under  the  following  five  headings  : 

1.  Pain  is  a  constant  and  invariable  accompaniment  of  the 
disease,  although  in  the  early  stages  it  may  not  be  specially 
prominent,  being  only  elicited  by  careful  examination.  It  is  of 
two  main  types,  the  local  and  the  referred.  Local  pain  is  more  or 
less  similar  in  character  to  that  always  experienced  in  disease  of 
bones,  although,  owing  to  the  cancellous  nature  of  the  osseous 
tissue  involved,  there  is  often  but  little  tension,  and  hence  it  may 
be  slight.  It  can,  however,  be  elicited  in  all  cases,  either  by 
pressure  or  percussion  over  the  spines,  or  perhaps  more  effectually 
by  pressing  upon  the  transverse  processes,  so  as  to  induce  rotation 
of  the  vertebral  bodies  one  on  another.  Movements  of  the  spine, 
bending  or  twisting,  are  similarly  painful,  whilst  the  same  result 
can  be  brought  about  by  jarring  the  spine,  as  by  a  blow  on  the 
head  or  nates.  The  old  plan  of  testing  for  pain  by  means  of  a 
hot  sponge  applied  over  the  back  is  comparatively  useless  in  this 
disease.  Referred  pain  is  produced  by  pressure  upon,  or  irritation 
of,  the  roots  of  the  nerves  as  they  emerge  from  the  intervertebral 
foramina ;  consequently  it  is  always  noticed  in  those  parts  of  the 
body  which  are  supplied  with  sensation  by  the  nerves  issuing 
from  the  spinal  canal  in  the  diseased  area.  If  the  lumbar  region 
is  affected,  the  pain  is  referred  down  the  legs ;  in  the  dorsi-lumbar 
region  it  may  follow  the  last  dorsal  nerve,  and  be  noticed  in  the 
lower  part  of  the  abdomen,  or  in  the  gluteal  region;  in  the  lower 
dorsal  region  pain  is  referred  to  the  epigastrium,  children  who  are 
unable  to  differentiate  its  precise  nature  complaining  of  '  belly- 
ache'; in  the  upper  dorsal  and  lower  cervical  regions  the  pain 
extends  into  the  arms,  whilst  in  the  upper  cervical  region  neuralgia 
follows  the  course  of  the  cutaneous  branches  of  the  cervical  nerves. 
Thus,  if  the  third  and  fourth  cervical  nerves  are  involved,  pain 
is  felt  along  the  course  of  the  descending  sternal,  clavicular  and 
acromial  branches  ;  if  the  second  and  third  are  implicated,  pain 
may  be  confined  to  the  great  auricular  and  occipital  nerves ;  if 
the  atlas  and  axis  are  affected,  the  neuralgic  pain,  if  any,  follows 
the  occipital  branches. 

2.  Rigidity  of  the  spine  is  a  constant  accompaniment  of  Pott's 
disease.  In  the  early  stages  it  results  from  muscular  spasm,  the 
object  being  to  fix  and  immobilize  the  painful  part.  If  the  lower 
portion  of  the  spine  is  involved,  the  back  is  held  stiff  and  straight, 
the  patient  abstaining  from  all  movements  which  would  bend  or 
stretch  it.     Thus,  in  order  to  pick  up  an  object  from  the  floor,  the 


654 


A   MANUAL  OF  SURGERY 


knees  and  hips  are  flexed,  and  the  patient  gradually  lets  himself 
down  with  an  absolutely  rigid  back  into  a  sitting  or  squatting 
posture  ;  the  body  is  raised  in  a  similar  manner  by  resting  the 
hands  upon  the  thighs,  the  patient,  as  it  were,  climbing  with 
extended  arms  up  his  own  legs.  In  a  child  rigidity  in  the  dorsi- 
lumbar  region  can  be  demonstrated  by  laying  him  on  his  face, 
grasping  the  ankles,  and  ascertaining  the  amount  of  movement 
of  the  spine  at  that  region  by  lifting  the  legs  from  the  table, 
and  also  by  moving  them  from  side  to  side.  In  a  healthy  child 
the  legs  can  be  elevated,  and  the  spine  bent  back  in  the  dorsi- 
lumbar  region,  nearly  to  an  angle  of  sixty  degrees  ;  whilst  lateral 


B 


Fig.   240. — Diagrams  to  illustrate  Deformities  in  Spinal   Curvature. 
(After  Noble  Smith.) 

In  A  the  result  of  the  bodies  falling  together  to  form  a  wedge-shaped  mass  is 
seen  in  the  anterior  displacement  of  the  upper  half  of  the  spine  ;  in  B  the 
compensatory  curves  utilized  by  Nature  to  maintain  the  erect  posture  are 
indicated  ;  in  C  the  same  process  is  seen  in  an  exaggerated  degree. 

mobility  to  the  extent  of  thirty  or  forty  degrees  on  either  side  of 
the  median  line  is  obtainable.  When  caries  is  present,  neither 
of  these  movements  can  be  made  without  including  the  thorax 
and  dorsal  spine.  In  cervical  caries  the  patient  steadies  the  head, 
and  at  the  same  time  raises  the  shoulders  by  the  help  of  the 
trapezius  and  sterno-mastoid  muscles,  whilst  the  chin  is  often 
supported  by  one  hand,  and  the  patient  twists  his  whole  body  in 
order  to  look  sideways. 

In  the  later  stages,  when  repair  is  taking  place,  or  has  occurred, 
rigidity  of  the  spine  is  due  to  osseous  ankylosis.  After  a  cure  has 
been  established,  compensatory^movements  of  other  portions  of 
the  spine  mask,  to  a  certain  degree,  the  localized  rigidity. 


DISEASES  OF  THE  SPINE  655 

3.  Deformity,  the  result  of  Nature's  method  of  repair  by  means 
of  osseous  ankylosis,  is  necessarily  present  in  almost  all  instances, 
although  in  a  few  cases,  taken  in  hand  early,  it  is  possible  that 
recovery  may  occur  without  it.  The  amount  and  character  of 
the  deformity  depend  on  a  variety  of  circumstances,  and  perhaps 
most  of  all  upon  the  number  of  vertebrae  affected.  Where  only 
two  bones  are  involved,  a  true  angular  deformity  may  result, 
the  body  of  the  upper  vertebra  being  welded  to  that  of  the 
lower,  so  as  to  produce  a  wedge-like  mass  (Fig.  240,  A),  the 
surfaces  of  which  are  inclined  to  one  another  at  an  angle  ;  com- 
pensatory curves  of  the  spine  elsewhere  enable  the  patient  to 
assume  the  erect  posture  (Fig.  240,  B).  In  the  lumbar  region, 
where  the  affection  is  often  limited  to  a  part  of  two  vertebrae, 
there  is  usually  little  or  no  displacement,  the  disease  being  limited 
to  the  centres  of  the  bones,  so  that  the  sides  may  escape  alto- 
gether, and  preserve  the  integrity  of  the  spinal  column  ;  when  a 
distinct  projection  of  the  spine  is  present,  the  portion  of  bone 
which  appears  most  prominent  is  the  spinous  process  of  the  lower 
of  the  vertebrae.  When  a  large  number  of  vertebrae  are  affected, 
as  is  common  in  the  dorsal  region,  the 
curvature  is  never  angular,  but  the  whole 
region  becomes  bent  forwards,  and  ky- 
photic in  type,  or  even  almost  rectangular. 
Owing  to  the  obliquity  and  length  of  the 
spinous  processes  of  the  dorsal  vertebrae, 
the  projection,  even  when  only  two  bones 
are  involved,  is  very  considerable  ;  in  the 
latter  case  the  spinous  process  of  the 
upper  vertebrae,  by  becoming  horizontal, 
is  the  more  prominent.  In  the  cervical 
region  there  is  rarely  much  deformity, 
owing  to  the  small  size  of  the  vertebrae, 
and  to  the  stunted  shape  and  deep  posi- 
tion of  the  spinous  processes;  if,  however,  Fl<*.  241.— Well-marked 
several  bones  are  involved,  the  head  may  Ag\ ^result  oTpon's 
be  carried  forwards,  togethei  with  the  upper     Disease. 

part  of  the  spine. 

Secondary  changes  in  the  shape  of  the  thorax  necessarily  ac- 
company the  more  advanced  cases  of  caries  in' the  dorsal  region, 
the  sternum  becoming  convex  anteriorly  so  as  to  compensate  for 
the  diminished  vertical  measurement  of  the  thorax,  and  the  ribs 
crowded  together  to  such  an  extent  as  to  almost  obliterate  the 
intercostal  spaces.  The  lower  floating  ribs  may,  however,  retain 
their  normal  position,  and  thus  a  horizontal  groove  may  be  pro- 
duced corresponding  to  the  line  of  the  tenth  rib.  In  such  cases 
the  patient  becomes  much  stunted  in  grow-th,  and  dwarfed,  con- 
stituting the  typical  'hunchback'  (Fig.  241). 

4.  Abscess  is  the  most  serious  result  of  spinal  disease,  for,  owing 


656  A   MANUAL  OF  SURGERY 


to  its  deep  origin,  it  often  attains  considerable  dimensions  before 
it  is  recognised  or  treated,  whilst  it  is  usually  impossible  to  deal 
with  the  causative  lesion  in  the  bones,  and  if  once  the  cavity  is 
allowed  to  become  septic,  an  exceedingly  grave  complication  is 
introduced  into  the  case,  which  may  even  determine  a  fatal  issue. 
The  pus  collects  originally  on  the  anterior  aspect  of  the  vertebrae, 
beneath  the  anterior  common  ligament  (Fig.  238),  which  may  be 
stripped  from  the  bones  for  a  considerable  distance,  owing  to 
the  tension  within  the  abscess  cavity.  It  thence  finds  its  way 
to  the  sides  of  the  bodies  after  perforating  the  ligament,  and 
burrows  in  various  directions,  according  to  the  portion  of  the 
spine  involved. 

In  the  cervical  region  a  chronic  retropharyngeal  abscess  is  first 
formed  ;  it  pushes  the  posterior  pharyngeal  wall  forwards,  and 
may  be  detected  from  the  mouth  as  an  elastic  fluctuating  swelling, 
which,  by  its  size,  often  leads  to  some  difficulty  in  swallowing  and 
breathing,  whilst  oedema  of  the  glottis  may  be  induced.  Left  to 
itself,  various  courses  are  open  to  it:  1.  The  abscess  may  burst 
and  discharge  into  the  pharynx,  the  cavity  necessarily  becoming 
septic,  and  the  osseous  lesion  thus  aggravated.  2.  It  may  travel 
downwards  behind  the  oesophagus  into  the  posterior  mediastinum, 
and  thence  extend  in  the  same  direction  as  abscesses  in  the  dorsal 
region.  3.  More  often  the  pus  finds  its  way  to  the  side  of  the 
neck,  being  guided  to  the  posterior  triangle  by  the  prevertebral 
fascia,  behind  which  it  is  situated  ;  less  frequently  it  pierces  this 
fascia,  and  presents  in  the  anterior  triangle.  4.  In  the  lower  part 
of  the  neck,  it  may  spread  under  the  clavicle  into  the  axilla,  being 
directed  by  the  same  fascia,  which  in  this  region  passes  down- 
wards behind  the  subclavian  trunks,  and  forms  the  posterior  wall 
of  the  sheath  of  the  axillary  vessels. 

In  the  dorsal  region,  the  abscess  starts  in  the  same  way  in  front 
of  the  vertebrae,  and  may  thence  extend  as  follows:  1.  Most 
frequently  it  passes  backwards  between  the  vertebral  ends  of  the 
ribs  to  form  a  dorsal  abscess,  burrowing  along  the  course  of  the 
posterior  branches  of  the  intercostal  nerves  and  arteries,  and 
forming  a  fluctuating  swelling,  3  or  4  inches  from  the  spinous  pro- 
cesses, with  an  impulse  on  coughing.  2.  It  may  extend  between 
the  ribs  and  the  parietal  pleura  along  the  anterior  branches  of  the 
intercostal  vessels,  coming  to  the  surface  at  the  spot  where  the 
lateral  cutaneous  branches  are  given  off.  Tuberculous  disease  of 
the  ribs,  leading  to  caries  or  necrosis,  or  even  a  localized  em- 
pyema, may  be  induced  in  such  cases.  3.  Very  rarely  the  abscess 
may  travel  up  to  the  neck,  pointing  behind  the  sterno-mastoid 
muscle.  4.  Not  uncommonly,  however,  it  works  its  way  down- 
wards, passing  under  the  ligamentum  arcuatum  internum  of  the 
diaphragm,  thus  entering  the  psoas  sheath,  and  giving  rise  to  a 
psoas  abscess. 

In    disease  of  the   dorsi-lumbar  or  lumbar  regions,   either   a 


DISEASES  OF  THE  SPINE  657 

lumbar  or  a  psoas  abscess  may  result.  A  lumbar  abscess  is  due  to 
the  passage  backwards  of  the  pus  along  the  posterior  branches  of 
the  lumbar  vessels  and  nerves  to  the  outer  border  of  the  erector 
spinae,  and  usually  presents  superficially  in  Petit's  triangle — i.e., 
between  the  adjacent  borders  of  the  latissimus  dorsi  and  external 
oblique  muscles.  It  there  forms  a  tense  fluctuating  swelling, 
with  an  impulse  on  coughing.  A  psoas  abscess  lies  within  the 
sheath  of  the  psoas  muscle,  the  pus  being  usually  superficial  to 
the  muscular  fibres,  some  of  which  are  probably  destroyed.  It 
passes  downwards,  giving  rise  to  a  fusiform  enlargement,  deeply 
placed  in  the  back  of  the  abdomen  ;  at  the  brim  of  the  pelvis,  it 
usually  burrows  outwards  under  the  fascia  iliaca  to  form  a  tense 
rounded  swelling  in  the  iliac  fossa  (Fig.  5  ;  p.  51).  It  thence 
travels  under  Poupart's  ligament,  behind  and  external  to  the 
common  femoral  vessels,  being  constricted  at  this  spot  so  as  to 
form  a  narrow  neck.  The  sack  then  expands  behind  the  common 
femoral  sheath,  the  vessels  being  often  displaced  forwards,  and 
the  vein  flattened  out  and  compressed.  Thence  passing  along 
the  tendon  of  the  ilio-psoas,  to  the  neighbourhood  of  the  lesser 
trochanter,  the  abscess  comes  into  relation  with  the  internal 
circumflex  artery,  and  usually  points  at  or  near  to  the  saphenous 
opening  to  the  inner  side  of  the  main  vessels.  It  may,  however, 
follow  the  different  branches  of  the  internal  circumflex  amongst 
the  adductor  muscles,  forming  a  large  swelling  on  the  inner  side 
of  the  thigh,  displacing  these  structures,  or  it  may  even  travel 
along  its  main  trunk  behind  the  neck  of  the  femur  to  reach  the 
surface  behind  the  great  trochanter.  In  other  rare  cases  the 
abscess  has  been  known  to  extend  down  the  leg,  and  has  even 
been  evacuated  by  the  side  of  the  tendo  Achillis.  Occasionally, 
the  pus  finds  its  way  down  into  the  pelvis  instead  of  passing  under 
Poupart's  ligament,  and  then  points  in  the  ischio-rectal  fossa,  or 
possibly  burrows  through  the  sacro-sciatic  foramen. 

The  constitutional  disturbance  associated  with  the  formation  of 
these  abscesses  is  usually  but  slight ;  perhaps  there  is  a  small  rise 
of  temperature,  but  if,  as  occasionally  happens,  ordinary  pyogenic 
organisms  find  their  way  into  the  sac  from  within  the  body,  this 
may  become  more  marked.  As  they  come  to  the  surface,  con- 
siderable pain  may  be  experienced  from  the  tension  and  irritation 
of  the  soft  parts,  and  fever  of  a  hectic  type  is  induced. 

5.  Paraplegia  is  fortunately  not  a  common  result  in  tuberculous 
caries  of  the  spine,  only  occurring  in  the  worst  or  in  neglected 
cases.  It  is  scarcely  ever  due  to  the  acuteness  of  the  curve.  It 
has  been  known  to  result  from  a  fracture  of  the  spine,  the  integrity 
of  which  has  been  weakened  by  the  inflammatory  process,  but  is 
usually  caused  by  an  extension  backwards  of  the  disease,  so  that 
a  nodule  or  button  of  tuberculous  material  forms  beneath  the 
posterior  common  ligament,  or  pushes  through  it,  compressing 
the  cord   against   the  laminae,   and   actually  invading    the    dura 

42 


658  •  A  MANUAL  OF  SURGERY 

mater.  It  occasionally  originates  in  the  pressure  induced  by  an 
abscess,  which  extends  backwards  into  the  spinal  canal. 

The  effect  produced  on  the  cord  varies  with  the  rapidity  and 
acuteness  of  the  process.  When  the  pressure  is  rapidly  developed, 
a  subacute  myelitis  ensues,  but  more  frequently  it  is  of  a  chronic 
or  sclerosing  type.  The  cord  is  then  found  to  be  constricted  or  in- 
dented by  the  tuberculous  mass,  and  perhaps  considerably  reduced 
in  size ;  its  texture  is  firmer  than  normal,  and  the  colour  grayish. 
The  onset  of  symptoms  may  be  suddenly  induced  by  haemorrhage 
or  displacement  of  bone,  but  is  more  usually  gradual.  The  dorsal 
region  (about  the  eighth  vertebra)  is  that  most  often  involved, 
since  there  is  plenty  of  space  in  the  cervical  region,  and  in  the 
lumbar  the  cord  has  broken  up  into  the  cauda  equina.  Statistics 
seem  to  indicate  that  paraplegic  phenomena  occur  in  about  one 
out  of  every  thirteen  cases. 

The  symptoms  arising  from  pressure  on  the  cord  must  be  dis- 
tinguished from  those  due  to  irritation  of,  or  pressure  on,  the 
nerve  roots.  The  latter  causes  neuralgic  pain  along  the  course  of 
some  particular  nerve,  possibly  in  the  later  stages  associated  with 
anaesthesia  (anesthesia  dolorosa),  or  a  limited  motor  weakness  if  the 
anterior  roots  are  involved.  In  compression  of  the  cord,  motor 
phenomena  are  more  evident  than  sensory,  since  the  sensory 
track  lies  towards  the  centre  of  the  cord,  and  so  is  more  protected 
from  injury.  At  first  there  is  some  dragging  of  the  toes  on  walk- 
ing, and  loss  of  power  in  the  legs,  combined  usually  with  neuralgia, 
weakness  of  the  sphincters,  and  exaggeration  of  the  reflexes. 
Later  on  the  paralysis  becomes  complete,  and,  as  degeneration  of 
the  cord  follows,  secondary  contractions  and  rigidity  occur,  and 
the  reflexes  diminish.  Absolute  incontinence  sometimes  super- 
venes, the  bladder  emptying  itself  periodically  and  involuntarily, 
or  the  urine  trickling  away  continually  from  either  a  full  or  empty 
viscus. 

Special  mention  must  be  made  here  of  a  grave  complication 
only  occurring  in  the  upper  cervical  region,  and  which  may  result 
in  sudden  death.  Tuberculous  disease  of  the  upper  two  vertebrae 
usually  originates  in  one  or  more  of  the  large  articulations  on 
either  side  of  the  atlas ;  if  these  joints  become  disorganized, 
displacement  may  occur  at  any  moment,  and  in  this  way  the 
occiput  slips  forwards  upon  the  atlas,  and  may  lead  to  gradual  or 
sudden  compression  of  the  cord  and  consequent  death.  The 
disease  sometimes  spreads  to  the  body  of  the  axis,  and  by  this 
means  the  odontoid  process  becomes  detached,  or  the  transverse 
ligament  gives  way ;  in  either  case,  the  weight  of  the  head  carries 
the  arch  of  the  atlas  forwards,  and  death  ensues  from  compression 
of  the  medulla. 

Course  of  the  Case  and  Prognosis. — Left  to  itself,  the  disease 
usually  progresses  more  or  less  steadily,  the  bone  lesion  becoming 
gradually  more   marked,  and   abscesses   tending   to   develop.      If 


DISEASES  OF  THE  SPINE  659 

treated  efficiently,  and  taken  in  hand  early,  repair  by  ankylosis 
may  be  confidently  expected.  Even  when  an  abscess  forms, 
prolonged  rest  may  lead  to  its  disappearance,  the  fluid  part  of 
the  pus  being  absorbed,  and  the  solid  elements  becoming  in- 
spissated and  dry,  forming  a  putty-like  mass  lying  on  the  front 
of  the  vertebral  column  ;  this  may  subsequently  break  down, 
probably  owing  to  infection  with  pyogenic  cocci,  constituting 
what  is  known  as  a  residual  abscess.  Should,  however,  the 
abscess  burst  or  be  opened,  and  become  septic,  symptoms  of 
hectic  fever  and  amyloid  disease  are  almost  certain  to  develop, 
and  the  patient  is  sooner  or  later  exhausted  by  the  discharge, 
and  dies  from  asthenia.  If  dealt  with  judiciously,  and  sepsis 
avoided,  the  abscesses  may  be  cured,  and  if  at  the  same  time 
the  spine  is  kept  at  rest,  the  lesion  in  the  bones  is  able  to  con- 
solidate. The  onset  of  paraplegia,  again,  must  not  be  looked  on 
as  rendering  the  case  hopeless,  since  with  prolonged  rest  the 
paralytic  phenomena  can  entirely  disappear.  Septic  cystitis  and 
bedsores  often  arise  as  complications,  and,  if  allowed  to  progress, 
cause  the  death  of  the  patient.  Occasionally,  as  a  result  of  the 
implication  of  the  spinal  canal,  diffuse  meningitis  follows,  leading 
to  a  rapidly  fatal  termination.  As  in  tuberculous  disease  else- 
where, the  patient  also  runs  the  risk  of  acute  miliary  tuber- 
culosis, whilst  other  organs,  e.g.,  the  lungs,  brain,  or  kidney,  may 
become  affected.  In  spite  of  these  possibilities,  however,  the 
prognosis  is  good  as  regards  life  in  cases  free  from  complications, 
and  where  suitable  treatment  is  practicable. 

The  Diagnosis  of  spinal  caries  is  never  a  matter  of  difficulty 
when  the  characteristic  deformity  exists,  but  in  the  early  stages, 
when  the  displacement  is  not  evident,  or  if  there  is  only  a  very 
slight  prominence  of  the  spinous  processes,  it  is  likely  to  be  mis- 
taken for  a  simple  rachitic  or  statical  curve  ;  whilst  if  neuralgic 
pain  is  a  prominent  symptom,  it  may  possibly  be  looked  on  as  a 
case  of  spinal  or  intercostal  neuralgia,  or  as  rheumatism,  or  even  be 
ascribed  to  renal  affections.  Tumours  of  the  spine,  such  as  cancer, 
or  hydatid  cysts,  syphilitic  disease,  and  aneurismal  erosion,  also 
produce  symptoms  somewhat  resembling  those  of  spinal  caries, 
and  in  adults  it  may  be  impossible  to  determine  from  the  local 
phenomena  alone  which  of  these  conditions  is  present,  although 
a  careful  consideration  of  the  general  history  and  of  the  onset  of 
the  symptoms  may  throw  some  light  upon  the  case.  Frequently 
the  course  of  the  disease  and  the  reaction  to  treatment  must  be 
mainly  relied  on  in  forming  a  diagnosis.  The  spine  should  always 
be  examined  from  before  and  from  behind,  and  pain  on  pressure 
over  the  transverse  processes  and  rigidity  of  the  back  are  the 
symptoms  on  which  most  stress  should  be  laid. 

The  diagnosis  of  the  abscesses  connected  with  spinal  caries 
is  sometimes  not  devoid  of  difficulty,  especially  when  they  point 
in  the  groin  or  the  lumbar  region,  since  similar  collections  of  pus 

42 — 2 


66o  A  MANUAL  OF  SURGERY 


may  arise  from  a  variety  of  other  causes.  (a)  A  pevinephritic 
abscess  is  recognised  by  the  association  or  pre-existence  of  symp- 
toms of  renal  disease,  whilst  a  spinal  lesion  may  be  absent.  Of 
course,  both  conditions  may  be  present  in  the  same  individual, 
and  the  diagnosis  can  then  only  be  made  by  an  exploration  of  the 
abscess  cavity,  (b)  An  empyema  occasionally  points  in  the  loin  or 
even  in  the  groin,  but  should  be  recognised  by  an  examination  of 
the  thorax,  (c)  A  chronic  abscess,  due  to  appendicitis  may  present 
very  similar  signs  to  those  of  a  deep-seated  abscess  in  the  ilio- 
psoas region  on  the  right  side,  if  it  has  not  extended  below 
Poupart's  ligament.  Careful  examination,  however,  will  demon- 
strate the  upward  extension  of  the  abscess  towards  the  spine  in 
the  latter  case,  whilst  the  previous  history  will  differ  consider- 
ably in  the  two  conditions.  The  character  of  the  pus  is,  more- 
over, a  distinctive  element,  in  that  it  has  almost  always  an  offen- 
sive smell  when  due  to  appendicitis,  on  account  of  the  presence  of 
the  Bac.  coli  com  munis,  (d)  An  iliac  abscess  may  arise  from  a  variety 
of  conditions  other  than  spinal  disease,  e.g.,  necrosis  or  caries  of 
the  ilium,  or  cellulitis  in  the  tissues  under  the  fascia  iliaca.  It  is 
recognised  by  being,  as  a  rule,  more  distinctly  limited  in  extent 
than  an  ilio- psoas  abscess,  and  by  the  absence  of  symptoms  of 
spinal  disease,  (e)  Abscesses  arising  in  connection  with  hip  disease 
occasionally  point  in  the  groin,  but  are  easily  distinguished  from 
a  psoas  abscess  by  not  extending  upwards  along  the  course  of 
the  psoas  muscle,  and  by  the  evident  signs  of  hip  disease  which 
are  always  present.  (/)  Diffused  or  ruptured  aneurism  of  the  iliac 
artery  may  give  rise  to  considerable  difficulty  in  diagnosis,  since 
a  non-pulsating  tumour  in  the  course  of  the  muscle  is  sometimes 
produced.  The  preceding  history,  the  absence  of  fluctuation,  the 
oedema  and  congestion  of  the  leg,  the  interference  with  the  pulse, 
and  the  rapid  increase  of  the  tumour,  should  indicate  the  nature 
of  the  case,  (g)  The  diagnosis  of  abscess  from  femoral  hernia  is 
given  elsewhere. 

Treatment.  —  The  great  essential  in  the  treatment  of  spinal 
caries  is  absolute  immobilization,  perhaps  associated  with  the 
application  of  some  mechanical  support,  which  takes  the  weight 
of  the  body  from  the  seat  of  disease.  This  may  be  effected  in  any 
of  the  following  ways  : 

(a)  By  the  Adoption  of  the  Recumbent  Posture. — The  patient  is  kept 
in  bed  either  in  the  prone  or  supine  position,  until  the  pain  in  the 
back  has  diminished  to  such  an  extent  as  to  warrant  the  applica- 
tion of  a  spinal  support.  In  any  but  the  youngest  children  the 
prone  position  on  a  suitably  constructed  couch  may  be  adopted 
with  advantage,  since  by  this  means  the  weight  of  the  body  is 
more  completely  taken  off  the  spine,  whilst  local  applications, 
such  as  blisters,  or  even  the  actual  cautery,  can  be  made.  In 
many  cases  it  is  advisable  to  combine  treatment  in  this  fashion 
with  the  application  of  a  removable  poroplastic  or  leather  spinal 


DISEASES  OF  THE  SPINE 


66 1 


jacket.  If  thought  desirable,  extension  by  weight  and  pulley 
attached  to  the  legs,  as  described  at  p.  476,  may  also  be  employed  ; 
pain  and  irritation  due  to  the  pressure  of  the  diseased  bones  one 
on  the  other  are  thereby  minimized. 

(b)  By  the  Application  of  Sayre's  Plaster  Jacket. — If  the  disease 
exists  in  the  dorsal  region,  the  trunk  is  encased  in  plaster  of  Paris, 
which  should  extend  from  the  axillae  to  just  below  the  iliac  crests. 
The  patient  is  stripped  to  below  the  waist,  and  a  closely-knitted 
woollen  vest  fitted  to  the  body,  and  fixed  by  straps  passing  over 
the  shoulders.  A  pad  or  folded  towel  is  placed  beneath  it  over 
the  abdomen  to  allow  for  distension  after  meals,  and  in  women 
similar  smaller  pads  may  be  placed  over  the  mammae  to  protect 
them.  Coarse  canvas  bandages,  into  the  meshes  of  which  plaster 
of  Paris  has  been  rubbed,  are  thoroughly  soaked  in  water,  to 
which  a  little  salt  may  be  advantageously  added,  and  then  wound 
evenly  round  the  body  until  a  layer  of  five  or  six  thicknesses  is 
obtained.  Over  this  a  paste  of  plaster  of  Paris,  prepared  as 
described  at  p.  430,  is  laid,  until  the  jacket  has 
attained  sufficient  thickness  and  consistency. 
It  is  allowed  to  dry  before  the  patient's  posi- 
tion is  altered.  In  adults,  where  the  disease  is 
chronic  and  not  acute,  the  jacket  should  be 
applied  whilst  the  spine  is  extended  by  sus- 
pending the  patient  by  the  head  and  axillae 
from  a  suitably  arranged  tripod.  In  children, 
or  when  the  disease  is  acute,  it  will  suffice  if 
the  parent  or  an  assistant  partially  supports  the 
patient  from  the  armpits,  or  the  apparatus  can 
even  be  applied  with  the  child  in  the  recumbent 
posture.  The  jacket  must  be  worn  until  all 
pain  and  evidence  of  active  disease  have  dis- 
appeared, and  after  that  the  patient  should  be 
fitted  with  a  poroplastic  support  for  a  time.  In 
disease  of  the  cervical  or  upper  dorsal  vertebrae, 
a  special  jury-mast  is  required,  in  order  to  steady 
the  head  and  take  the  weight  off  the  spine 
(Fig.  242).  It  consists  of  an  iron  rod,  fixed  to 
a  plaster  or  poroplastic  jacket,  accommodating 
itself  to  the  curves  of  the  head  and  neck ; 
above,  it  extends  forwards  as  far  as  the  vertex, 
and  has  attached  to  its  upper  end  straps,  which  pass  downwards 
beneath  the  occiput  and  under  the  chin. 

(c)  By  the  Use  of  Phelps'  Box. — This  plan  of  treatment,  which 
has  been  advocated  by  Phelps  of  New  York,  consists  of  a  wooden 
box  6  inches  deep,  the  lower  end  of  which  is  divided  into  two 
portions,  one  for  each  leg,  a  suitable  aperture  being  left  at  the 
junction  of  the  divided  parts  for  the  passage  of  the  excreta. 
Careful  padding  is  applied  to  the  whole  of  the  interior,  and  the 


Fig  242.—  Sayre's 
Plaster  Jacket, 
with  Jury-Mast 
for  Cervical 
Disease.     (Till- 

MANNS.) 


662  A  MANUAL  OF  SURGERY 

child  is  strapped  and  bandaged  into  this  apparatus,  and  kept 
there  for  a  period  varying  from  six  to  twelve  months.  The 
whole  trunk  is  thus  absolutely  immobilized,  and  the  child  can  be 
easily  carried  about  in  his  box,  and  taken  into  the  open  air. 
Extension  can  also  be  made,  if  necessary,  by  elastic  accumulators 
attached  to  the  head  and  neck,  or  legs. 

(d)  In  very  young  children  perhaps  the  simplest  apparatus  is 
a  double  Thomas's  splint,  with  a  suitable  crutch  above  to  fix  and 
support  the  head. 

During  the  whole  course  of  treatment,  the  general  condition  of 
the  individual  must  be  carefully  attended  to,  and  suitable  food 
and  tonics  administered.  Wherever  possible,  the  child  should  be 
taken  regularly  into  the  open  air,  or  preferably  sent  to  the  seaside. 
When  all  symptoms  of  pain  and  irritation  have  disappeared,  the 
patient  may  be  allowed  gradually  to  get  about  again  with  a 
mechanical  support,  and,  indeed,  this  should  not  be  dispensed 
with  for  six  or  eight  months  after  apparently  complete  recovery. 

Counter -irritation  is  but  seldom  required.  It  may  be  useful, 
however,  when  severe  pain  exists  in  the  early  stages,  especially 
in  adults.  The  best  means  to  employ  is  the  actual  cautery, 
either  applying  a  button  cautery  at  several  spots  on  each  side  of 
the  spine,  or  searing  the  skin  longitudinally. 

Recently  it  has  been  proposed  by  Calot  and  others  to  overcome 
the  deformity  of  Pott's  disease  by  forcible  straightening  under  an 
anaesthetic.  A  considerable  number  of  cases  have  now  been 
treated  in  this  way,  and  with  a  moderate  degree  of  success ; 
unfortunately  many  deaths  have  been  the  direct  result  of  this 
procedure,  whilst  the  subsequent  immobilization  needs  to  be  very 
prolonged,  and  the  deformity  may  recur.  Personally  we  consider 
that  although  it  may  be  safe  and  desirable  to  straighten  the  back 
in  a  few  cases,  yet  the  risks  are  so  great  and  the  process  so 
opposed  to  Nature's  method  of  cure  that  unless  future  statistics 
show  much  better  results  than  hitherto,  the  proceeding  is  scarcely 
justifiable.  The  most  interesting  point  observed  in  this  connec- 
tion is  the  fact  that  cases  of  paraplegia  seem  to  be  immensely  im- 
proved by  this  process,  and  that  within  a  few  days.  It  is  also 
now  maintained  that  no  very  great  degree  of  force  is  required  to 
do  all  that  is  desirable  ;  the  patient's  head  and  feet  are  steadied  by 
assistants  making  traction,  and  the  surgeon  merely  uses  as  much 
force  as  can  be  applied  by  one  hand  placed  over  the  curve. 

The  Treatment  of  the  Chronic  Abscesses  is  always  a  matter  of 
anxiety,  since,  when  once  opened,  they  usually  take  a  considerable 
time  to  heal,  and  if  allowed  to  become  septic,  the  prognosis  of  the 
case  is  seriously  affected.  A  general  description  of  the  methods 
employed  has  already  been  given  at  p.  55. 

A  Retro -pharyngeal  Abscess  should  always  be  dealt  with  from  the 
neck,  as  described  in  Chapter  XXVII. 

A  Dorsal,  Lumbar,   or  Psoas  Abscess   should  be  tapped  with  a 


DISEASES  OF  THE  SPINE  663 

large  aseptic  trocar  and  cannula ;  after  the  escape  of  the  pus, 
the  cavity  is  thoroughly  washed  out  with  a  mild  antiseptic 
lotion,  or  with  sterilized  water  at  a  temperature  of  1050  to  no°  F. 
In  the  case  of  a  psoas  abscess,  this  irrigation  may  be  combined 
with  gentle  massage  of  the  abscess  cavity,  in  order  to  detach  as 
far  as  possible  the  pyogenic  membrane,  and  to  assist  in  the  re- 
moval of  curdy  debris.  When  the  lotion  returns  uncoloured, 
or  but  slightly  tinged  with  blood,  an  ounce  or  two  of  a  10  per 
cent,  emulsion  of  iodoform  in  glycerine  is  injected,  and  diffused, 
if  possible,  through  the  abscess  cavity  by  manipulation.  The 
cannula  is  then  withdrawn,  and  the  external  wound  closed. 
Occasionally  a  cure  can  be  obtained  in  this  way  by  one  tapping, 
but  only  when  no  active  disease  is  present,  and  when  the 
patient's  general  health  is  good  ;  more  commonly  the  fluid  will 
re-collect,  and  the  same  process  may  need  to  be  repeated  two  or 
three  times.  Sometimes  the  fluid  finds  its  way  along  the  track 
of  the  cannula,  and  a  sinus  results  ;  such  must  be  dressed  anti- 
septically  until  cicatrization  has  occurred.  The  best  position 
in  which  to  tap  a  psoas  abscess  is  at  a  spot  just  internal  to 
the  anterior  superior  spine ;  a  small  incision  is  made  in  the 
skin,  sufficient  to  allow  of  the  insertion  of  the  trocar  through  the 
abdominal  muscles  into  the  cavity  of  the  abscess,  but  the  surgeon 
must  make  certain  that  the  intestines  have  been  previously  dis- 
placed to  one  side.  In  a  large  abscess  no  fear  need  be  entertained 
on  this  score,  since  the  parietal  peritoneum  is  always  pushed 
inwards  ;  but  if  there  is  any  doubt,  the  abdominal  muscles  must 
be  cleanly  divided  through  an  incision  about  1^  inches  long,  so 
as  to  expose  the  abscess  sac ;  a  sinus  is,  however,  more  likely  to 
form  if  this  is  done.  Should  the  abscess  point  below  Poupart's 
ligament,  close  to  the  saphenous  opening,  it  may  be  necessary  to 
open  it  there,  perhaps  in  addition  to  tapping  it  in  the  usual  place. 
It  must  be  remembered  that  the  femoral  vessels  are  displaced 
somewhat  and  stretched  over  the  sac,  and  precautions  should  be 
taken  to  prevent  puncturing  the  vein,  an  accident  which  has 
occurred. 

Some  prefer  to  open  the  abscess  freely,  and  scrape  out  its 
interior  with  a  Barker's  flushing  gouge.  Certainly  by  this  means 
the  tuberculous  pyogenic  membrane  and  debris  can  be  more 
thoroughly  removed,  but  the  sharp  edge  of  the  instrument  is 
capable  of  doing  a  considerable  amount  of  harm  in  this  situation, 
and  there  is  also  more  likelihood  of  a  sinus  remaining.  Personally 
we  are  not  in  favour  of  its  use  for  this  purpose,  and  maintain  that 
the  method  which  we  have  advocated  above  is  better,  since  there 
is  less  probability  of  the  wound  becoming  infected  with  the  tuber- 
culous material,  and  hence  of  the  formation  of  a  sinus. 

Occasionally  it  may  seem  advisable  to  freely  open  the  sac  of  a 
psoas  abscess,  and  where  the  disease  originates  in  the  lumbar 
vertebrae  it  has  been  recommended  by  Sir  F.  Treves  and  others  to 


664  A  MANUAL  OF  SURGERY 

cut  down  along  the  outer  border  of  the  erector  spinae,  and  deal 
with  it  from  behind.  A  vertical  incision  is  made  in  this  situation, 
down  to  the  transverse  processes,  and  the  lumbar  fascia  and 
quadratus  lumborum  are  divided  by  a  transverse  cut  opposite  the 
tip  of  one  of  these ;  the  abscess  sac  is  then  easily  reached  and 
opened.  The  advantage  of  this  plan  is  that  the  bodies  of  the 
vertebrae  can  be  examined,  and  even  scraped,  or  sequestra  removed. 
When  symptoms  of  paraplegia  arise  in  the  course  of  Pott's 
disease,  it  is  usually  unnecessary  to  do  more  than  maintain  the 
immobilization  of  the  spine,  since,  as  already  stated,  the  natural 
tendency  of  these  cases  is  towards  recovery.  At  the  same  time, 
extra  precautions  should  be  adopted  in  order  to  prevent  bedsores 
over  points  of  pressure.  Should  any  difficulty  in  micturition 
arise,  regular  catheterism  must  be  adopted,  and  the  greatest  care 
directed  to  the  sterilization  of  the  catheters,  septic  cystitis  being 
always  due  to  external  contamination.  In  such  cases  it  would 
be  wise  to  purify  the  penis  and  urethra,  and  to  keep  the  former 
wrapped  in  a  dry  aseptic  dressing  in  the  intervals  between 
catheterism.  A  certain  amount  of  forcible  extension  may  be 
permitted  in  these  cases,  and  will  probably  do  good.  Laminec- 
tomy (p.  644)  is  required  in  order  to  relieve  pressure  upon  the 
cord  in  the  following  cases :  (a)  When  septic  cystitis  or  the 
existence  of  deep  bedsores  is  threatening  life  ;  (b)  when,  in  spite 
of  prolonged  rest,  the  symptoms  persist  or  increase  ;  (c)  when 
paraplegic  symptoms  develop  late  in  the  case,  and  are  possibly 
due  to  a  development  of  fibro-cicatricial  tissue  outside  the  mem- 
branes (peri-pachymeningitis).  (d)  Finally,  whenever  the  tuber- 
culous process  mainly  affects  the  neural  arches,  there  is  no  reason 
for  not  treating  it  by  operation,  if  necessary. 

III.  Syphilitic  Disease  of  the  spine  develops  in  the  shape  of 
gummata,  commencing  beneath  the  periosteum  which  covers  the 
bodies ;  it  is  of  unfrequent  occurrence,  and  gives  rise  to  symptoms 
exactly  similar  to  those  of  tuberculous  caries,  from  which,  indeed, 
the  condition  cannot  be  diagnosed,  except  by  the  history  and  its 
reaction  to  treatment.  It  usually  occurs  in  adults,  and  is  said  to 
mainly  affect  the  cervical  vertebras  (Tubby).  Suppuration  and 
abscess  formation  are  not  commonly  observed.  The  co-existence 
of  a  syphilitic  history  and  of  specific  lesions  elsewhere  may  help 
one  in  coming  to  a  decision  as  to  the  nature  of  the  affection. 

Treatment  consists  in  the  administration  of  suitable  anti- 
syphilitic  drugs,  and  in  the  use  of  a  spinal  support. 

IV.  Rheumatic  Spondylitis  is  a  condition  occasionally  met  with 
arising  from  the  same  causes,  and  associated  with  much  the  same 
phenomena  as  rheumatism  elsewhere.  It  may  involve  either  the 
ligamentous  or  muscular  tissues,  or  may  attack  the  intervertebral 
joints.     Any  part  of  the  spine  is  involved,  but  perhaps  the  most 


DISEASES  OF  THE  SPINE  665 


marked  features  are  presented  in  the  cervical  region.  Consider- 
able impairment  in  the  movements  of  the  head  is  then  produced, 
and  the  neck  may  be  laterally  deflected,  somewhat  simulating 
torticollis.  If  untreated,  adhesions  form  between  the  bones,  and 
the  loss  of  movement  may  be  permanent.  The  treatment  is  of  an 
ordinary  anti-rheumatic  nature. 

The  so-called  Gonorrhoea!  Rheumatism  also  affects  the  spine 
occasionally,  and  brings  about  much  the  same  results. 

V.  Osteo-arthritis  sometimes  attacks  the  vertebral  column, 
leading  to  destruction  of  the  intervertebral  discs  and  of  the 
articular  cartilages,  together  with  erosion  of  the  bones  and  the 
formation  of  osteophytic  masses  around.  A  large  portion,  if  not 
the  whole,  of  the  spine  is  usually  involved  by  this  disease,  and 
a  prominent  feature  is  the  almost  invariable  supervention  of 
ankylosis,  either  from  ossification  of  the  anterior  or  posterior 
common  ligaments,  or  from  interlocking  or  fusion  of  osteophytes. 
A  marked  kyphosis  results,  and  great  pain  is  present.  Finally, 
the  process  spreads  to  the  articulations  between  the  ribs  and  the 
vertebrae,  and  when  these  become  fixed  the  respiratory  move- 
ments are  considerably  impaired,  and  hence  death  is  likely  to 
ensue  from  pulmonary  mischief.  Treatment  is  as  for  similar 
disease  elsewhere. 

Tumours  of  the  Spine  are  usually  malignant  in  character,  and  most  com- 
monly secondary  developments  of  cancer  or  sarcoma.  Simple  tumours,  such 
as  osteoma  and  hydatid  cysts,  do  occur,  as  also  primary  sarcoma.  The  chief 
symptoms  are  severe  and  localized  pain,  which  is  constant,  and  unrelieved  by 
rest  in  the  recumbent  posture,  together  with  early  excurvation  and  paraplegia. 
These  three  phenomena  manifesting  themselves  in  an  adult  should  always 
suggest  the  presence  of  a  morbid  growth.  Treatment  necessarily  is  but  rarely 
feasible,  although  an  exploratory  operation  is  quite  justifiable  if  the  disease  is 
primary  and  the  patient  not  profoundly  cachectic. 

Tumours  of  the  Spinal  Cord  and  Membranes  develop  in  several  situations, 
and  the  symptoms  are  thereby  somewhat  modified.  (a)  Outside  the  spinal 
dura.  Lipoma  and  sarcoma  are  here  most  often  seen,  and  the  symptoms  of 
cord  pressure,  such  as  loss  of  power  and  sensation,  are  preceded  by  those  of 
spinal  irritation,  e.g.,  neuralgic  pain,  increased  on  movement,  and  are  often 
limited  for  some  time  to  one  side,  (b)  They  may  grow  from  the  inner  aspect  of 
the  dura  mater,  and  thus  produce  symptoms  of  cord  pressure  and  meningeal 
irritation  concurrently.  Sarcoma,  fibroma  and  gumma,  are  the  commonest 
forms  of  neoplasm  in  this  situation,  (c)  From  the  spinal  cord  itself,  myxoma, 
psammoma,  and  sarcoma  may  originate.  The  symptoms  are  those  of  para- 
plegia combined  with  some  localized  and  referred  pain  or  tenderness,  and 
usually  bilateral  from  the  start.  Left  to  themselves,  patienlis  suffering  from 
any  of  these  growths  are  certain  to  die,  and  hence  an  exploratory  laminec- 
tomy, with  a  view  to  removal  of  the  growth,  if  practicable,  is  always  indicated 
when  a  diagnosis  has  been  effected.  The  possibility  of  the  disease  being 
syphilitic  in  origin  must  not  be  overlooked,  and  hence  a  preliminary  thorough 
course  of  iodide  of  potassium  should  always  be  instituted  before  operating. 
The  results  hitherto  obtained  have  been  distinctly  encouraging,  although 
many  of  the  cases  are  left  till  too  late,  and  the  mortality  is  certain  to  be 
high. 


666  A   MANUAL  OF  SURGERY 


The  only  inflammatory  disease  of  the  cord  which  need  be  alluded  to  here 
is  one,  the  results  of  which  have  already  been  mentioned  constantly  in  the 
chapter  dealing  with  the  deformities  of  the  body  (Chapter  XVI.),  viz.,  Infan- 
tile Paralysis.  This  condition  is  due  to  an  inflammation  of  the  anterior  cornua 
of  the  grey  substance  of  the  cord  (anterior  poliomyelitis),  as  a  result  of  which 
the  multipolar  ganglion  cells  situated  therein  are  destroyed.  The  symptoms 
come  on  abruptly,  and  are  often  introduced  by  a  short  febrile  attack  ;  paratysis 
shows  itself  at  once,  and  quickly  attains  its  maximal  proportions,  being  possibly 
followed  by  a  certain  amount  of  recovery.  The  portions  that  remain  paralyzed 
early  lose  their  nutrition,  owing  to  the  destruction  of  their  trophic  ganglionic 
centres,  and  become  cold  and  bluish  in  colour ;  finally,  deformities  due  to  the 
unbalanced  action  of  opposing  groups  of  healthy  muscles  may  appear,  whilst 
the  development  and  growth  of  the  affected  limbs  are  impaired.  The  distribu- 
tion of  this  affection  is  very  variable,  but,  speaking  generally,  the  legs  are  most 
commonly  affected,  the  lower  halves,  and  not  the  upper,  being  mainly  in- 
volved ;  various  forms  of  talipes  may  result  therefrom,  as  also  weak  and  flail- 
like conditions  of  the  knee  and  ankle.  When  the  thigh  is  included,  the 
quadriceps  extensor  and  adductors  are  usually  picked  out.  In  the  arm  the 
deltoid  is  most  often  paralyzed,  and  after  this  the  muscles  on  the  extensor  side- 
of  the  forearm,  excluding  the  supinator  longus.  The  face  and  neck  are  rarely 
involved,  but  the  abdominal  and  back  muscles  may  be  attacked.  The  Treat- 
ment in  the  early  stages  is  directed  towards  improving  the  general  health, 
and  maintaining  the  nutrition  of  the  affected  muscles  as  far  as  possible  by 
electricity  and  friction.  In  the  later  stages,  when  deformed  or  weak  and 
flail-like  limbs  have  resulted,  various  means  may  be  adopted  in  order  to 
improve  the  functions  of  the  part,  (a)  Mechanical  support  is  often  needed,  and 
this  must  be  carefully  regulated,  in  order  to  assist,  and  not  to  hamper,  the 
movements  of  the  individual  by  its  unnecessary  weight.  In  paralytic  talipes, 
irons  fixed  to  the  boots,  and  rising  above  the  knee,  or  even  sometimes  running 
up  to  the  pelvis,  are  frequently  required,  (b)  Tenotomy,  or  division  of  muscles 
or  fasciae,  may  also  be  needed  in  certain  deformities,  (c)  Tenoplasty,  or  the 
grafting  of  a  healthy  tendon  into  a  paralyzed  one,  has  been  occasionally 
utilized,  as  also  the  transplantation  of  the  bony  attachments  so  as  to  put  the 
relaxed  and  weak  muscles  on  the  stretch,  (it)  Arthrodesis,  or  the  fixation  of 
joints,  is  a  useful  proceeding  under  circumstances  where  the  unnatural 
mobility  is  difficult  to  control,  or  would  necessitate  considerable  increase  in 
the  weight  of  the  apparatus  required,  or  where,  from  the  poverty  of  the 
patient,  the  apparatus  cannot  be  obtained.  It  is  especially  serviceable  in 
cases  where  two  joints  in  a  limb  are  flail-like,  one  of  which  may  then  be 
ankylosed  with  advantage.  The  operation  consists  in  a  modified  excision, 
the  cartilage  alone  being  sawn  or  scraped  from  the  ends  of  the  bones. 
(e)  Where  the  whole  limb  is  hopelessly  paralyzed  and  a  great  inconvenience 
to  the  patient,  amputation  is  often  the  best  practice. 


CHAPTER  XXIII. 
HEAD     INJURIES. 

Injuries  of  the  Scalp. 

Wounds  of  the  scalp  are  produced  either  by  sharp  or  blunt 
instruments,  by  falls  on  the  head,  or  by  gunshot  injuries.  From 
the  tenseness  of  the  scalp  over  the  cranium,  it  often  happens  that 
a  blunt  weapon,  such  as  a  policeman's  truncheon,  will  cause  a 
wound  nearly  as  cleanly  cut  as  if  it  had  been  made  with  a  sharp 
instrument.  The  depth  to  which  the  injury  extends  is  a  most 
important  element  in  these  cases,  and,  so  long  as  it  is  limited  to 
those  parts  superficial  to  the  occipito-frontalis  aponeurosis,  but 
little  harm  is  done  ;  if,  however,  the  layer  of  loose  cellular  tissue 
between  the  aponeurosis  and  the  pericranium  is  opened  up  and 
infected,  septic  cellulitis  (p.  93)  is  likely  to  ensue,  and  fatal  conse- 
quences may  result.  The  superficial  extent  of  the  wound  is  a 
matter  of  little  moment,  since  the  vascular  supply  is  so  good  that 
sloughing  is  uncommon  ;  a  large  portion  of  the  scalp  may  be  torn 
up  and  bruised,  and  yet,  if  it  is  carefully  washed  and  rendered 
aseptic,  there  is  every  probability  that  it  will  retain  its  vitality. 

The  Treatment  of  scalp  wounds  is  conducted  on  exactly  the 
same  lines  as  that  of  wounds  elsewhere  ;  that  is  to  say,  after 
efficient  purification  they  may  be  stitched  up,  provision  being 
made  for  drainage,  if  necessary.  The  hair  should,  of  course,  be 
cut  away  from  the  neighbourhood  of  the  wound,  and  an  antiseptic 
dressing  applied.  Haemorrhage  from  the  scalp  may  be  severe, 
owing  to  the  division  of  some  of  the  large  arterial  branches  ;  it 
is  dealt  with  according  to  the  general  rules  of  surgery. 

Contusions  of  the  scalp  may  occur  without  solution  of  continuity 
of  the  surface,  and  results  in  the  formation  of  bruises  or  haema- 
tomata.  A  similar  condition  is  found  in  new-born  infants ;  it 
is  due  either  to  pressure  or  injury  to  the  head  during  its  passage 
through  the  mother's  pelvis,  or  to  the  compression  of  obstetric 
instruments.  Three  varieties  of  the  so-called  cephallunnatoma 
have  been  described,  viz. :  (a)  the  Superficial,  which,  confined  to 
the  dense  subcutaneous  tissue,  is  necessarily  small  and  limited. 


668  A  MANUAL  OF  SURGERY 


(b)  The  Subaponeurotic,  occupying  the  loose  tissue  under  the 
aponeurosis,  and  only  limited  by  the  attachments  of  this  structure. 
It  forms  a  large,  soft,  fluctuating  swelling,  upon  which  the  scalp 
appears  to  float,  bagging  down  over  the  eyes  or  occiput,  (c)  The 
Subpericranial  is  limited  by  the  pericranium  dipping  down  into 
the  sutures  around  the  bone  with  which  it  is  connected.  Most 
commonly  it  forms  over  one  of  the  parietal  bones,  presenting  a 
soft,  fluctuating  swelling,  which  soon  gains  an  indurated  margin 
owing  to  a  deposit  of  fibrin,  and  in  this  condition  may  simulate  a 
depressed  fracture  of  the  skull,  inasmuch  as  the  cup-like  fluid  centre 
allows  the  finger  to  sink  in  and  touch  bone  below.  It  is  not  diffi- 
cult to  recognise,  however,  since  the  indurated  margin  can  be 
readily  indented  by  the  finger,  whilst  the  edge  is  definitely  raised 
above  the  surface  of  the  cranium,  and  hence  the  sensation  of 
depression  of  bone  felt  through  the  fluid  is  only  apparent.  In 
old-standing  cases  ossification  of  the  walls  of  this  cavity  has  even 
been  known  to  occur.  Treatment. — All  that  is  required  is  the 
application  of  evaporating  lotions.  There  is  hardly  ever  any 
need  to  lay  open  or  drain  these  swellings. 

Traumatic  Cephal -hydrocele  is  the  name  given  to  a  rare  condition 
following  head  injuries,  especially  in  children.  It  is  characterized 
by  the  formation  of  a  fluid  swelling  under  the  scalp,  which  pulsates 
synchronously  with  the  heart-beat,  and  has  a  definite  impulse  on 
any  expiratory  effort ;  it  varies  in  size  from  time  to  time,  and  is 
sometimes  partially  reducible.  It  contains  cerebro-spinal  fluid, 
and  is  due  to  a  simple  fracture  of  the  vault,  laying  open  either 
one  of  the  lateral  ventricles  or  the  subarachnoid  cavity.  In 
one  case  it  was  proved  on  operation  to  be  connected  with  an 
arachnoid  cyst,  due  to  a  localized  subarachnoid  haemorrhage. 
Probably  it  is  wise  to  leave  this  condition  studiously  alone, 
although,  if  one  could  be  tolerably  certain  that  the  ventricle  was 
not  affected,  it  might  be  laid  open  and  drained. 

Injuries  to  the  Cranial  Bones. 

Contusions  of  the  Cranial  Bones  apart  from  fracture  may  lead  to 
serious  results,  i.  Many  of  the  inflammatory  conditions  of  bone 
described  elsewhere  may  be  originated  ;  e.g.,  if  the  patient  is  in 
a  condition  of  low  germicidal  power,  acute  osteomyelitis  may 
follow,  associated  with  pyaemia  from  thrombosis  of  the  large 
veins  of  the  diploe  ;  or  chronic  sclerosis  anfl  overgrowth  of  the 
bone,  local  or  diffuse,  may  supervene.  Syphilitic  or  tuberculous 
manifestations  may  be  similarly  lighted  up  if  the  patient  is  the 
subject  of  either  of  these  diseases.  2.  In  addition  to  such 
osseous  conditions,  pus  may  form  within  the  cranium  outside 
the  dura  mater  [subcranial  abscess,  p.  690),  and  necessitate  trephin- 
ing. 3.  The  dura  mater  may  be  detached  by  a  simple  contusion, 
leading   to    meningeal    haemorrhage    (p.  68 1).      4.    Any   of    the 


HEAD  INJURIES  669 


cerebral  lesions  detailed  hereafter  may  be  produced.  Contusions 
of  the  cranium  must  obviously  never  be  treated  lightly,  even 
when  they  are  associated  with  unbroken  skin  ;  much  more  are 
they  serious  when  compound,  owing  to  the  risks  of  sepsis. 

Fractures  of  the  Skull  may  be  described  for  convenience 
under  the  following  headings:  Fissured  Fractures  of  the  Vault ; 
Fractures  of  the  Base  (usually  fissured)  ;  and  Depressed  or  Punctured 
Fractures. 

I.  Fissured  Fractures  of  the  Vault  are  always  due  to  external 
violence,  direct  or  indirect.  In  the  former  case  the  skull  first  yields 
at  the  injured  spot,  but  the  fissure  may  extend  from  it  for  some 
distance  ;  in  the  latter  the  fracture  results  from  the  yielding  of 
the  skull  when  compressed  beyond  its  natural  limits  of  elasticity. 

A  simple  fissure  gives  rise  to  no  symptoms  indicating  its  pre- 
sence wTith  certainty.  There  may  be  some  amount  of  superficial 
ecchymosis,  but  nothing  more  definite.  When  compound  the  line 
of  fracture  may  be  seen  as  a  red  streak,  or  even  felt  with  the  finger 
as  an  irregular  ridge.  It  consists  of  a  mere  longitudinal  fissure, 
or  may  be  starred  ;  if  uncomplicated,  it  is  of  but  little  importance, 
and  needs  nothing  beyond  general  treatment — of  course,  the 
greatest  care  being  taken  to  ensure  asepsis.  Occasionally,  how- 
ever, an  osseous  growth  forms  from  protuberant  callus  on  the 
inner  aspect  of  the  cranium  at  the  site  of  fracture,  and  gives 
rise  to  traumatic  epilepsy  or  insanity  (p.  703). 

II.  Fractures  of  the  Base  of  the  Skull  are  almost  always 
fissured,  only  occasionally  punctured  or  depressed. 

Causes. — (a)  Violence  may  be  directed  to  the  vertex  or  to  some  part  of 
the  cranial  convexity,  as  from  a  blow  or  fall  upon  a  hard  substance. 
There  has  been  a  good  deal  of  discussion  as  to  how  a  fall  on 
the  vertex  causes  fracture  of  the  base.  The  old  idea  of  contre- 
coup — i.e.,  that  the  force  was  transmitted  from  one  side  of  the 
skull  to  the  other,  producing  a  fracture — may  be  decently  buried 
and  forgotten,  whilst  two  main  theories  still  hold  the  field,  each 
being  probably  responsible  for  a  certain  number  of  cases,  (i.) 
Aran's  theory  of  irradiation  maintains  that  a  fracture  of  the  base  is 
always  due  to  direct  extension  of  the  fissure  from  the  injured  vertex, 
a  proposition  probably  quite  true  in  many  cases,  but  insufficient 
to  explain  all.  (ii.)  A  more  recent  idea,  known  as  the  bursting  or 
compression  theory,  is  based  on  the  fact  that  the  cranium  is  not  a 
solid  and  totally  unimpressionable  body,  but  is  highly  elastic,  as 
has  been  proved  by  the  observation  that  hair  and  even  pieces  of 
skin  have  been  found  nipped  in  a  fissured  fracture  of  the  vault, 
which  had  evidently  gaped  open  and  closed  again.  Severe  com- 
pression necessarily  diminishes  the  diameter  of  the  skull  along  the 
axis  of  greatest  pressure,  making  it  bulge  in  other  diameters  ;  and 


670  A  MANUAL  OF  SURGERY 


it  this  distension  exceeds  the  limits  of  elasticity,  the  bone  gives 
way.  The  direction  of  fractures  produced  in  this  manner  varies. 
Most  commonly  the  lines  of  fracture  are  parallel  to  the  direction 
of  the  compressing  force,  the  bone  thus  bursting  open  along  its 
convexity  (fracture  by  bursting)  ;  less  frequently  it  gives  way  at 
right  angles  to  the  direction  of  the  force  where  the  bulging  is 
greatest  (fracture  by  compression).  Inasmuch,  however,  as  the 
force  is  transmitted  equally  in  all  directions,  the  weakest  part  is 
most  likely  to  give  way,  viz.,  the  base.  It  has  been  pointed  out 
by  Felicet  that  the  skull  consists  of  alternate  strong  and  weak 
parts,  the  stronger  buttresses  being  formed  by  the  occipital  ridges, 
the  petrous  bone,  the  greater  and  lesser  wings  of  the  sphenoid, 
and  the  frontal  crest,  and  that  consequently  fractures  are  more 
likely  to  involve  the  intervening  weaker  parts.  Whether  these 
ideas  are  justified  is  a  question  ;  certainly  the  figures  quoted  by 
Phelps*  indicate  that  irradiation  is  responsible  for  a  very  large 
proportion  of  fractures  of  the  base,  (b)  Direct  injury  to  the  base 
of  the  skull  is  undoubtedly  the  cause  of  a  certain  number  of 
fractures,  and  some  of  these  are  depressed,  and  not  fissured,  in 
character.  Thus,  the  point  of  an  umbrella  or  stick  may  be  thrust 
through  the  upper  wall  of  the  orbit,  or  up  the  nose  through  the 
cribriform  plate  of  the  ethmoid  ;  the  condyle  of  the  jaw  may 
be  driven  through  the  glenoid  cavity  into  the  middle  fossa  by  a 
blow  on  the  chin  ;  direct  injury  from  a  fall  or  a  stab  may  pene- 
trate the  occipital  bone,  whilst  a  gunshot  wound  in  the  mouth 
is  another  illustration  of  this  kind  of  injury,  (c)  The  impact  or  re- 
sistance of  the  vertebral  column  against  the  occipital  condyles  produces 
fractures  in  the  posterior  fossa  which  radiate  from  the  foramen 
magnum,  and  may  even  occasion  a  ring-shaped  fracture  around 
it  (Fig.  243).  They  result  from  falling  on  the  vertex  into  a  soft 
mass,  e.g.,  a  bale  of  wool,  or  by  alighting  from  a  height  on  the 
heels  or  nates. 

The  fracture  may  run  in  any  direction,  longitudinal,  oblique, 
transverse,  etc.,  according  to  the  direction  of  the  compressing  or 
fracturing  force,  and  it  may  affect  any  part  of  the  base,  either 
being  limited  to  one  of  the  fossae  or  involving  all;  it  may 
follow  the  sutural  lines  in  part,  but  it  is  no  uncommon  thing  to 
see  even  the  dense  petrous  bone  traversed  by  a  fissure  (Fig.  244). 
Naturally,  transverse  fractures  tend  to  be  limited  to  one  of  the 
fossae,  whilst  a  longitudinal  fissure  may  involve  them  all. 

Some  fractures  of  the  base  of  the  skull  are  simple  in  nature, 
but  the  majority  are  compound.  In  the  anterior  fossa  the  fissure 
extends  through  the  cribriform  plate  and  nasal  mucosa,  and  then 
lays  open  the  nose  ;  or  a  communication  may  be  established  with 
the  external  air  through  a  penetrating  wound  in  the  orbit,  or 
through  the  ethmoidal  or  sphenoidal  sinuses.  In  the  middle  fossa 
a  fracture  through  the  base  of  the  sphenoid  opens  the  roof  of  the 

*   '  Traumatic  Lacerations  of  the  Brain.'      London  :   Henry  Kimpton  ;    1898. 


HEAD  INJURIES 


671 


naso-pharynx,  or  the  fracture  may  involve  the  tympanic  cavity. 
Tn  the  posterior  fossa  the  basi-occipital  may  be  broken,  and  the 
naso-pharynx  again  opened,  although  the  fracture  here  is  more 
commonly  simple. 

Fractures  of  the  base  of  the  skull,  though  very  serious,  are  by 
no  means  necessarily  fatal,  and,  indeed,  during  the  last  twenty 
years  or  more  the  results  have  immensely  improved,  owing  to  the 
use  of  antiseptic  precautions.  The  main  dangers  to  be  apprehended 
are  :  (i.)  Damage  to  the  base  of  the  brain,  including  the  pons  and 
medulla,  especially  in  cases  where  the  foramen  magnum  is  splintered 
from  the  impact  of  the  spine  against  the  condyles  ;  (ii.)  haemorrhage 


Fig.  243. — Fracture  of  the  Base  of  the 
Skull  from  Force  acting  against  the 
Occipital  Condyles,  and  producing 
almost  an  Annular  Fracture  around 
the  Foramen  Magnum.     (Tillmanns.) 


Fig.  244. —  Transverse  Frac- 
ture across  the  Base  of 
the  Skull. 


arising  either  from  the  venous  sinuses,  or  from  the  meningeal  or 
cerebral  arteries ;  and  (hi.)  septic  meningitis,  due  to  the  fact  that 
the  injury  not  only  fractures  the  bones,  but  also  lays  open  the  dura 
mater,  a  grave  addition  to  a  compound  fracture. 

The  Signs  of  a  fractured  base  are  sometimes  exceedingly 
equivocal,  but  for  convenience  may  be  arranged  under  four  heads : 

1.  Signs  of  severe  cerebral  mischief,  such  as  concussion  of  the  brain 
and  prolonged  unconsciousness.  This  is,  however,  by  no  means 
always  present  ;  thus,  in  a  case  we  had  in  hospital  a  few  years 
back,  the  patient  was  capable  of  going  about  his  work  for  ten  days 
after  the  accident. 

2.  Hemorrhage  manifests  itself  in  various  directions,  according 
to  the  situation  of  the  fracture. 

In  the  anterior  fossa  there  may  be  free  bleeding  from  the  nose, 


672  A  MANUAL  OF  SURGERY 


owing  to  the  fracture  extending  through  the  cribriform  plate  of 
the  ethmoid  ;  but  a  portion  of  the  blood  may  pass  backwards 
into  the  pharynx,  and,  being  swallowed,  is  perhaps  subsequently 
vomited.  More  often,  however,  the  line  of  fracture  runs  across 
the  roof  of  the  orbit,  causing  escape  of  blood  into  the  areolar 
tissue  of  this  cavity.  The  ecchymosis  shows  itself  as  a  gradually 
developing  subcutaneous  distension,  involving  the  lower  lid,  bluish- 
purple  in  colour  at  first,  but  passing  later  through  the  other  stages 
of  a  bruise  ;  there  is  probably  no  contusion  of  the  skin,  as  in  the 
ordinary  black  eye,  which  is  at  first  reddish-purple  ;  the  ocular 
conjunctiva  is  considerably  involved,  but  the  effusion  rarely  extends 
above  the  cornea,  and  its  posterior  limits  cannot  be  seen.  The 
bleeding  usually  arises  from  laceration  of  the  dura  mater  and 
bone,  bnt,  when  abundant,  may  come  from  the  cavernous  sinus, 
and  the  eye  may  even  be  pushed  forwards  (proptosis) ;  in  some 
cases  pulsation  is  to  be  felt  within  the  orbit,  and  then  a  traumatic 
orbital  aneurism  or  aneurismal  varix  is  present. 

In  the  middle  fossa  the  blood  may  enter  the  nose  or  mouth,  a 
part  being  swallowed,  but  more  commonly  it  escapes  from  the 
ears.  If  abundant,  it  probably  comes  from  one  of  the  vascular 
channels  at  the  base  of  the  brain  ;  but  if  only  slight  in  amount 
and  of  short  duration,  it  may  be  induced  by  any  of  the  following 
lesions,  as  well  as  by  a  fractured  base,  viz.  :  (a)  A  simple  rupture 
of  the  membrana  tympani ;  (b)  separation  of  the  cartilage  of  the 
pinna,  with  tearing  of  the  lining  of  the  external  meatus;  (c)  fracture 
of  the  anterior  and  lower  part  of  the  tympanic  plate,  as  by  a  blow 
on  the  jaw,  which  drives  the  condyle  forcibly  against  it. 

In  the  posterior  fossa  the  bleeding  is  usually  subcutaneous,  show- 
ing itself  around  the  mastoid  process,  and  extending  downwards 
amongst  the  muscles  at  the  back  of  the  neck. 

3.  Discharge  of  cerebrospinal  fluid  is  an  indication  that  a  com- 
munication exists  with  the  subdural  space.  The  fluid  may  be 
discharged  from  one  or  both  ears,  but  has  also  been  met  with 
coming  from  the  nose  or  cranial  vault  ;  when  from  the  ear,  the 
dura  mater  has  probably  been  laid  open  through  the  prolongation 
which  accompanies  the  auditory  nerve  in  the  internal  meatus  by 
a  fracture  traversing  the  petrous  bone.  It  is  watery  and  limpid  in 
character,  with  a  specific  gravity  of  about  1005,  slightly  alkaline, 
and  containing  a  fair  quantity  of  chloride  of  sodium,  with  traces 
of  albumen,  and  of  a  substance  known  as  pyrocatechin,  which, 
like  grape-sugar,  reduces  cupric  salts  on  boiling.  At  first  it  may 
be  slightly  blood-stained,  but  this  soon  ceases,  the  fluid  becoming 
quite  clear.  The  amount  discharged  may  be  small,  but  not  un- 
frequently  it  comes  away  in  large  quantities,  soaking  the  pillow 
and  dressings,  and,  indeed,  can  sometimes  be  caught  in  a  test-tube 
as  it  trickles  from  the  meatus.  As  a  rule,  the  flow  commences 
soon  after  the  injury,  and  quickly  ceases ;  but  a  few  years  back  a 
curious  case  occcured,  under  the  care  of  Lord  Lister  at  King's 


HEAD  INJURIES  673 


College  Hospital,  of  a  man  who  had  fallen  backwards  off  a  high 
bed  upon  his  occiput ;  he  was  temporarily  stunned,  but  returned 
to  bed,  and,  on  awaking  the  next  morning,  found  that  both  eyes 
were  black.  He  continued  work  for  some  days,  complaining, 
however,  of  headache,  and  at  the  end  of  that  time  of  earache, 
which  grew  steadiiy  worse,  until  relieved  by  something  giving 
way  in  his  left  ear.  This  was  followed  by  a  copious  discharge  of 
cerebro-spinal  fluid,  which  was  maintained  for  some  time,  and 
from  the  after-history  there  can  be  no  doubt  that  it  was  due  to  a 
fractured  base. 

Escape  of  brain  substance  from  the  ear  has  also  occurred  in  a ' 
few  instances,  most  of  them  fatal. 

4.  Lesions  of  the  nerves  issuing  from  the  base  of  the  skull  are 
occasionally  produced.  For  symptoms,  etc.,  see  Chapter  XIII. 
The  nerve  most  commonly  involved  is  the  facial,  as  it  passes 
through  the  aqueductus  Fallopii  ;  the  paralysis  may  develop  either 
immediately,  or  more  often  about  the  second  or  third  week  after 
the  injury,  disappearing  in  about  a  month,  and  then  evidently  due 
to  its  implication  in  the  callus.  A  certain  amount  of  deafness  is 
often  associated  with  it  from  injury  to  the  portio  mollis. 

The  Prognosis  of  fractured  base  has  much  improved  during 
recent  years,  as  a  result  of  the  application  of  antiseptics  to  the 
auditory  meatus,  thereby  preventing  the  occurrence  of  sepsis 
within  the  meninges.  If  the  patient  escapes  death  from  cerebral 
complications,  the  bones  of  the  skull  unite  raqidly,  and  a  good 
result  may  be  expected,  although  troublesome  sequelae  may  follow, 
from  the  injury  sustained  by  nerves  or  vessels,  or  their  compres- 
sion in  callus  or  new  bone. 

Treatment. — Seeing  that  the  chief  danger  to  the  patient  arises 
from  septic  contamination  of  the  meninges,  the  greatest  care  must 
be  directed  towards  preventing  decomposition  of  the  discharges. 
Unfortunately,  it  is  impossible  to  apply  dressings  to  the  naso- 
pharynx, or  even  to  thoroughly  wash  it  out  with  antiseptics,  and 
the  only  satisfaction  about  such  cases  is  that  the  rarity  of  the  loss 
of  cerebro-spinal  fluid  suggests  that  the  membranes  of  the  brain 
are  not  very  often  damaged  in  that  situation,  whilst  it  has  also 
been  shown  that  in  the  majority  of  cases  the  upper  part  of  the 
nasal  cavity  is  aseptic  (St.  Clair  Thomson).  With  the  ear,  how- 
ever, things  are  very  different ;  the  meatus  should  be  well  syringed 
with  carbolic  lotion  (1  in  20),  and  plugged  with  some  efficient 
dressing,  a  large  pad  of  the  same  being  bandaged  over  the  affected 
side  of  the  head.  This  must  be  replaced  as  often  as  necessary. 
Beyond  this,  the  treatment  of  fractured  base  is  directed  to  the 
cerebral  condition,  and  does  not  differ  from  that  usually  applied  to 
head  injuries,  viz.,  cold  to  the  shaved  head  (preferably  by  means 
of  Leiter's  tubes),  a  smart  calomel  purge  to  start  with,  low  diet, 
and  absolute  quiet  in  a  dark  room.  The  patient  should  be  kept 
from  going  about  his  work  for  at  least  six  weeks. 

43 


674  A   MANUAL  OF  SURGERY 

III.  Depressed  and  Punctured  Fractures  usually  involve  the 
vault  of  the  cranium,  and  are  due  to  direct  violence,  either  from 
a  fall  or  blow,  causing  a  simple  or  compound  fracture,  or  from  a 
penetrating  injury  occasioning  a  punctured  fracture.  In  both 
cases  there  is  often  a  considerable  amount  of  comminution. 

It  is  quite  possible  for  the  outer  table  to  be  broken  and  depressed, 
without  any  injury  to  the  inner,  where  an  air  cavity  exists  in  the 
bone,  or  if  the  diploe  is  very  thick  ;  thus,  the  bone  may  be  driven 
in  over  the  frontal  sinus  without  injury  to  its  inner  wall,  or  the 
mastoid  may  be  similarly  affected.  The  inner  table  has  also  been 
broken,  and  fragments  even  separated,  as  a  result  of  a  simple 
depression  without  fracture  of  the  outer  table ;  this  rarely  occurs 
in  adults,  but  is  not  uncommon  in  children.  Amongst  the  latter, 
it  is  also  possible  for  a  considerable  depression  to  exist  without 
any  fracture  even  of  the  inner  table. 

More  usually  both  inner  and  outer  tables  are  involved,  and 
when  such  is  due  to  force  reaching  it  from  without,  the  inner 
table  is  always  more  damaged  than  the  outer,  especially  in  the 
punctured  variety  (Fig.  245,  A  and  B).  When,  however,  the  force 
is  applied  from  within,  as  by  a  bullet  which  has  traversed  the 
brain,  the  outer  table  suffers  more  than  the  inner.  The  causes  of 
this  condition  are  similar,  from  whichever  side  the  force  comes  ; 
we  shall,  however,  only  discuss  the  case  of  a  wound  coming  from 
without,  (a)  The  inner  table  is  less  supported  than  the  cuter, 
having  merely  the  soft  brain  and  dura  mater  within,  and  hence  is 
extensively  splintered,  just  as  a  nail  driven  through  an  unsupported 
piece  of  wood  causes  ripping  up  of  its  under  surface,  (b)  The  loss 
of  momentum  of  the  fracturing  body  will  assist  this  ;  the  greater 
the  momentum  of  a  bullet,  the  more  cleanly  it  cuts,  a  smaller 
momentum  breaking  or  splintering  rather  than  cutting  ;  of  course, 
a  considerable  amount  of  force  is  expended  in  penetrating  the 
outer  table,  (c)  The  debris  caused  by  the  injury  to  the  outer  table 
will  add  to  the  bulk  of  the  penetrating  body,  and  its  wedge-like 
action  still  further  increases  the  injury  to  the  inner  table,  (d)  All 
force  tends  to  radiate  and  diffuse  itself  from  the  spot  struck,  and 
hence,  if  the  outer  table  is  first  injured,  the  force  will  be  dis- 
seminated over  a  much  wider  area  of  the  inner. 

The  Symptoms  and  Signs  arising  from  a  depressed  fracture  vary 
widely  in  their  nature,  and  are  partly  due  to  the  injury  inflicted 
on  the  bone,  partly  to  that  sustained  by  the  brain,  whilst  the 
septicity  or  not  of  the  wound  is  of  the  gravest  significance. 

Locally,  when  an  external  wound  is  present,  one  sees  blood  or 
cerebro-spinal  fluid  escaping,  or  even  brain-substance  protruding. 
The  damage  to  the  bone  may  be  seen  or  felt,  and  the  extent  of 
the  depression  or  comminution  ascertained.  When  there  is  no 
external  wound,  a  hematoma  of  variable  size  forms  under  the 
scalp,  more  or  less  obscuring  the  fracture.  The  character  of  the 
lesion  is  a  matter  of  considerable  importance  from  a  prognostic 


HEAD  INJURIES 


675 


point  of  view.     When  the  bone  shelves  evenly  in  all  directions,  a 
pond  or  saucer  fracture  is  said  to  be  present,  and  such  is  tolerably 


Fig.  245. — Depressed  Fracture  of  Skull  seen  from  Without  and  from 
Within.      (From  Specimen  in  King's  College  Museum.) 

amenable  to  treatment ;  when,  however,  the  depression  is  sudden 
and  complete,  the  detached  portion  lying  below  the  level  of  the 

43—2 


676  A   MANUAL  OF  SURGERY 


rest  of  the  bone,  it  is  termed  a  gutter  fracture,  and  the  prognosis  is 
increasingly  grave.  The  two  forms  are,  however,  often  associated. 
Necessarily,  considerable  variations  are  met  with  in  this  type  of 
fracture,  according  to  the  nature  of  the  injury  and  the  means  by 
which  it  was  inflicted.  Thus,  if  it  is  due  to  a  fall  on  the  vertex, 
there  is  often  a  ragged,  irregular  scalp-wound,  through  which  the 
depression  can  be  seen  or  felt ;  if  caused  by  the  puncture  of  a 
sharp  tool,  such  as  a  pickaxe,  there  is  only  a  small  external 
opening  corresponding  to  the  hole  in  the  skull,  in  which  the  point 
of  the  instrument  may  be  found  embedded.  A  slicing  cut  with  a 
sabre  or  hatchet  produces  a  clean  incision  through  the  scalp, 
together  with  a  linear  groove  in  the  skull,  perhaps  somewhat 
bevelled,  which  may  or  may  not  penetrate  its  whole  thickness. 
Sometimes  detached  portions  of  the  skull  are  raised  above  their 
ordinary  level,  constituting  an  elevated  fracture ;  it  is  usually 
associated  with  depression  of  surrounding  parts. 

Gunshot  injuries  of  the  skull  manifest  any  degree  of  severity, 
according  to  the  velocity  and  angle  of  incidence  of  the  projectile. 
A  non-penetrating  wound  produces  either  a  severe  localized  con- 
tusion or  a  depression  with  or  without  comminution.  Jf  a  modern 
conical  bullet,  travelling  at  a  high  rate  of  speed,  strikes  the  skull, 
it  will  probably  penetrate,  and  possibly  may  traverse  both  sides 
and  thus  escape,  doing  comparatively  little  harm,  except  along  its 
immediate  track.  If,  however,  the  bullet  is  of  an  expanding  type, 
or  fired  from  close  at  hand,  considerable  additional  mischief  in  the 
shape  of  fissures  extending  widely  through  the  skull  is  induced. 
It  has  been  known  for  some  time,  and  the  point  has  been  empha- 
sized by  Professor  Horsley,  that  if  a  bullet  traverses  a  dry  and 
empty  skull,  but  little  harm  results,  except  the  formation  of  the  two 
openings  where  the  bullet  entered  and  left  the  cavity,  and  these 
with  the  modern  weapon  are  small.  If,  however,  the  skull  is  first 
filled  with  damp  sand  or  with  water,  or  if  the  brain  is  left  in  situ, 
and  a  bullet  fired  through  it,  the  effects  are  much  more  serious, 
varying  directly  with  the  viscosity  of  the  contents  ;  such  a  result 
is  evidently  due  to  the  momentum  of  the  penetrating  body  being 
transmitted  to  the  molecules  of  water  or  brain  substance,  and 
thence  spreading  explosive-like  in  all  directions.  Not  only  does 
this  radiation  of  the  force  affect  the  skull,  but  the  most  grave 
consequences  to  the  brain  itself  ensue  from  the  displacement  of 
cerebro-spinal  fluid,  inducing  increased  pressure  upon  the  centres 
grouped  around  the  fourth  ventricle,  and  leading  primarily  to  a 
cessation  of  respiration.  Thus,  a  bullet  fired  through  the  skull 
and  brain  of  a  living  dog  caused  the  breathing  to  stop,  although 
the  heart  still  continued  to  beat ;  by  performing  artificial  respira- 
tion for  a  time,  natural  breathing  was  re-established. 

In  a  simple  depressed  fracture  the  patient  usually  suffers  from 
concussion,  followed  almost  immediately  by  compression,  the 
latter  due  in  part  to  the  depressed  bone,  but  mainly  to  exudation 


HEAD  INJURIES  677 


of  blood  and  bruising  of  the  brain,  and  if  this  is  at  all  extensive 
and  remains  unrelieved  a  fatal  result  follows  almost  immediately. 
Where,  however,  the  depression  is  but  slight,  the  symptoms  of 
compression  may  be  absent  or  not  marked,  and  the  patient 
recovers,  perhaps  to  become  the  subject  of  traumatic  epilepsy  or 
insanity  at  a  later  date,  induced  by  the  irritation  of  the  dura  mater 
and  of  the  subjacent  cortex.  If  the  depressed  fragments  irritate 
the  motor  area,  convulsions,  spasms,  or  paralysis  may  be  thereby 
induced. 

In  a  compound  depressed  or  punctured  fracture  the  immediate  effects 
are  not  necessarily  severe,  the  patient  perhaps  not  even  suffering 
from  concussion,  though  brain  substance  presents  in  the  wound ; 
the  more  limited  the  spot  injured,  the  less  the  concussion.  The 
explanation  of  this  fact  is  that  the  blow  has  expended  its  force  in 
fracturing  the  cranium,  and  hence  does  little  harm  to  the  brain, 
in  the  same  way  that  a  watch  may  receive  but  slight  damage  from 
a  fall  if  the  glass  is  broken,  whilst  if  the  latter  remains  intact  the 
works  are  liable  to  suffer. 

Left  to  itself,  such  a  fracture  is  sure  to  become  septic,  and 
inflammation  of  the  bone,  brain,  or  membranes  will  follow. 

Septic  osteitis  leads  to  necrosis  of  the  fragments,  which  may  be 
seen  lying  dead  and  yellow  at  the  bottom  of  the  wound,  whilst  the 
inflammation  may  either  spread  along  the  diploe  to  the  surround- 
ing bone,  causing  extensive  necrosis  with  pyaemia,  or  between  the 
bone  and  the  dura  mater,  leading  to  a  subcranial  abscess. 

When  once  the  dura  mater  has  been  penetrated,  inflammation 
is  liable  to  spread  to  the  meninges,  and  then  a  diffuse  or  localized 
suppurative  meningitis,  accompanied  or  not  with  a  localized 
suppuration  of  the  brain,  will  ensue.  Even  if  the  dura  mater 
has  not  been  opened  by  the  injury,  the  irritation  of  depressed 
spicules  of  bone  and  the  presence  of  a  septic  exudation  often  lead 
to  its  ulceration  at  a  later  date.  If  there  is  a  free  external  open- 
ing, allowing  a  ready  exit  to  the  discharge,  and  thus  preventing 
tension,  the  process  may  be  quite  limited,  and  compression  of  the 
brain  or  diffuse  septic  meningitis  is  avoided  ;  but  if  the  bones 
are  locked  together  as  well  as  depressed,  and  the  external  wound 
is  small,  retention  of  inflammatory  products  may  lead  to  their 
diffusion,  and  the  symptoms  of  compression  will  soon  become 
evident.     A  hernia  cerebri  may  also  form  subsequently. 

When  the  fragments  of  depressed  bone  are  early  removed, 
even  if  perfect  asepsis  is  not  attained,  the  patient  has  a  good 
chance  of  recovery  ;  whilst  laceration  of  the  dura  need  not  result 
in  meningitis,  since  the  opening  in  the  subdural  space  can  be  shut 
off  by  adhesions  of  the  arachnoid  in  a  very  short  time. 

When  an  aseptic  condition  of  the  wound  is  obtained  by  early 
interference,  and  depressed  fragments  of  bone  are  successfully 
elevated  or  removed,  the  prognosis  becomes  much  better,  and  the 


678 


A   MANUAL  OF  SURGERY 


case  may  run  an  uncomplicated  course  towards  recovery,  unless 
some  deeper  cerebral  lesion  co-exists. 

The  Treatment  of  these  cases  has  been  much  changed  by  the 
introduction  of  antiseptics,  the  opinion  now  prevalent  being  that 
a  patient  runs  greater  risks  from  leaving  a  slight  depression 
unrelieved  than  by  making  even  what  may  prove  to  be  an  un- 
necessary exploration  with  the  trephine.  We  may,  therefore, 
epitomize  the  treatment  thus  : 

(i.)  In  all  punctured  fractures,  operate. 

(ii.)  In  all  compound  depressed  fractures,  operate. 

(iii.)  In  simple  depressed  fractures  :  In  adults,  always  operate  ; 
in  children,  if  gutter-shaped,  operate  ;  if  pond-shaped,  wait  for 
symptoms,  unless  the  fracture  is  a  bad  one. 


Fig.  246. — Instruments  used  in  Trephining  for  or  Elevating  4  De- 
pressed Fracture,  including  Trephine,  Elevator,  and  Hey:s  Saw 
(Down  Brothers.) 


The  most  debatable  of  these  propositions  is  that  relating  to  the 
simple  depressed  fracture  in  an  adult.  It  may  be  objected  that 
many  such  cases  have  recovered  without  operation,  and  that 
therefore  in  shallow  depressions  one  should  wait  for  symptoms  ; 
but  whilst  admitting  the  fact,  we  recall  cases  where  the  neglect 
of  such  treatment  has  led  to  serious  trouble,  and  we  have  been 
called  on  not  unfrequently  to  trephine  for  traumatic  epilepsy  due 
to  this  very  type  of  injury.  The  operation  is  so  slight,  and  the 
risk  so  insignificant  when  asepsis  is  maintained,  that  the  patient 
should  be  given  the  benefit  of  an  exploration,  especially  since  one 
can  never  be  certain  of  the  amount  of  injury  sustained  by  the 
inner  table. 

When  an  operation  has  once  been  decided  on,  the  sooner  it  is 
undertaken    the    better.       The    scalp    should    be    shaved    and 


HEAD  INJURIES 


679 


thoroughly  purified.  An  anaesthetic  may  or  may  not  be  given, 
according  to  the  condition  of  the  patient.  In  a  simple  depressed 
fracture  the  surgeon  should  never  incise  the  skin  directly  over  the 
wound,  but  should  turn  down  a 
flap  to  avoid  the  presence  of  a 
cicatrix  over  the  lesion  in  the 
bone.  Having  cleared  away 
blood-clot  and  exposed  the  frac- 
ture, if  there  is  no  projecting 
margin  of  bone  he  will  have  to 
trephine,  placing  the  centre-pin 
upon  some  firm  undepressed 
bone  as  near  the  edge  of  the 
wound  as  possible  (Fig.  247). 
An  elevator  can  now  be  intro- 
duced, the  fragments  prised  up 
into  position,  and  the  condition 
of  the  inner  table  investigated. 
The  opening  in  the  skull  may 
be  enlarged  by  cutting  pliers  or 
a  Hey's  saw,  but  all  the  bony 
tissue  taken  away  during  the 
operation  should  be  kept  in 
warm  boracic  lotion,  or,  better 
still,  in  warm  saline  solution  or 
blood  serum,  if  obtainable. 
When  the  loss  of  substance 
is  small,  there  is  no  need  to 
replace  the  fragments ;  but 
when  it  is  of  considerable  size, 
it     is    wise     to     attempt    this, 

wedging  them  accurately  together,  so  that  none  lie  loose  in  the 
wound.  An  opening  for  drainage  may  be  left  between  them, 
if  need  be.  In  other  cases  they  may  be  chipped  up  into  small 
pieces  and  powdered  over  the  wound. 

In  a  compound  depressed  fracture,  the  skin-wound  may  be 
enlarged,  or  a  flap  turned  down,  and  the  bone  dealt  with  according 
to  circumstances.  It  may  suffice  to  saw  off  a  portion  of  a  pro- 
jecting fragment,  so  as  to  allow  entrance  to  the  elevator,  or  it 
may  be  necessary  to  trephine.  In  these  cases,  the  fragments 
of  bone  removed  must  be  well  purified  in  warm  carbolic  lotion 
(1  in  40)  before  being  placed  in  the  saline  solution.  The  brain 
and  membranes  will  need  careful  purification  if  wounded,  and 
this  may  be  accomplished  without  fear  by  washing  with  a  5  per 
cent,  carbolic  solution.  Protruding  brain  substance  may  be 
removed,  and  the  dura  mater  lightly  stitched  across  the  gap  ;  the 
bones  may  then  be  replaced,  but  room  must  be  left  for  a  drainage- 
tube  to  pass  within  the  dura  to  carry  away  any  fresh  effusion  ;  it 


Fig.  247. —  Punctured 
of    Skull,    showing 


Fracture 
Spot   for 


Application  of  Trephine. 


6So  A  MANUAL  OF  SURGERY 


may  be  removed  in  forty-eight  hours,  if  the  case  progresses  satis- 
factorily. 

In  a  punctured  fracture,  although  the  opening  in  the  bone  may 
be  small,  a  large  circle  is  removed,  since  the  inner  table  is  almost 
always  extensively  damaged.  The  centre-pin  should  rest  on 
sound  bone,  as  near  the  opening  as  possible  (Fig.  247),  and  care 
must  be  taken  to  include  all  depressed  fissures  in  the  field  of 
operation. 

In  all  cases  the  patients  should  be  confined  to  bed  with  the  head 
low,  and  the  general  rules  suitable  to  head  injuries  followed.  It 
is  by  no  means  certain  that  elevation  of  the  depressed  bone  will 
relieve  the  symptoms,  as  they  may  be  due  to  haemorrhagic  effusion 
into  the  brain  which  cannot  be  reached. 

For  treatment  of  gunshot  injuries  of  the  skull,  see  pp.  205  and 
698. 

Injuries  to  the  Intracranial  Bloodvessels. 

1.  Wounds  of  the  Venous  Sinuses  are  by  no  means  uncommon, 
being  torn  across  in  fractures,  or  punctured  either  by  some 
sharp  instrument,  or  by  spicules  of  bone.  The  superior  longi- 
tudinal, petrosal,  lateral,  and  cavernous  sinuses  are  those  most 
frequently  involved,  especially  the  first,  because  it  is  more  inti- 
mately connected  with  the  bones  than  any  of  the  others.  When 
there  is  no  external  wound,  and  only  the  outer  wall  of  the  sinus 
has  been  opened,  the  haemorrhage,  if  at  all  severe,  will  strip 
up  the  dura  mater  and  compress  the  brain,  producing  effects 
resembling  those  due  to  meningeal  haemorrhage,  but  slower  in 
their  onset,  and  less  severe  in  their  course ;  if  the  wound  is  small, 
the  bleeding  is  not  so  great,  since  comparatively  little  pressure 
suffices  to  arrest  it  by  flattening  the  sinus  against  the  bone,  or 
the  hole  may  be  filled  by  the  spicule  of  bone,  and  bleeding  does 
not  occur  till  it  is  displaced.  If,  however,  the  inner  wall  of  the 
sinus  is  torn  across-,  the  blood  finds  its  way  between  the  meninges, 
and  gives  rise  to  the  symptoms  of  diffuse  intra-meningeal  haemor- 
rhage. When  an  external  wound  exists,  there  is  the  usual 
evidence  of  venous  bleeding,  but  it  is  readily  checked  and  rarely 
fatal.  Septic  thrombosis  and  pyaemia  are  the  chief  dangers, 
but  entrance  of  air  has  also  led  to  a  fatal  issue  in  a  few  cases. 
Treatment,  when  practicable,  consists  in  plugging  the  sinus  with 
aseptic  gauze,  and  applying  an  antiseptic  compress,  possibly  re- 
moving fragments  of  bone  in  order  to  expose  it.  Where  the  outer 
wall  alone  has  been  torn,  it  may  be  possible  to  suture  it  without 
interfering  with  its  continuity.  For  symptoms  and  treatment  of 
septic  thrombosis,  see  p.  694. 

2.  Wounds  of  the  Middle  Meningeal  Artery. — This  vessel,  which 
enters  the  skull  at  the  foramen  spinosum,  and  subsequently  divides 


HEAD  INJURIES 


68 1 


into  two  branches  which  ramify  between  the  skull  and  the  dura 
mater,  is  occasionally  ruptured,  with  or  without  a  fracture  of  the 
skull.  The  anterior  branch  is  most  frequently  injured  as  it  crosses 
the  anteroinferior  angle 
of  the  parietal  bone,  as  the 
result  of  a  fissured  frac- 
ture ;  but  it  is  very  liable 
to  be  torn  by  a  punctured 
wound,  since  the  bone  is 
very  thin  in  that  locality, 
or  by  a  depressed  fracture. 
The  artery  is,  however, 
sometimes  ruptured  by  a 
blow  on  the  side  of  the 
head,  sufficiently  severe  to 
detach  the  dura  mater, 
but  without  causing  any 
injury  to  the  bone  ;  this 
membrane  always  carries 
the  vessel  with  it,  and  if 
it  emerges  from  a  bony 
canal  just  at  that  spot, 
as  so  often  happens,  the 
artery  is  torn  across  by 

the    projecting    inner   lip 

.     jf     j  &  f       Fig.  248.— Meningeal  Hemorrhage. 

ot    the  canal.       Whether  (From    Specimen   in   College  of   Sur- 

or     not     the     dura     is  geons'  Museum.) 

primarily    detached,    the 

blood  soon  collects  between  it  and  the  bone,  pressing  the  brain 
inwards,  and  burrowing  down  towards  the  base  of  the  skull 
(Fig.  248).  Such  is  due  mainly  to  the  force-pump-like  action  of 
the  arterial  pressure,  for  when  fluid  is  driven  into  a  closed  cavity, 
the  power  of  the  jet  is  multiplied  by  the  area  occupied.  The  clot 
rarely  measures  more  than  4  inches  in  diameter.  The  posterior 
division  is  only  wounded  in  about  5  to  10  per  cent,  of  the  cases. 

The  Symptoms  are,  unfortunately,  often  obscured  by  some  co- 
existent cerebral  lesion  or  complication  :  but  in  a  typical  case 
three  stages  should  be  present,  viz. :  (a)  A  primary  concussion, 
as  the  result  of  the  blow  ;  (b)  a  temporary  return  to  conscious- 
ness ;  and  (c)  the  gradual  supervention  of  coma  within  twenty- 
four  hours,  and  that  usually  without  any  considerable  rise  of 
temperature.  The  interval  of  consciousness  varies  widely,  but  is 
not  often  longer  than  an  hour  or  two,  whilst  in  many  cases  it  is 
scarcely  recognisable.  As  accessory  signs,  the  following  may  be 
mentioned  :  (a)  Since  the  blod-clot  is  situated  close  to  the  motor 
area  of  the  cortex,  and  especially  over  the  centres  for  the  head 
and  arm,  twitching  of  these  parts,  followed  perhaps  by  paralysis, 
may  be  a  well-marked  feature,  and  usually  supervenes  before  the 


682  A  MANUAL  OF  SURGERY 


onset  of  coma ;  (b)  when  the  clot  extends  to  the  base  of  the  skull, 
it  presses  on  the  cavernous  sinus,  and  may  induce  passive  con- 
gestion of  the  eyeball,  paresis  of  some  of  the  ocular  muscles,  and 
proptosis,  with  possibly  a  dilated  pupil  and  high  temperature  ; 
and  (c)  when  a  fissure  exists  in  the  bone,  blood  may  filter  through 
into  the  temporal  fossa,  and  cause  a  marked  fulness  in  that  region. 
The  Prognosis  is  extremely  unfavourable,  von  Bergmann  stating 
that  out  of  ninety-nine  cases  only  sixteen  recovered. 

The  Diagnosis  of  subcranial  haemorrhage  is  easy  if  there  is  an 
open  wound,  or  if  the  symptoms  are  at  all  typical ;  but  even  then 
one  cannot  be  certain  that  the  middle  meningeal  artery  has  given 
way,  and  that  the  symptoms  are  not  due  to  venous  bleeding.  An 
examination  of  the  injury  and  of  the  part  struck,  and  the  rapidity 
of  onset  of  the  symptoms,  may  help  in  this  matter,  but  it  is  often 
impossible  to  make  a  diagnosis  with  certainty. 

The  Treatment  consists  in  trephining  in  order  to  remove  the 
blood-clot  and  secure  the  artery,  if  still  bleeding.  The  spot 
selected  for  dealing  with  the  anterior  division  of  the  artery  is 
i|-  inches  behind  the  external  angular  process  of  the  frontal  bone, 
and  1 1  inches  above  the  zygoma  (Fig.  295,  F),  and  this  point 
should  be  marked  on  the  bone  with  a  bradawl  through  the  scalp 
before  commencing  the  operation.  The  scalp  is  shaved  and 
thoroughly  purified,  and  a  flap  turned  down,  including  everything 
as  far  as  the  pericranium  (Fig.  72,  E).  A  crucial  incision  is 
then  made  over  the  selected  spot,  and  the  pericranium  reflected 
sufficiently  to  allow  a  i-inch  trephine  to  be  applied.  On  removing 
the  disc  of  bone,  a  mass  of  blood-clot  presents,  which  should  be 
broken  up  with  the  finger  and  washed  away.  If  the  artery  is 
seen  bleeding  on  the  dura  mater,  it  may  be  possible  to  pick  it  up, 
and  tie  or  twist  it,  or  a  fine  curved  needle  threaded  with  catgut 
may  be  passed  under  it,  and  thus  a  ligature  applied.  If,  how- 
ever, the  blood  comes  from  a  canal  in  the  bone,  the  outer  table 
must  be  clipped  away,  sufficiently  to  enable  the  canal  to  be  seen 
and  plugged  by  a  small  piece  of  aseptic  wax,  sponge,  or  gauze, 
which  may  be  left  without  danger.  The  flap  is  then  replaced,  and 
stitched  down,  a  drain-tube  being  inserted  for  a  time. 

The  posterior  branch  of  the  artery  can  be  reached  by  trephining 
immediately  below  the  parietal  eminence  at  the  same  level  as  for 
the  anterior  branch — i.e.,  1^  inches  above  Reid's  base  line  ;  or, 
again,  it  can  be  exposed  nearer  its  origin  at  a  spot  if  inches 
behind  the  external  angular  process  of  the  frontal  bone,  and  f  inch 
above  the  upper  margin  of  the  zygoma  (Fig.  295,  G). 

3.  Wounds  of  the  Internal  Carotid  Artery,  in  its  intracranial 
portion,  are  rare,  but  if  complete  are  necessarily  fatal.  They 
usually  result  from  penetrating  wounds  of  the  orbit,  or  from  a 
gunshot  wound,  or  the  vessel  may  be  torn  by  a  splinter  of  bone  in 
a  fracture  of  the  base  of  the  skull.     Mere  fissures  through  the 


HEAD  INJURIES  683 

carotid  canal  do  little  harm,  since  there  is  plenty  of  room  within 
it  around  the  artery.  Occasionally,  however,  the  artery  is  slightly 
torn,  and  an  aneurismal  varix  develops  between  it  and  the  cavernous 
sinus.  Of  seventy-five  cases  of  pulsating  exophthalmos,  Riving- 
ton  found  that  forty-one  were  caused  by  trauma,  and  were  prob- 
ably of  this  nature.  Treatment. — -The  injury  is  fatal  in  the 
majority  of  cases  before  help  can  be  obtained  ;  if  not,  compres- 
sion or  ligature  of  the  carotid  trunk  in  the  neck  is  the  only  hope. 
See  also  on  intraorbital  aneurism  (p.  275). 

4.  Intrameningeal  Haemorrhage  arises  from  wounds  of  the 
cerebral  cortex  or  membranes  in  cases  of  fractured  skull,  or  from 
concussion  without  fracture.  The  blood  may  be  derived  from  the 
veins  and  capillaries  so  abundantly  present  in  the  pia  mater,  or 
from  lesions  of  the  inner  wall  of  venous  sinuses,  or  even  from  the 
middle  meningeal  artery,  if  the  dura  mater  is  also  opened.  It 
may  be  widely  diffused  over  the  surface  of  the  hemispheres,  or  be 
more  localized.  It  is  often  but  slowly  absorbed,  and  may  become 
encapsuled,  constituting  what  is  known  as  an  arachnoid  cyst — i.e., 
a  closed  cavity  containing  serum,  the  wails  of  which  are  formed  of 
fibrous  tissue  stained  brown  with  haematin. 

The  Symptoms  are  those  of  cerebral  compression,  and  usually 
supervene  directly  on  concussion  without  any  conscious  interval. 
The  coma  is  often  of  long  duration,  though,  as  a  rule,  not  of  great 
intensity.  Perfect  recovery  may  ensue,  even  though  unconscious- 
ness is  prolonged  for  weeks  ;  but  adhesions  may  form  as  the 
result  of  a  chronic  meningitis  lighted  up  by  the  accident,  and 
these  may  lead  to  subsequent  trouble.  No  focal  symptoms  are 
produced  unless  the  haemorrhage  arises  from  or  presses  upon  the 
motor  area,  when  convulsions,  or  later  on  paralysis,  may  ensue. 

The  Treatment  is  symptomatic,  the  patient  being  kept  absolutely 
quiet,  and  all  excitement  and  noise  which  might  induce  cerebral 
congestion  excluded.  Should  there  be  any  focal  symptoms 
indicating  the  position  of  greatest  pressure,  or  should  there  be 
some  concurrent  lesion  of  the  skull,  the  trephine  may  be  applied 
at  this  spot.  It  must  not  be  forgotten,  however,  that  the  chief 
haemorrhage  often  occurs  (as  will  be  presently  pointed  out),  not 
at  the  point  to  which  the  injury  was  directed,  but  at  an  exactly 
opposite  spot  on  the  other  side  of  the  cranium,  and  hence  con- 
siderable uncertainty  may  arise  both  as  to  the  advisability  of  an 
operation  and  as  to  its  site.  Should  the  right  locality  have  been 
exposed,  the  dura  mater  will  probably  bulge  into  the  wound, 
after  the  circle  of  bone  has  been  removed;  it  is  blackish  blue  in 
colour,  owing  to  the  clot  lying  beneath  it,  and  the  cerebral  pulsa- 
tions will  not  be  detected.  It  is  carefully  incised,  and  the  blood- 
clot  removed  ;  any  bleeding-points  should  be  tied  or  compressed, 
or  it  may  be  necessary  to  insert  a  small  wick  of  aseptic  gauze  for 
a  day  or  two,  in  order  to  drain  off  serum  and  blood. 


634  A  MANUAL  OF  SURGERY 


5.  Cerebral  Haemorrhage  occurs  more  frequently  from  idiopathic 
causes  than  from  trauma,  except  in  the  case  of  severe  lacerations. 
In  the  more  aggravated  forms,  death  is  almost  certain  to  follow  in 
a  short  time  from  coma ;  the  symptoms  of  the  less  serious  cases 
are  discussed  later  on  under  the  heading  '  Laceration  of  the 
Brain  '  (p.  694). 

General  Conditions  of  the  Brain  after  Head  Injuries. 

Concussion  of  the  Brain,  or  stunning,  is  a  clinical  condition 
characterized  by  a  more  or  less  complete  suspension  of  its  func- 
tions as  a  result  of  an  injury  to  the  head,  which  may  or  may  not 
have  produced  an  anatomical  lesion.  It  varies  with  the  severity 
of  the  cause  from  a  slight  momentary  giddiness  and  confusion  of 
thought  to  the  most  complete  insensibility,  and  is  closely  allied  to 
shock,  from  which  it  is  often  distinguished  with  difficulty. 

In  fatal  cases,  one  finds  on  post-mortem  examination  merely 
the  same  conditions  as  obtain  in  shock,  viz.,  engorgement  of  the 
lungs,  viscera,  and  the  right  side  of  the  heart,  whilst  the  brain 
presents  some  lesion  of  varying  severity,  from  mere  punctiform 
ecchymoses  to  actual  disintegration  and  disorganization.  The 
symptoms  are  supposed  to  be  due  to  a  paralysis  of  the  vaso- 
motor centres  in  the  medulla  and  subsequent  loss  of  vascular 
tone,  allowing  the  blood  to  gravitate  to  the  most  distensile  parts, 
viz.,  the  portal  system.  Reflex  inhibition  of  the  heart  through 
the  vagus  may  also  assist  in  their  production.  More  recently 
Duret  has  suggested  that  the  blow  on  the  skull  causes  a  tem- 
porary depression,  and  this  leads  to  compression  of  a  cone-shaped 
area  of  the  brain  substance.  As  a  result,  the  cerebro-spinal  fluid 
is  displaced  and  forced  downwards  to  the  base  of  the  skull,  where 
it  tends  to  collect,  particularly  in  the  fourth  ventricle,  and  thus 
the  vital  centres  grouped  around  this  space  are  compressed,  and 
anaemia  of  the  brain  (which  all  authorities  admit  to  be  present)  is 
produced.     This  explanation  of  concussion  is  very  feasible. 

The  Symptoms  vary  considerably  in  degree,  but  in  a  well-marked 
case  the  stage  of  concussion  is  evidenced  by  unconsciousness, 
more  or  less  complete,  although  the  patient  can  sometimes  be 
roused  by  shouting  ;  he  lies  on  his  back,  with  the  muscles  relaxed 
and  flaccid ;  the  eyelids  are  closed,  and  the  conjunctivae  may  be 
insensitive  ;  the  pupils  vary,  but  are  equal  and  often  contracted, 
usually  reacting  to  light,  but  in  bad  cases  they  are  dilated,  and  do 
not  contract  when  light  is  admitted.  The  surface  of  the  body  is 
pale,  cold,  and  clammy,  and  in  bad  cases  insensitive  even  to 
strong  electric  shocks.  The  respirations  are  slow,  shallow,  and 
sighing,  whilst  the  pulse  is  weak,  fluttering,  and  scarcely  sensible 
to  the  fingers  ;  the  temperature  is  subnormal ;  the  sphincters  are 
relaxed,  with  perhaps  unconscious  evacuations  from  both  bladder 
and  bowel.  The  reflexes  are  present  in  the  milder  cases,  though 
sluggish  ;  in  the  more  severe  they  may  be  entirely  absent. 


HEAD  INJURIES  685 


This  condition  may  last  for  a  considerable  time,  and  then  pass 
slowly  into  more  profound  unconsciousness  and  death,  or  be 
followed  by  the  phenomena  of  inflammation,  compression,  or 
cerebral  irritation.  If,  however,  the  case  is  going  on  to  recovery, 
reaction  soon  begins  to  manifest  itself.  The  patient  is  presumably 
put  to  bed,  and  warmth  carefully  applied  to  the  extremities. 
The  first  sign  of  reaction  is  probably  a  slightly  increased  rate  of 
both  breathing  and  pulse,  whilst  he  may  be  able  to  tell  his  name 
and  address ;  sometimes  the  earliest  indication  of  recovery  is  that 
he  turns  on  his  side,  and  pulls  the  bedclothes  up  to  his  face,  since 
he  feels  cold  and  chilly  as  a  result  of  the  cutaneous  anaemia. 
Gradually  he  becomes  more  and  more  rational,  and  the  functions 
of  both  mind  and  body  are  restored,  reaction  being  fully  estab- 
lished by  the  occurrence  of  vomiting,  due  to  a  condition  of  cerebral 
hyperaemia  following  the  anaemia.  Probably  he  suffers  from 
headache  for  some  days,  and  a  slight  amount  of  fever  will  follow  ; 
but  this  passes  off,  and  leaves  the  patient  either  quite  well,  or 
with  a  somewhat  irritable  brain  requiring  prolonged  rest.  Subse- 
quent events  may,  however,  prove  that  more  mischief  has  been 
done  than  appears  at  first.  One  sequela  of  concussion  may  be 
that  some  special  function  of  the  brain  is  permanently  lost  or 
impaired,  such  as  memory,  hearing,  or  vision  ;  thus,  a  patient 
may  forget  the  names  of  places  or  persons,  or  may  lose  all  memory 
of  time  ;  speech  may  become  defective  or  stammering,  or  a  certain 
amount  of  asthenopia  (weakness  of  vision)  may  supervene.  Such 
individuals  are  very  liable  to  recurrent  attacks  of  inflammation, 
one  of  which  may  prove  fatal.  Others  are  left  with  an  in- 
ordinately irritable  brain,  incapable  of  standing  excess  of  work  or 
errors  of  diet ;  and,  in  such,  a  sudden  fatal  issue  is  not  uncommon, 
Others,  again,  seem  to  suffer  from  a  general  loss  of  nerve  tone 
(neurasthenia),  rendering  them  incapable  of  fulfilling  their  ordinary 
duties  in  life. 

The  Treatment  of  concussion  very  closely  resembles  that  of 
shock,  viz.,  the  patient  is  at  once  put  to  bed,  with  the  head  low, 
and  is  covered  with  warm  blankets  ;  hot -water  bottles  may  be 
applied  to  the  extremities,  and  friction  to  the  surface.  Any  need- 
less stimulation  must  be  avoided  for  fear  of  exciting  haemorrhage  ; 
an  enema  of  hot  coffee  may  be  given,  or,  if  in  extremis,  brandy,  or 
a  hypodermic  injection  of  strychnine.  On  the  establishment  of 
reaction,  but  not  before,  a  good  purge,  such  as  5  grains  of  calomel, 
should  be  administered,  and  the  patient  is  then  kept  for  some  days 
in  bed  on  a  restricted  diet,  with  the  bowels  freely  open  and  all 
sources  of  excitement  excluded. 

When  the  unconsciousness  is  prolonged,  and  the  absence  of 
signs  of  fracture  in  the  cranium  or  of  focal  symptoms  prevents  the 
localizing  of  the  lesion,  the  head  should  be  shaved,  and  an  icebag 
or  Leiter's  tubes  applied ;  the  bowels  are  kept  acting  freely,  and 
the  state  of  the   bladder  attended  to  ;  the  room  must   be  kept 


686  A   MANUAL  OF  SURGERY 


dark  and  quiet,  the  attendants  making  as  little  noise  in  walking 
and  talking,  etc.,  as  possible  ;  sufficient  nourishment  must  be  given, 
either  by  a  spoon,  if  the  patient  can  thus  take  it,  or  by  nutrient 
enemata.  In  the  former  case  iced  milk  and  chicken  broth  or  beef- 
tea  must  be  depended  upon. 

Cerebral  Irritation. — By  cerebral  irritation  is  meant  a  clinical 
condition  which  sometimes  follows  concussion,  characterized  by 
great  irritability  of  both  mind  and  body.  It  usually  results  from 
blows  or  falls  on  the  temple,  forehead,  or  occiput,  and  is  probably 
due  to  a  superficial  laceration  of  the  brain,  possibly  in  the  frontal 
region,  and  the  hyperaemia  caused  by  its  subsequent  repair. 

The  Symptoms  are  very  characteristic,  and  usually  manifest 
themselves  two  or  three  days  after  the  injury.  They  may  be 
divided  into  two  groups,  (a)  Bodily  Symptoms :  The  patient  lies 
on  his  side  in  a  condition  of  general  flexion,  the  back  arched,  the 
legs  drawn  up  to  his  abdomen  with  the  knees  bent,  and  the  hands 
and  arms  drawn  in.  He  is  restless,  and  may  toss  about,  but 
never  fully  extends  himself,  or  lies  supine.  The  eyes  are  closely 
shut,  and  he  resists  all  attempts  to  open  them  ;  the  pupils  are 
contracted  ;  the  temperature  is  usually  a  little  raised,  but  the 
surface  of  the  body  and  head  are  both  cool ;  the  pulse  is  quiet 
but  weak  ;  the  sphincters  are  usually  in  a  normal  condition,  and 
the  excreta  are  often  passed  in  the  bed,  but  the  bladder  may 
occasionally  need  to  be  emptied  by  catheter.  In  some  mild 
instances  the  patient  may  get  up  to  empty  his  bladder  and  then 
return  to  bed.  (b)  Mental  Condition  :  The  patient  is  by  no  means 
unconscious,  but  he  takes  no  heed  of  what  is  passing  around,  and 
is  intensely  and  morbidly  irritable.  When  disturbed,  he  will 
gnash  his  teeth,  frown,  swear,  and  resent  the  intrusion  in  the  most 
expressive  manner.  At  the  end  of  a  few  days,  or  perhaps  after  a 
week  or  two,  a  marked  alteration  in  the  condition  of  the  patient 
usually  shows  itself.  He  is  less  irritable,  begins  to  stretch  himself 
out,  and  with  this  is  conjoined  an  improvement  in  both  pulse  and 
temperature.  A  change  is  sometimes  noticed  in  his  mental  state, 
since  he  may  be  quite  childish  and  weak.  '  Irritability  gives  way 
to  fatuity'  (Erichsen).  In  this  stage  he  may  need  to  be  treated 
as  a  child,  and  even  taught  the  names  of  persons  and  things ;  later 
on  he  may  glibly  detail  the  history  and  cause  of  his  accident, 
giving  a  fresh  story  every  day,  but  frequently  there  is  an  absolute 
lapse  of  memory  concerning  the  accident  and  the  events  which 
led  to  it.  After  a  time  the  brain  recovers,  but  more  or  less  serious 
after-effects  are  likely  to  ensue.  Sometimes  the  symptoms  pass 
over,  however,  into  those  of  subacute  or  chronic  meningitis. 

In  the  Treatment  the  surgeon  must  remember  that  there  is  a 
considerable  tendency  to  asthenia,  and  hence,  while  the  patient  is 
kept  quiet  and  free  from  all  noise  or  excitement,  he  must  be  well 
supported  by  a  light  and  nourishing  diet.     The  head  should  be 


HEAD  INJURIES  687 


placed  low  and  shaved,  and  Leiter's  tubes  fitted  on,  if  the  patient 
will  permit  it ;  but  it  is  better  to  omit  this  entirely  than  to  apply 
cold  intermittently.  The  bowels  must  be  kept  well  open,  and 
possibly  small  doses  of  bromides,  or  even  opium,  may  be  useful. 
If  any  signs  of  meningeal  inflammation  follow,  such  as  rise  of 
temperature  and  pulse,  heat  of  head,  and  great  sleeplessness, 
blisters  or  leeches  may  be  applied  locally,  and  mercury  ad- 
ministered internally. 

Compression  of  the  Brain. — Compression  is  the  term  given  to  a 
clinical  condition  due  to  some  abnormal  and  excessive  intra- 
cranial pressure  which  disturbs  the  functions  of  the  brain.  When 
of   traumatic  origin,   it    may  arise    from    the    following    causes  : 

(a)  Depressed  bone  or  the  presence  of  a  foreign  body,  in  which 
case  the  symptoms  of  concussion  merge  directly  into  those  of 
compression,  and  usually  without  any  interval  of  consciousness. 

(b)  Extravasation  of  blood  within  the  cranium,  either  outside  the 
membranes,  or  on  the  surface  of  the  brain,  or  within  its  substance. 
If  the  bleeding  is  extradural,  there  will  probably  be  a  short 
interval  of  consciousness  between  the  concussion  and  the  com- 
pression ;  if  the  bleeding  is  cerebral,  the  symptoms  of  compression 
may  manifest  themselves  at  once  without  any  interval  being 
noticed,  (c)  It  may  be  due  to  an  acute  spreading  oedema,  the 
explanation  of  which  is  subsequently  given  (p.  695).  (d)  It  may 
arise  from  a  collection  of  inflammatory  exudation  or  pus,  in  which 
case  the  symptoms  are  preceded  by  those  of  inflammation,  and  at 
the  earliest  will  not  manifest  themselves  before  the  third  day, 
whilst  they  may  be  deferred  for  a  week  or  two. 

Compression  may  also  arise  as  a  result  of  idiopathic  haemorrhage, 
tumours,  gummata,  or  abscesses,  e.g.,  as  a  complication  of  middle- 
ear  disease. 

The  Symptoms  of  compression  are  essentially  those  of  coma. 
When  the  condition  is  wrell  established,  the  patient  lies  on  his 
back  absolutely  unconscious,  and  cannot  be  roused  either  by 
shouting  or  shaking.  His  breathing  is  slow,  laboured,  and  ster- 
torous, the  lips  and  cheeks  being  puffed  in  and  out.  The  stertor 
arises  from  paralysis  of  the  soft  palate,  and  the  puffing  of  the 
cheeks  from  paralysis  of  the  facial  muscles.  In  the  later  stages 
the  respirations  may  be  more  rapid  and  irregular,  somewhat 
approaching  the  Cheyne-Stokes  type.  Death  arises  from  cessa- 
tion of  the  respiratory  act.  The  pulse  is  full  and  slow  at  first, 
but  later  on  becomes  rapid  and  irregular,  owing  to  increased 
pressure  upon  and  exhaustion  of  the  medullary  centres.  The 
surface  of  the  body  may  either  be  cool,  hot,  or  perspiring ;  the 
body  temperature  similarly  varies,  in  some  cases  being  hyper- 
pyrexial,  in  others  low,  and  where  the  compressing  force  is 
unilateral,  there  may  be  some  difference  on  the  two  sides  of  the 
body.      The  pupils  become  dilated  without    responding  to  light, 


688  A   MANUAL  OF  SURGERY 


but  vary  according  to  the  degree  of  compression  and  the  situation 
of  the  compressing  agent.  If  the  cerebral  pressure  is  equally 
diffused,  both  pupils  first  contract,  and  then  gradually  dilate  and 
become  reactionless  ;  but  if  one  hemisphere  is  affected  more  than 
the  other,  the  pupil  on  that  side  passes  rapidly  through  these 
changes,  whilst  on  the  opposite  side  they  are  not  developed  until 
later.  Thus,  it  is  a  common  thing  to  find  the  pupils  unequal  in 
size,  and  reacting  differently  to  light.  The  whole  body  in  the 
later  stages  is  in  a  condition  of  motor  paralysis,  but  at  an  earlier 
period  of  the  case  there  may  be  some  difference  on  the  two  sides, 
if  the  lesion  is  unilateral ;  thus,  if  the  left  side  of  the  brain  is 
primarily  affected,  a  right-sided  hemiplegia  is  likely  to  be  present 
at  a  time  when  the  muscles  on  the  left  side  can  still  respond  to 
cerebral  stimuli.  A  localized  compression  involving  the  motor 
area  may  lead  to  convulsions  in  the  corresponding  group  of 
muscles.  The  bladder  is  paralyzed,  and  hence  retention  ensues, 
whilst  the  sphincter  ani  is  relaxed,  and  faeces  pass  involuntarily, 
although  marked  constipation  is  usually  present. 

The  symptoms  in  some  cases  are  ushered  in  by  severe  pain 
or  headache,  which  is  partly  due  to  pressure  upon  and  tearing 
of  the  dura  mater,  and  partly  to  the  altered  vascular  conditions  of 
the  brain  ;  the  brain  substance  itself  is  not  sensitive,  and  hence 
the  pain  is  not  directly  referable  to  any  lesion  of  or  pressure  upon 
it.  Naturally  the  clinical  picture  is  modified  according  to  the 
cause  of  the  compression,  and  it  is  impossible  to  discuss  here 
more  than  the  general  features.  The  course  of  the  case,  too,  varies 
widely  according  to  whether  or  not  the  compressing  agent  can 
be  removed  by  the  surgeon,  or  absorbed  by  natural  processes. 
Patients  not  uncommonly  recover  from  small  cerebral  and  intra- 
meningeal  haemorrhages  causing  temporary  compression,  but 
rarely  do  so  without  operation  if  the  symptoms  are  due  to 
depressed  bone,  the  presence  of  a  foreign  body,  or  large  exuda- 
tions of  blood,  serum,  or  pus. 

The  Diagnosis  of  coma  from  compression,  when  a  complete 
history  of  the  case  can  be  obtained,  is  often  easy,  and,  indeed,  the 
whole  clinical  aspect  may  be  so  typical  that  no  question  as  to  the 
cause  of  unconsciousness  can  be  raised.  But  when  a  person  is 
found  in  the  streets  unconscious,  where  no  history  either  of  the 
patient  or  of  an  accident  is  obtainable,  and  where  no  serious 
lesion  of  the  skull  is  present,  the  diagnosis  is  often  extremely 
obscure,  since  coma  may  be  due  to  many  other  causes,  e.g.  : 
(a)  Cerebral  lesions,  such  as  apoplexy,  whether  the  result  of 
haemorrhage,  embolus,  or  thrombosis ;  or  it  may  be  the  con- 
sequence of  a  preceding  epileptic  fit,  or  due  to  a  rapidly  spreading 
oedema  in  cases  of  cerebral  tumour  or  abscess,  (b)  Various  toxic 
agents  may  induce  coma  ;  they  may  be  introduced  into  the  system 
from  without,  as  in  the  case  of  alcohol,  opium,  or  other  narcotics, 
or  may  be  developed  within  the  body,  as  in  uraemia  or  diabetic 


HEAD  INJURIES  6S9 


coma,  (c)  Heatstroke  or  exposure  to  cold  may  also  lead  to 
unconsciousness.  In  the  latter  case  there  can  be  but  little  doubt 
as  to  the  cause,  since  the  patient  is  cold,  pale,  and  in  a  state  of 
severe  prostration  ;  in  the  former  the  diagnosis  may  for  a  time  be 
doubtful,  (d)  Lastly,  it  must  not  be  forgotten  that  two  or  more 
of  these  conditions  may  co-exist.  Thus,  a  drunken  man  may  fall 
and  break  his  skull,  and  then  the  smell  of  liquor  in  his  breath 
may  lead  to  an  erroneous  diagnosis. 

It  is  therefore  evident  that  a  very  careful  examination  of  the 
patient  is  required  before  any  conclusion  can  be  arrived  at  as 
to  the  cause  of  the  coma,  and  it  is  often  impossible  to  make  a 
diagnosis.  In  such  cases  the  patient  should  be  carefully  tended 
and  watched,  and  not  shut  up  for  the  night  in  a  police-cell  without 
attendance. 

The  following  points  should  always  be  observed  in  the 
examination:  (1)  A  rapid  note  should  be  made  as  to  the  sur- 
roundings of  the  patient — whether  there  is  blood  or  vomit  near 
him,  how  the  body  is  lying,  and  the  nature  of  the  ground. 
(2)  The  depth  of  the  coma  should  be  ascertained,  and,  if  possible, 
the  man  should  be  roused,  and  asked  to  give  an  account  of  him- 
self. (3)  A  most  thorough  and  complete  investigation  should  be 
made  as  to  his  condition.  His  skull  must  be  first  examined,  to 
settle  if  possible  whether  or  not  a  fracture  is  present  ;  the  surface 
temperature  of  the  body  is  noted,  as  also  the  character  of  the 
pulse  and  respirations.  The  tongue  should  be  looked  at,  as  it  is 
often  bitten  in  an  epileptic  fit,  and  the  smell  of  the  breath  should 
also  be  noted.  The  condition  of  the  pupils  may  throw  some  light 
on  the  case;  in  opium-poisoning  they  are  small  and  equal,  a 
condition  also  seen  in  haemorrhage  into  the  pons  ;  in  alcoholism 
they  are  often  dilated  and  fixed,  but  vary  considerably  in  different 
cases.  The  amount  of  power  and  the  state  of  the  reflexes  are 
then  observed,  any  inequality  probably  indicating  a  unilateral 
lesion  in  the  brain.  The  urine  must  be  drawn  off,  and  carefully 
examined  for  albumen  and  sugar.  (4)  in  dubious  cases,  and 
especially  where  there  is  any  suspicion  of  drunkenness  or  poison, 
the  stomach  should  be  emptied  and  washed  out.  (5)  Finally,  if 
the  cause  is  still  uncertain,  the  patient  should  be  put  to  bed  and 
carefully  watched. 

The  Treatment  of  compression  must  be,  where  possible,  directed 
to  removing  the  cause.  When  it  is  due  to  depressed  bone  or  a 
foreign  body,  immediate  operation  is  required  ;  collections  of  pus 
should  be  opened  and  blood-clots  removed.  Failing  such  measures, 
the  treatment  of  the  condition  resolves  itself  into  keeping  the 
patient  quiet,  with  the  head  low  and  cool,  the  room  dark  and 
noiseless,  the  bowels  open  (using  croton-oil  on  sugar,  cr  enemata, 
for  this  purpose),  and  the  bladder  empty.  The  patient  may  have 
to  be  fed  by  the  rectum,  and  if  the  breathing  or  pulse  is  very 
laboured,  and  cyanosis  begins  to  show  itself,  venesection  may  be 

44 


690  A   MANUAL  OF  SURGERY 


advisable.  Considerable  interference  with  the  respiration  arises 
from  falling  back  of  the  tongue,  as  often  occurs  in  profound  anaes- 
thesia during  surgical  operations,  and  if  due  to  this  cause  the  head 
may  be  rolled  over  to  one  side,  or  the  tongue  pulled  forwards. 
Occasionally  patients  remain  in  this  condition  for  weeks  or  months. 

Intracranial  Inflammation.  -Inflammation  of  the  cranial  con- 
tents is  often  met  with  as  a  result  of  injury,  and  although  we 
shall  describe  several  distinct  varieties,  it  must  be  remembered 
that  the  various  forms  run  into  one  another,  and  that  in  practice 
mixed  types  are  the  more  common,  giving  rise  to  a  corresponding 
complexity  of  symptoms.  For  descriptive  purposes  the  following 
groups  may  be  distinguished  : 

(i.)  Subcranial  Inflammation.  —  This  may  occur  in  the  form 
either  of  an  effusion  of  pus  between  the  dura  mater  and  the 
bone  (subcranial  abscess),  or  as  a  thickening  of  the  dura  mater 
(pachymeningitis). 

The  former  results  from  either  a  compound  depressed  or  a 
punctured  fracture,  in  which  the  dura  mater  is  only  separated 
from  the  bone  and  not  lacerated,  especially  when  the  external 
wound  is  small  and  efficient  drainage  is  not  obtained.  It  some- 
times occurs,  however,  in  consequence  of  a  simple  contusion  or 
fracture  of  the  skull,  leading  to  a  detachment  of  the  membranes 
and  a  collection  primarily  of  blood  and  later  of  inflammatory  fluids 
in  the  cavity  thus  produced.  Microbic  invasion  is  here  due  to 
auto-infection,  or  to  the  passage  of  organisms  through  the  bone. 
Apart  from  injury,  its  most  common  cause  is,  without  doubt, 
extension  of  inflammation  either  from  the  superjacent  bone  or 
from  the  middle  ear.  The  Symptoms  produced  are  (1)  those 
generally  characteristic  of  suppuration,  viz,,  a  high  temperature, 
with  perhaps  rigors.  (2)  The  signs  of  intracranial  pressure  in 
the  form  of  fixed  headache  followed  by  coma  are  also  present. 
(3)  If  there  is  no  open  wound,  an  oedematous  swelling  of  the  scalp, 
known  as  Potfs  puffy  tumour,  may  develop  over  the  site  of  the 
abscess  (Fig.  249).  When  there  is  a  compound  fracture  of  the  skull, 
the  margins  of  the  wound  look  unhealthy,  and  at  its  base  may  be 
seen  bare  bone,  yellow  and  dry,  from  which  the  pericranium  has 
separated,  with  perhaps  pus  oozing  out  between  the  fragments. 
If  the  pus  burrows  towards  the  base  of  the  skull,  optic  neuritis 
may  develop.  (4)  Focal  symptoms  of  spasm  or  paralysis  may 
complicate  the  case  if  the  dura  over  the  motor  area  is  involved. 
The  Treatment  of  such  a  condition  consists  in  evacuating  the 
abscess  cavity  through  a  sufficient  opening  made  by  trephining, 
or  by  removing  loose  portions  of  bone,  and  providing  for  drainage. 
Sometimes  more  than  one  opening  is  required  for  this  purpose. 

Simple  pachymeningitis,  or  thickening  of  the  dura  mater,  may 
result  from  a  slight  simple  depressed  fracture,  or  even  from  con- 
tusion with  or  without  a  fissured  fracture.     No  immediate  symp- 


HEAD  INJURIES  691 


toms  need  arise,  but  those  characteristic  of  chronic  meningitis 
described  below  are  usually  met  with  at  a  later  date  ;  in  fact,  it 
is  impossible  to  distinguish  clinically  between  the  two  affections. 

(ii.)  Acute  Diffuse  Meningitis  is  always  infective  in  nature,  and 
generally  due  to  the  pyogenic  cocci.  Formerly  some  cases  were 
supposed  to  result  from  merely  mechanical  causes,  but  they  also 
are  probably  due  to  bacteria  of  lesser  virulence,  such  as  the 
pneumococcus.  The  symptoms  vary  considerably  in  their  in- 
tensity, according  to  the  method  of  inoculation  and  the  activity 
of  the  organisms.  The  superficial  part  of  the  brain  is  involved 
in  the  inflammation  as  well  as  the  meninges,  and  the  term 
meningo-encephalitis  would  perhaps  be  the  better  appellation. 

The  Symptoms  appear  about  forty-eight  hours  after  the  injury, 

Inflamed    CEdematous 
bone.       scalp  tissue. 


Subdural  space. 

^.Scalp. 

sf .Cranium. 

,  Brain  covered 
by  pia  mater 
and  arachnoid. 


Fig  249. — Subcranial  Suppuration,  involving  Overlying  Bone  and 
causing  an  CEdematous  Condition  of  the  Scalp — Pott's  Poffy 
Swelling  (Semi-diagrammatic).  (From  Treves'  '  System  of  Sur- 
gery.') 

although  sometimes  infection  may  be  delayed  beyond  this  period. 
In  the  early  stages  the  patient  complains  of  severe,  constant,  and 
increasing  headache,  associated  with  heat  of  head,  a  forcible 
pulsation  of  the  carotids,  a  full  pulse,  and  general  irritability  of 
the  brain,  as  indicated  by  vomiting,  intolerance  of  light  and  sound, 
delirium,  and  perhaps  convulsive  twitchings  of  the  muscles,  not 
only  of  the  head  and  back,  but  also  of  the  extremities.  High 
fever  is  usually  present,  and  possibly  a  rigor  may  occur  at  the 
onset.  As  the  disease  progresses,  the  patient  gradually  becomes 
comatose,  and  dies  from  cerebral  compression. 

According  to  the  site  of  infection,  the  inflammatory  phenomena 
may  manifest  themselves  more  acutely  over  one  part  than  another, 
and  for  descriptive  purposes  two  chief  varieties  have  been  distin- 
guished, viz.,  meningitis  of  the  convexity,  and  meningitis  of  the 
base.     The  general  symptoms  are  alike  in  both  forms,  but  when 

44—2 


692  A  MANUAL  OF  SURGERY 

the  convexity  is  involved,  convulsions  are  a  more  prominent 
feature  in  the  case,  and  may  at  first  be  limited  to  localized  groups 
of  muscles,  whilst  in  basal  meningitis  the  temperature  tends  to 
run  higher,  the  head  and  neck  are  more  retracted,  optic  neuritis 
is  more  frequent,  and  some  form  of  squint  is  not  uncommonly 
observed. 

On  post-mortem  examination  the  skull-cap  is  separated  from  the 
meninges  with  some  difficulty  ;  the  dura  mater  is  thick  and  con- 
gested, and  the  subjacent  veins  are  manifestly  distended  ;  the 
cerebro-spinal  fluid  is  increased  in  amount,  and  turbid  from  ad- 
mixture with  lymph  or  pus  ;  the  arachnoid  is  thick  and  opaque  ; 
the  surface  of  the  convolutions  is  flattened  and  cedematous,  and 
lymph  occupies  all  the  sulci,  matting  them  together  ;  the  cortical 
grey  matter  is  usually  red  and  congested  ;  the  underlying  white 
substance  of  the  centrum  ovale  is  injected,  numerous  puncta 
cruenta  being  evident ;  the  ventricles  are  distended  with  cerebro- 
spinal fluid,  and  the  choroid  plexuses  are  engorged  with  blood. 

The  Treatment  consists  in  shaving  the  head  and  applying  cold 
by  means  of  an  icebag  or  Leiter's  tubes,  care  being  taken  that 
the  application  is  continuous,  and  not  intermittent.  In  the 
robust  general  venesection  is  useful,  but  in  weaker  individuals 
cupping  or  leeching  may  replace  it.  The  bowels  are  freely  opened 
and  a  bland  diet  ordered.  The  patient  should  be  kept  absolutely 
quiet  in  a  darkened  room,  and  every  source  of  irritation  and 
excitement  removed.  Even  if  recovery  ensues,  it  is  somewhat 
delayed,  and  similar  precautions  as  to  quiet,  etc.,  must  be  main- 
tained for  some  time.  In  the  later  stages,  blistering  of  the  scalp 
or  neck,  and  the  administration  of  mercury,  are  advisable. 

Attempts  have  been  recently  made  to  relieve  the  symptoms 
and  determine  a  cure  by  means  of  operative  measures,  directed 
towards  reducing  the  intracranial  tension ;  the  subarachnoid 
space  has  been  opened  below  the  tentorium,  whilst  others  have 
utilized  Quincke's  plan  of  puncturing  the  spinal  membranes 
between  the  third  and  fourth  lumbar  vertebrae,  i.e.,  below  the 
termination  of  the  spinal  cord.  In  no  case  of  acute  meningitis 
has  a  successful  result  followed,  and  when  one  considers  the 
intricate  character  of  the  space  to  be  drained,  the  fact  that  it  is 
sure  to  be  subdivided  into  separate  cavities  by  deposits  of  lymph, 
and  especially  when  it  is  remembered  that  the  important  fourth 
ventricle  only  communicates  with  the  subarachnoid  space  through 
the  small  foramen  of  Majendie,  which  is  certain  to  be  early  blocked 
— all  these  considerations  go  to  prove  that  it  is  useless  attempting 
any  such  measures. 

Acute  Meningoencephalitis  is  sometimes  limited  in  character, 
when  resulting  from  penetrating  wounds.  Such  can  only  occur 
when  there  is  no  tension  from  retained  discharges,  diffusion  along 
the  meninges  being  prevented  by  the  formation  of  adhesions. 
Localized  suppuration  is  usually  present,  involving  even  the  brain 


HEAD  INJURIES 


693 


substance ;  but  with  care  recovery  is  possible,  although  an 
adherent  cicatrix  will  be  formed,  perhaps  giving  rise  to  subsequent 
epileptic  symptoms.  A  similar  condition  may  result  from  bruising 
of  the  bone  and  a  localized  suppurative  inflammation  connected 
therewith  (Fig.  250). 

(in.)  A  Subacute  form  of  meningitis  is  occasionally  met  with, 
coming  on  at  a  somewhat  later  date.  The  patient  may  have 
apparently  recovered  from  his  injury,  with  the  exception  of  a 
fixed  pain  in  the  head.  The  onset  of  the  symptoms  is  often  due 
to  some  indiscretion,  and  may  be  gradual  or  sudden.  In  all 
probability  this  affection  is  also  microbic  in  origin,  and  the  delay 
in  its  appearance  depends  either  on  the  small  number  of  bacteria 
present,  or  on  their  being  in  a  low  state  of  virulence  ;  or  possibly 
they  have  been  latent  for  a  time,  and  are  aroused  into  activity  by 
later  causes ;  or,  again,  they  may  have  gradually  worked  their 
way  inwards  along  lymphatics  or  vessels  from  the  periphery  to 

Collection  of 

pus  beneath       Inflamed 

dura  mater.  bone. 


pia  mater 
and  arachnoid. 


Fig     250. — Superficial   Abscess    of    Brain,   spreading   from    Subdural 
Space  (Semi-diagrammatic).     (From  Treves'  'System  of  Surgery.') 


the  meninges.  The  symptoms  are  similar  in  character  to  those 
of  acute  meningitis,  though  somewhat  less  severe  ;  but  a  fatal 
result  is  very  apt  to  follow.  In  the  treatment  of  this  form,  no 
active  antiphlogistic  measures  should  be  adopted,  since  the 
patient's  condition  is  somewhat  asthenic.  Absolute  rest  and  quiet 
are  essential ;  counter-irritation  should  be  applied  to  the  scalp 
and  neck,  and  possibly  mercury  administered. 

(iv.)  Chronic  Meningitis  may  result  from  any  injury  of  the 
meninges,  and  is  very  likely  to  occur  in  syphilitic  patients.  It 
is  evidenced  by  infiltration  and  thickening  of  the  membranes, 
which  are  usually  adherent  to  one  another  and  to  the  cerebral 
cortex.  It  gives  rise  to  a  localized  headache,  which  is  constant, 
and  increased  on  excitement  or  the  injudicious  use  of  stimulants, 
whilst  tenderness  is  often  noted  on  deep  pressure,  and  traumatic 
epilepsy  may  ensue.     The  treatment  consists  in  attention  to  the 


694  A  MANUAL  OF  SURGERY 

general  health,  abstinence  from  excitement  or  stimulants,  the 
local  application  of  counter-irritants,  and  possibly  the  adminis- 
tration of  mercury ;  the  bowels  must  be  kept  regular,  and  if 
epilepsy  follows,  and  the  lesion  can  be  localized,  trephining  may 
be  necessary. 

(v.)  Cerebral  Abscess. — For  pathology,  symptoms  and  treatment 
of  this,  see  p.  718. 

(vi.)  In  conclusion,  one  other  form  of  intracranial  inflammation 
must  be  mentioned,  viz.,  Infective  Thrombosis  of  the  Sinuses. 
This,  though  seen  after  injuries,  is  more  commonly  associated 
with  suppurative  diseases  of  the  bone  apart  from  trauma,  and 
one  variety,  viz.,  that  affecting  the  lateral  sinus,  is  almost  exclu- 
sively caused  by  disease  of  the  middle  ear.  It  is  also  induced  by 
extension  from  scalp  injuries  as  a  complication  of  subaponeurotic 
cellulitis,  or  may  spread  inwards  from  erysipelatous  lesions  of  the 
face  or  suppurative  conditions  of  the  nose.  Putting  aside  the 
results  of  chronic  otorrhcea,  the  cavernous  sinus  is  much  more 
frequently  involved  than  any  other. 

Pathologically,  the  same  manifestations  are  observed  as  in  any 
case  of  infective  phlebitis.  The  sinus  becomes  impervious  owing 
to  the  presence  of  a  thrombus,  and  this  in  turn  becomes  dis- 
integrated, and  gives  rise  to  multiple  emboli,  whilst  various  inflam- 
matory conditions  of  the  surrounding  tissues  necessarily  result, 
e.g.,  necrosis  or  caries  of  bones,  subcranial  abscess,  or  meningitis. 

The  symptoms  are  mainly  of  a  pyaemic  nature.  The  tempera- 
ture is  high,  but  with  remissions,  and  often  with  repeated  rigors ; 
fixed  headache  and  early  and  continuous  vomiting  are  also  marked 
features  of  the  case.  With  these  may  be  associated  evidences  of 
meningeal  mischief,  or  of  pulmonary  trouble  in  the  shape  of 
dyspnoea,  but  sometimes  diarrhoea  and  septicemic  manifestations 
may  be  the  more  prominent. 

If  the  cavernous  sinus  is  involved,  marked  exophthalmos,  with 
congestion  of  the  orbit,  and  even  of  the  eyelids  and  face,  may 
result,  and  ptosis  or  squint  may  also  be  set  up  by  implication  of 
the  nerves  which  lie  in  the  walls  of  the  sinus. 

If  the  superior  longitudinal  sinus  is  affected,  there  may  be 
turgescence  of  the  veins  of  the  scalp  and  forehead  together  with 
tenderness  along  the  line  of  the  sinus  and  epistaxis,  whilst  convul- 
sions may  be  induced  by  irritation  of  the  neighbouring  motor  area. 

For  local  results  and  treatment  of  thrombosis  of  the  lateral 
sinus,  see  p.  820. 

Treatment,  except  for  the  lateral  sinus,  is  but  rarely  possible, 
and  hence  the  importance  of  preventing  this  disease  by  a  most 
careful  attention  to  asepsis.  For  the  lateral  sinus  much  can  be 
done,  but  for  the  other  sinuses  all  that  is  feasible  is  attention  to 
general  measures. 

Laceration  of  the  Brain. — Injuries  to  the  brain  and  its  mem- 


HEAD  INJURIES  695 


branes  are  very  frequent  complications  of  blows  and  falls  on  the 
head,  and  all  the  most  serious  results  of  these  accidents  arise  from 
this  source.  They  are  produced  in  many  different  ways,  and 
cause  very  varied  symptoms  ;  but  the  most  important  distinction 
to  draw  is  between  those  wounds  which  communicate  with  the 
exterior  and  those  which  do  not. 

I.  Non-penetrating  Wounds  of  the  Brain  result  from  blows  and 
falls,  which  may  or  may  not  produce  simple  fissured  or  depressed 
fractures  of  the  skuil,  but  not  unfrequently  the  most  serious  cere- 
bral symptoms  follow  injuries  in  which  the  bones  do  not  participate. 
In  depressed  fractures  the  brain  is  usually  most  contused  or  torn 
immediately  below  the  injured  spot  ;  but  in  cases  where  there  is 
no  depression,  the  greatest  mischief  is  frequently  found  at  a  point 
exactly  opposite  to  that  struck,  whilst  the  local  bruise  may  be 
much  slighter.  Thus,  in  the  case  of  one  of  our  students  who, 
in  an  epileptic  fit,  fell,  striking  the  left  occipital  region  on  a  stone 
pavement,  we  found  postmortem  a  fissured  fracture  at  the  spot 
struck  and  a  bruise  on  the  left  occipital  convolution,  whilst  the 
anterior  portion  of  the  right  frontal  lobe  was  severely  contused, 
and,  indeed,  disintegrated.  The  explanation  of  this  fact  is  that 
the  force  of  the  injury  is  transmitted  to  the  brain  substance  in  a 
wave  which  concentrates  its  violence  against  the  opposite  side  of 
the  skull.  In  very  sharp  sudden  localized  blows,  as  from  a  spent 
bullet,  local  bruising  of  the  subjacent  brain  may  be  alone  produced. 

Pathological  Anatomy. — The  immediate  effects  of  such  an  injury 
vary  considerably.  There  may  be  a  mere  bruise,  evidenced  by  a 
few  points  of  extravasation,  on  the  surface  or  in  the  grey  matter  ; 
or  the  more  superficial  parts  of  the  brain  may  be  totally  disinte- 
grated and  mixed  with  clots  ;  or,  if  laceration  has  occurred,  clots 
may  be  found  adhering  to  the  injured  spot,  or  extending  from  it 
widely  into  the  subarachnoid  space,  or  even,  under  rare  circum- 
stances, into  the  lateral  ventricle.  The  later  effects  in  cases  where 
the  wound  does  not  communicate  with  the  exterior  are  mainly 
those  of  inflammation  or  degeneration.  Soon  after  the  accident 
considerable  exudation  follows,  causing  the  ecchymosed  brain 
substance  to  swell  and  become  cedematous ;  this  may  speedily 
subside,  but  in  the  more  serious  cases  a  spreading  oedema  may  be 
caused,  owing  to  the  pressure  of  the  swollen  tissues  upon  the 
superficial  veins  in  the  pia  mater  ;  the  circulation  in  these  is 
hindered,  and  increased  exudation  follows,  leading  to  general 
cerebral  pressure  and  even  death,  a  consequence  hastened  by 
the  excess  of  cerebro-spinal  fluid  usually  induced  by  the  process. 
Under  such  circumstances  the  greater  part  of  the  brain  is  cede- 
matous and  glistening,  the  injured  area  being  yellowish  red  in 
colour,  with  evident  points  of  extravasation  scattered  through  it. 
Still  later,  degeneration  of  the  brain  substance  may  follow  owing 
to  the  disturbance  of  its  circulation,  and  is  indicated  by  the 
presence  of  a  pulpy  yellowish  mass,  soft  enough  to  be  washed 


696  A   MANUAL  OF  SURGERY 

away  by  a  stream  of  water,  and  containing  fat  globules  and 
granular  cells,  with  debris  of  nerve  fibres  (yellow  softening).  If 
the  area  involved  is  small  and  unimportant,  the  patient  may 
recover  perfectly,  the  softened  tissue  being  absorbed ;  if  large  or 
implicating  important  centres,  death  or  paralysis  must  ensue.  In 
cases  of  laceration  of  the  brain  which  recover,  a  tough  depressed 
cicatrix  is  formed,  usually  adherent  to  the  membranes,  and  con- 
taining haematoidin  crystals,  whilst  extravasated  blood  may  be 
organized  into  a  dirty  brownish  lamina,  adherent  to  the  pia  mater, 
or  into  an  arachnoid  cyst. 

Clinical  History. — The  symptoms  necessarily  differ  with  the 
severity  and  locality  of  the  lesion. 

Whenever  concussion  occurs  after  ahead  injury,  and  the  patient 
recovers  slowly  after  it,  the  surgeon  will  rightly  suspect  laceration 
or  contusion  of  the  brain. 

If  concussion  is  rapidly  followed  by  the  symptoms  of  cerebral 
irritation,  there  can  be  no  doubt  as  to  the  existence  of  a  laceration, 
which  is  probably  situated  in  the  frontal  region. 

If  compression  has  supervened  within  twelve  or  twenty-four 
hours,  it  is  due  to  either  depressed  bone  or  haemorrhage  into  the 
cerebral  hemispheres,  if  there  is  no  interval  of  consciousness  ;  but 
if  the  patient  has  rallied  for  a  time  before  its  incidence,  haemorrhage 
from  the  meningeal  vessels  or  venous  sinuses  is  to  be  diagnosed, 
or  a  rapidly  spreading  oedema. 

If  localized  or  general  convulsions  occur  within  twenty-four 
hours  of  the  accident,  perhaps  going  on  to  compression,  haemor- 
rhage into  the  cortex  of  the  motor  area,  or  diffuse  extravasation 
into  the  subarachnoid  space,  is  probably  present.  It  is  not  easy 
to  distinguish  between  these  two,  but  haemorrhage  into  the  cortex 
usually  produces  a  more  regular  extension  of  the  convulsions, 
which  commence  by  twitching  of  some  part  of  the  body  which  the 
patient  at  the  time  is  perhaps  incapable  of  moving  voluntarily. 
Thus,  if  bleeding  is  occurring  into  the  cortical  centres  for  the  face 
on  the  left  side  of  the  body,  paralysis  of  the  right  side  of  the  face 
may  be  present,  and  it  is  here  that  the  convulsions  will  start, 
spreading  regularly  to  the  right  side  of  the  neck,  arm,  and  leg, 
and  then  involving  the  left  leg,  arm,  and  side  of  the  head  in  order, 
finally  becoming  general,  as  in  an  epileptic  fit.  After  each  con- 
vulsion the  paralysis  is  found  to  have  spread.  In  haemorrhage 
outside  the  convolutions  the  paralysis  is  less  marked  and  the  con- 
vulsions less  regular,  though  perhaps  more  generalized,  but  the 
symptoms  of  compression  develop  sooner. 

If  coma  supervenes  rapidly,  and  is  accompanied  by  hemiplegia, 
haemorrhage  into  the  corpus  striatum,  internal  capsule,  or  perhaps 
into  the  ventricles,  is  likely  to  be  present. 

In  simple  cases  concussion  is  usually  recovered  from  in  a  few 
hours  ;  the  temperature  subsequently  rises  to  about  ioo°  F.,  and 
remains  so  for  a  few  days,  whilst  the  patient  complains  of  fixed 


HEAD  INJURIES  697 


pain  and  headache,  which  under  suitable  treatment  may  entirely 
disappear.  Some  impairment  of  sense  or  function  may,  however, 
persist. 

If  subacute  localized  inflammation  ensues,  pain  and  headache 
will  be  complained  of  with  some  fever,  and  insensibility  may 
supervene  in  four  or  five  days,  preceded  by  convulsions  if  the 
motor  area  is  affected. 

Suppuration  in  the  white  substance  occasionally  results  at  a 
later  date  in  this  form  of  injury,  giving  rise  to  the  symptoms  of 
cerebral  abscess. 

The  Treatment  of  these  cases  is  always  an  exceedingly  anxious 
matter  for  the  surgeon.  In  the  majority  of  instances  it  is  merely 
symptomatic,  following  the  usual  course  adopted  in  concussion, 
compression,  cerebral  irritation,  etc.,  as  indicated  elsewhere. 
The  patient  is  kept  absolutely  quiet  in  bed,  with  an  ice-bag  to  the 
head,  and  a  purge  administered.  Depressed  bone,  if  present, 
will,  of  course,  be  dealt  with  by  operation.  Early  convulsions 
and  paralysis  are  carefully  watched  to  see  if  any  indication  as  to 
the  site  of  the  bleeding  can  be  obtained,  since  it  is  possible  that 
trephining  over  the  injured  spot  and  removing  blood-clots  might 
be  advisable ;  but  the  clinical  records  as  to  such  treatment  are 
very  scanty.  Late  convulsions  and  paralysis  due  to  inflammation 
are  best  treated  by  shaving  the  head  and  applying  an  ice-cap. 
If  the  pulse  is  full  and  hard,  and  the  patient  otherwise  young 
and  healthy,  general  venesection  may  be  adopted  ;  the  bowels 
must  be  moved  by  a  smart  purgative,  such  as  croton-oil,  whilst 
bromide  in  full  doses  may  be  administered.  If  the  convulsions 
continue  in  spite  of  such  treatment,  and  become  more  severe  and 
extensive,  the  patient  will  almost  certainly  die  of  coma  ;  trephining 
over  the  injured  area  is  then  distinctly  indicated,  the  surgeon 
hoping  to  find  and  remove  some  clot,  or,  at  any  rate,  to  relieve 
tension  within  the  dura. 

II.  Penetrating  Wounds  of  the  Brain  result  from  blows  or 
falls,  as  in  compound  depressed  fractures  ;  or  from  the  entrance 
of  foreign  bodies,  such  as  bullets  ;  or  from  stabs  or  punctures, 
which  most  commonly  occur  in  the  weaker  parts  of  the  cranium, 
e.g.,  the  temple  or  upper  wall  of  the  orbit ;  or  from  sabre-cuts  or 
axe-wounds,  in  which  an  oblique  or  almost  valvular  incision  is 
made  through  the  scalp  and  cranium,  laying  bare  and  wounding 
the  brain  and  its  membranes. 

In  these  cases  the  general  disturbance  is  often  slight,  compared 
with  the  extent  of  the  local  injury,  so  that,  although  brain  sub- 
stance may  protrude  from  the  wound,  there  is  sometimes  but 
little  concussion.  Any  of  the  conditions  due  to  haemorrhage 
detailed  above  may  follow,  but  they  may  be  less  severely  felt, 
except  in  cases  where  the  bleeding  is  into  the  substance  of  the 
brain,  since  the  blood  can  escape  from  the  wound.  The  inflam- 
matory phenomena  following  such   lesions   are    mainly  septic    in 


A   MANUAL  OF  SURGERY 


origin,  and  may  be  localized  or  diffuse.  In  the  latter  instance 
general  meningoencephalitis  manifests  itself  in  the  course  of  two 
or  three  days,  and  is  rapidly  fatal  ;  in  the  former  case  adhesions 
prevent  the  extension  of  the  trouble  beyond  the  neighbourhood 
of  the  wound.  Hernia  cerebri  is  very  likely  to  follow,  and  not 
unfrequently  a  deep  cerebral  abscess  will  complicate  matters  at  a 
later  date.  In  cases  that  have  been  successfully  rendered  aseptic, 
the  course  is  similar  to  that  run  by  a  non-penetrating  wound, 
except  that,  if  anything,  the  immediate  prognosis  is  better,  since 
the  opening  in  the  skull  and  the  possible  removal  of  damaged 
brain  substance  diminishes  the  likelihood  of  compression  from 
simple  or  spreading  oedema.  Where  the  lesion  has  involved  the 
motor  area,  permanent  monoplegia  may  persist. 

The  Symptoms  arising  from  a  penetrating  wound  of  the  brain 
have  been  in  measure  indicated  above.  In  the  worst  cases  im- 
mediate death  may  result,  or  severe  concussion,  merging  quickly 
into  compression,  i'rom  which  the  patient  never  recovers.  In  the 
less  serious  cases  there  will  be  a  varying  degree  of  concussion, 
followed  after  a  short  interval  by  the  phenomena  of  inflammation, 
localized  or  diffuse,  which  have  already  been  sufficiently  described. 
Focal  symptoms  may  also  arise  from  destruction  of  the  cortical 
centres. 

Treatment. — In  all  cases  of  punctured  or  compound  depressed 
fracture,  we  have  stated  that  a  thorough  exploration  of  the 
wound  should  be  made,  and  all  depressed  or  injured  bone  re- 
moved. Foreign  bodies  should  be  also  taken  away,  if  found  close 
to  the  wound  ;  but  it  is  doubtful  whether  a  bullet  should  be 
sought  for,  if  it  has  penetrated  deeply  into  the  brain,  or  if  it  has 
traversed  the  brain  and  fractured  the  bone  on  the  other  side. 
Probably  an  aseptic  incision,  with  removal  of  the  splintered  frag- 
ments and  a  limited  search  for  the  bullet,  is  the  best  treatment 
to  adopt,  and,  even  if  unsuccessful,  will  do  but  little  harm,  if 
the  patient's  general  state  warrants  an  operation.  When  he  is 
evidently  moribund,  it  is  better  practice  not  to  interfere.  Pro- 
truding brain  tissue  is  gently  removed,  and  the  whole  wound 
thoroughly  purified  with  carbolic  lotion  ;  even  the  i  in  20  solution 
may  be  used  without  fear.  The  dura  mater  should,  if  possible, 
be  drawn  together  by  one  or  two  sutures,  and  a  small  drain-tube 
or  a  gauze  wick  inserted  within  it.  Fragments  of  bone,  if  kept 
warm  and  aseptic,  may  be  replaced  (p.  679),  and  the  scalp- wound 
closed,  except  at  the  drain  opening ;  the  gauze  or  tube  should  be 
removed,  if  all  is  going  well,  in  about  two  days'  time.  If  the 
temperature  rises  as  a  result  of  septic  infection,  the  wound  must 
be  reopened,  and  every  effort  made  to  relieve  tension,  and  thus 
localize  the  mischief.  Should  diffusion  occur,  as  indicated  by  an 
increasing  severity  of  the  symptoms,  the  patient  must  be  treated 
in  accordance  with  the  general  principles  already  laid  down  for 
dealing  with  acute  meningitis. 


HEAD  INJURIES 


699 


(In  our  description  of  lacerations  of  the  brain  we  have  purposely 
omitted  any  mention  of  the  fact  that  symptoms  may  arise  from 
inflammatory  conditions  affecting  the  bones  (p.  711).  In  actual 
practice  the  course  of  events  is  often  considerably  modified  by 
such  a  complication.) 

Localized  Injuries  to  the  Brain. 

Thus  far  we  have  merely  discussed  the  general  symptoms 
arising  from  lacerations  and  wounds  of  the  brain.     We  must  now 


Fig.  251. — Brain  and  Convolutions  in  Situ. 

The  fissures  of  Rolando  and  Sylvius  are  indicated,  and  the  situation  of  the 
chief  motor  centres.  P.  O.  F.,  Parieto-occipital  fissure;  /  /,  level  of 
tentorium  with  cerebellum  below  it.  The  position  of  the  lateral  sinus  is 
also  seen. 

rapidly   pass   in    review   the    special    symptoms    resulting    from 
injuries  of  particular  regions. 

Upper  and  Middle  Frontal  Convolutions. — Neither  motor  nor 
sensory  symptoms  are  noted,  but  cerebral  irritation  and  subse- 
quent weak-mindedness  are  likely  to  follow,  especially  if  the  left 
side  is  seriously  involved  ;  lesions  to  the  right  frontal  lobe  do  but 
little  harm  to  a  right-handed  individual.  x\pparently  the  intel- 
lectual faculties  are  limited  to  one  side  of  the  brain,  in  the  same 
way  as  the  power  of  speech. 


700  A  MANUAL  OF  SURGERY 

Third  Frontal  Convolution. — Motor  aphasia,  i.e.,  the  inability  to 
produce  or  articulate  words,  results  from  lesions  on  the  left  side 
in  right-handed  individuals,  and  on  the  right  side  in  left-handed 
people.  Injury  to  the  opposite  convolution  has  no  effect.  If  only 
one  side  is  damaged,  the  other  convolution  can  after  a  time  be 
educated  so  as  to  take  on  the  function  of  the  damaged  region. 

The  Motor  Area  (Fig.  251)  is  comprised  of  the  ascending  frontal 
and  ascending  parietal  convolutions,  respectively  in  front  and 
behind  the  fissure  of  Rolando,  of  the  posterior  half  of  the  third 
frontal  convolution,  and  of  the  superior  parietal  lobule.  The 
centres  for  the  leg  occupy  the  upper  part  of  the  ascending  parietal 
convolution  and  the  whole  of  the  superior  parietal  lobule,  those 
for  the  hip  being  in  front,  and  for  the  feet  and  toes  behind.  The 
arm  centres  are  located  on  either  side  of  the  middle  of  the  fissure 
of  Rolando,  the  shoulder  being  in  front  and  above,  and  the  hand 
and  fingers  below  and  behind  ;  whilst  the  centres  for  the  head, 
face,  and  lips  are  clustered  together  at  the  junction  of  the  ascend- 
ing and  third  frontal  convolutions,  the  centre  for  movements  of 
the  angle  of  the  mouth  being  highest,  whilst  the  lowest  part  of 
the  ascending  frontal  convolution  governs  the  movements  of  the 
tongue  and  lips.  Lesions  involving  any  of  these  areas  produce 
either  spasm  or  paralysis  of  the  appropriate  region  on  the  opposite 
side  of  the  body. 

Wounds  of  one  Occipital  Lobe  may  cause  a  temporary  hemiopia, 
but  no  persistent  loss  of  vision,  unless  the  angular  gyrus  is  also 
destroyed.  Lesions  of  the  latter  region  are  always  associated 
with  permanent  disturbances  of  vision. 

The  Upper  Temporo- sphenoidal  Lobe  contains  the  cortical 
auditory  centre,  and  lesions  in  this  region  cause  deafness  ;  the 
function  of  the  middle  and  lower  lobes  is  not  yet  ascertained  with 
certainty. 

Injury  to  the  Corona  Radiata  leads  to  paralysis  of  the  regions 
represented  by  the  overlying  cortex,  but  without  convulsions; 
whilst  if  the  corpus  striatum  or  internal  capsule  is  lacerated,  as  by 
haemorrhage,  hemiplegia,  with  perhaps  hemianesthesia,  will  result. 

Wounds  of  the  Cerebellum  cause  giddiness,  vertigo,  and  ataxy,  the 
patient  reeling  about  in  a  most  characteristic  manner,  as  if  drunk. 

A  wound  of  the  Cms  Cerebri  occasions  more  or  less  complete 
hemiplegia  of  the  opposite  side  of  the  body,  associated  with  total 
paralysis  of  the  3rd  (oculo-motor)  nerve  on  the  side  of  the  injury. 

Laceration  or  contusion  of  the  Pons  Varolii,  if  not  immediately 
fatal,  may  lead  to  paralysis  of  the  opposite  side  of  the  body  to  the 
injury,  together  with  paralysis  of  the  5th,  6th,  7th,  or  gth  nerves, 
on  the  same  side  as  the  lesion,  constituting  the  so-called  '  crossed 
paralysis.'  Marked  contraction  of  the  pupils  (myosis)  may  also 
be  present. 

Wounds  of  the  Medulla  are  usually  fatal.  If,  however,  the 
patient  should  escape,  he  is  liable  to  suffer  from  disturbed  func- 


HEAD  INJURIES 


701 


tions   of   the   circulatory   and   respiratory   centres,  with    perhaps 
Cheyne-Stokes  respiration  and  saccharine  diabetes. 

Cranio-Cerebral  Topography. 

We  cannot  do  more  in  this  work  than  give  a  diagram  repre- 
senting the  relations  of  the  convolutions  to  the  sutures  (Fig.  251), 
and,  in  addition,  indicate  the  usual  position  of  the  two  most 
important  fissures,  viz.,  those  of  Rolando  and  Sylvius,  and  how 


Fig.  252. — Diagram  of  Head  to  indicate  Method  of  finding  the 
Fissures  of  Rolando  and  Sylvius  by  Reid's  Method.     (After  Reid.) 

Sy.  a.fiss.,  Anterior  branch  of  Sylvian  fissure  ;  P.  O.  Fiss.,  Parieto-occipital 
fissure  ;  trans,  fiss.,  transverse  fissure  along  line  of  tentorium  ;  A,  external 
angular  process  of  frontal  bone  ;  B,  occipital  protuberance  ;  C  D,  anterior 
perpendicular  in  front  of  tragus  ;  E  F,  posterior  perpendicular  through 
back  of  mastoid  process. 

to  mark  out  their  situation  on  the  cranium,  although  it  must  be 
premised  that  their  position  is  by  no  means  constant. 

The  Fissure  of  Rolando  may  be  found  topographically  by  the 
following  methods:  (a)  The  upper  extremity  of  the  fissure 
corresponds  to  a  point  half  an  inch  behind  the  centre  of 
the  line  extending  from  the  root  of  the  nose  to  the  occipital 
protuberance.  The  direction  of  the  sulcus  is  downwards  and 
forwards  at  an  angle  of  about  670  to  the  middle  line.  This  may 
be  indicated  by  laying  a  half-sheet  of  letter-paper  over  the  skull, 


702  A  MANUAL  OF  SURGERY 

the  long  side  corresponding  to  the  middle  line,  and  with  its  centre 
over  the  upper  limit  of  the  fissure  ;  the  anterior  half  is  now  folded 
over  obliquely  from  this  point,  leaving  an  angle  of  450  between 
the  front  of  the  paper  and  the  middle  line  of  the  skull ;  and  then 
the  same  process  is  again  repeated,  bisecting  the  angle  and 
leaving  one  of  about  670,  so  that  the  anterior  limit  of  the  folded 
paper  corresponds  to  the  line  of  the  fissure,  which  is  about 
3§  inches  in  length,  (b)  A  more  exact  method  is  that  defined 
by  Dr.  Reid,  the  measurements  for  which  are  all  worked  from 
the  so-called  Reid's  base-line,  which  is  one  drawn  on  the  skull 
from  the  lower  margin  of  the  orbit  backwards  through  the  centre 
of  the  external  auditory  meatus,  reaching  the  middle  line  behind 
just  below  the  occipital  protuberance  (Fig.  252).  From  it  are 
drawn  upwards  two  perpendiculars,  one  (C  D)  corresponding 
to  the  small  depression  in  front  of  the  external  auditory  meatus, 
the  other  (E  F)  to  the  posterior  border  of  the  mastoid  process. 
The  fissure  of  Rolando  extends  from  the  upper  limit  of  the 
posterior  vertical  line  to  the  point  where  the  anterior  line  inter- 
sects the  fissure  of  Sylvius. 

The  Fissure  of  Sylvius  is  indicated  by  a  line  drawn  from  a  point 
i|-  inches  directly  behind  the  external  angular  process  of  the 
frontal  bone  (Fig.  252,  A),  and  about  the  same  distance  above 
the  zygoma,  to  a  spot  three-fifths  of  an  inch  below  the  most 
prominent  part  of  the  parietal  eminence.  The  undivided  portion 
of  the  fissure  is  represented  by  the  first  three-quarters  of  an  inch, 
and  from  here  the  anterior  limb  (Sy.  a.  fiss.)  rises  vertically 
upwards  for  about  an  inch,  whilst  the  posterior  limb  extends 
backwards  for  the  rest  of  the  line.  If  prolonged  to  the  middle 
line  behind,  it  indicates  with  tolerable  accuracy  the  situation  of 
the  parieto-occipital  fissure  (P.  O.  Fiss.). 

Many  complicated  craniometers  have  been  devised  from  time 
to  time,  but  need  no  description.  For  practical  purposes  the 
above  measurements  suffice  as  a  foundation  to  work  out  a 
complete  topography  of  the  brain  ;  and,  after  all,  when  it  is  a 
matter  of  operation,  the  surgeon  does  not  usually  limit  his  field 
to  a  single  small  trephine  aperture. 

Hernia  Cerebri. 

By  hernia  cerebri  is  meant  a  protrusion  of  the  brain  substance 
through  an  acquired  opening  in  the  skull.  It  thus  differs  from 
an  encephalocele,  which  consists  in  the  protrusion  of  brain 
substance  through  some  congenital  defect. 

It  is  always  an  evidence  of  increased  intracranial  pressure,  and 
may  be  looked  upon  as  Nature's  safety-valve  for  the  relief  of 
compression.     It  is  met  with  in  two  distinct  forms  : 

1.  When  an  opening  has  been  made  by  the  surgeon  for  the 
treatment  of  a  cerebral  tumour,  w7hich  is  subsequently  found  to 


HEAD  INJURIES  703 


be  irremoveable.  The  disc  of  bone  is  not  replaced,  and  the  brain 
substance  protrudes  through  the  opening  under  the  scalp  ;  by 
this  means  a  temporary  relief  of  intracranial  tension  is  brought 
about,  the  patient's  life  prolonged,  and  possibly  consciousness 
for  a  time  restored.  The  tumour,  however,  continues  growing, 
and  sooner  or  later  the  patient  dies  comatose. 

2.  The  other  variety,  due  to  a  compound  depressed  or  punctured 
fracture,  is  the  result  of  sepsis  in  the  underlying  brain  substance, 
and  the  increased  pressure  within  the  skull  thereby  induced  leads 
to  a  protrusion  of  inflamed  and  cedematous  brain  matter  through 
the  wound  in  the  dura,  which  is  usually  of  small  size.  The  tumour 
is  soft  and  dusky  in  colour,  and  pulsates  synchronously  with  the 
heart,  the  pulsations  being  often  evident  to  the  naked  eye,  and  it 
usually  increases  in  size  somewhat  rapidly.  At  first  the  mental 
condition  of  the  patient  is  unimpaired,  but  sooner  or  later  coma 
follows,  if  the  hernia  progresses,  ending  in  the  patient's  death. 
To  begin  with,  the  mass  consists  mainly  of  cedematous  granula- 
tion tissue  covered  by  blood-clot,  without  much  brain  substance, 
but  later  on  brain  tissue  itself  may  protrude.  The  condition  is 
usually  fatal,  though  recovery  is  occasionally  seen.  Treatment. — 
Prevention  of  this  affection  must  always  be  aimed  at  by  en- 
deavouring to  render  any  wound  involving  the  meninges  aseptic 
and  providing  for  drainage.  Punctured  wounds  and  depressed 
fractures  of  the  skull,  even  when  giving  rise  to  no  urgent  symp- 
toms, should  always  be  operated  upon,  since  free  relief  of  tension 
may  prevent  the  formation  of  a  hernia  cerebri,  even  should  absolute 
asepsis  not  be  attained.  If,  however,  protrusion  occurs,  it  may 
be  possible  in  a  few  cases  to  apply  a  dry  dressing  and  elastic 
pressure,  and  thus  prevent  it  increasing  in  size  ;  this,  however, 
must  not  be  attempted  when  the  inflammatory  symptoms  are  at 
all  marked.  In  such  cases  it  is  of  little  use  to  slice  off  the  tumour 
and  apply  pressure,  and  possibly  the  best  treatment  that  has  been 
suggested  is  to  paint  the  projecting  mass  with  absolute  alcohol 
once  or  twice  a  day ;  it  is  an  efficient  antiseptic,  and  also  tends  by 
its  dehydrating  power  to  diminish  the  size  of  the  hernia.  If  such 
treatment  is  successful,  the  tumour  slowly  granulates  over  and 
cicatrizes.     Traumatic,  epilepsy  may,  however,  ensue. 

Traumatic  Epilepsy  is  the  term  applied  to  an  epileptic  condition 
resulting  from  injuries.  It  may  arise  from  any  of  the  following 
conditions  :  (1)  A  neuralgic  and  irritable  cicatrix  in  the  scalp  ; 
(2)  a  slight  unrelieved  depression  of  the  skull ;  (3)  excessive 
formation  of  callus  after  a  fissured  fracture,  or  chronic  thickening 
of  the  bone  from  osteitis  after  a  contusion,  whereby  the  dura  mater 
is  pressed  upon  and  irritated  ;  (4)  chronic  meningitis,  usually 
associated  with  an  adherent  cicatrix  in  the  brain,  and  particu- 
larly liable  to  occur  in  syphilitic  patients  ;  (5)  a  single  depressed 
spicule  of  bone  projecting  into  the  cerebral  substance.     A  similar 


704  A   MANUAL  OF  SURGERY 

condition  is  seen  apart  from  injury  in  consequence  of  irritative 
lesions  of  the  dura  mater  or  cerebral  cortex,  as,  for  example, 
from  an  osteoma  on  the  inner  wall  of  the  cranium,  or  enlarged 
Pacchionian  bodies.  The  Symptoms  produced  are  epileptic 
seizures  of  the  Jacksonian  type,  with  or  without  a  definite  aura, 
according  to  the  function  of  the  portion  of  cerebral  cortex  which 
is  involved.  Localization  of  the  lesion  depends  partly  on  the 
character  of  the  aura,  partly  on  the  associated  symptoms,  such 
as  a  fixed  headache,  or  the  presence  of  a  cicatrix.  The  Treat- 
ment is  not  particularly  satisfactory.  If  there  is  any  means  of 
determining  the  site  of  the  irritation,  an  exploratory  operation  is 
always  justifiable,  since  some  removeable  fragment  or  spicule  of 
bone  may  be  the  cause  of  the  symptoms.  If,  however,  nothing  is 
found  except  an  adherent  cicatrix  between  the  membranes  and 
the  underlying  brain,  it  is  very  questionable  whether  the  surgeon 
should  proceed  further.  In  a  considerable  number  of  cases  the 
cicatrix  and  surrounding  brain  substance  have  been  removed  ; 
the  fits  have  ceased  for  a  time,  but  in  almost  every  instance 
recurrence  has  sooner  or  later  followed,  owing  to  the  formation 
of  a  fresh  cicatrix  at  the  site  of  operation.  Moreover,  permanent 
paralysis  of  the  portion  of  the  trunk  governed  by  the  removed 
cortical  area  has  resulted,  and  hence  the  general  opinion  at  the 
present  time  is  that  such  an  operation  is  unadvisable,  except  as  a 
life-saving  measure  when  the  fits  are  extremely  numerous  and 
severe.  Such  a  decision  emphasizes  the  importance  of  the  state- 
ment made  before  as  to  the  necessity  of  dealing  with  all  cases  of 
simple  depressed  fracture  in  adults  by  operation.  If  it  is  decided 
that  an  exploration  is  desirable,  the  sooner  it  is  undertaken  the 
better,  since  the  longer  the  epileptic  habit  lasts,  the  less  favour- 
able is  the  prognosis. 

As  an  alternative  to  excision  of  the  cicatrix,  various  plastic 
measures  have  been  suggested  in  order  to  prevent  the  scar  in  the 
brain  and  dura  being  dragged  on  by  the  scalp,  or  irritated  through 
it,  when  the  bone  over  it  is  defective.  See  autoplasty  and  hetero- 
plasty  (p.  709). 

Traumatic  Insanity  is  sometimes  produced  by  slight  depressions 
or  lesions,  similar  in  nature  to  those  causing  epilepsy,  and  can 
occasionally  be  relieved  by  operation.  Certainly,  when  a  distinct 
history  of  injury  precedes  the  mental  aberration,  and  when  there 
is  any  localizing  lesion  or  symptom,  an  exploratory  operation  is 
justifiable,  and  in  a  number  of  cases  excellent  results  have 
followed.  The  type  of  insanity  is  not  constant,  but  varies  with 
the  condition  and  environment  of  the  individual. 


CHAPTER  XXIV. 

DISEASES   OF  THE    SCALP,  CRANIUM,  AND    CRANIAL 
CONTENTS. 

Diseases  of  the  Scalp. 

It  would  involve  a  needless  amount  of  repetition  to  mention  and 
describe  in  detail  all  the  many  conditions  which  may  be  met  with 
in  the  hairy  scalp,  and  therefore  it  is  only  necessary  to  deal  with 
those  which  are  of  the  greatest  importance. 

Suppuration  is  of  common  occurrence,  arising  mainly  from  septic 
infection  from  without,  but  being  occasionally  due  to  disease  of 
the  subjacent  bones.  The  extent  of  the  abscesses  is  limited  by 
the  same  anatomical  features  as  obtain  in  connection  with  haemor- 
rhage. Thus,  a  subcutaneous  abscess  is  necessarily  small  in  size, 
owing  to  the  density  of  the  tissues  in  which  it  is  located  ;  it  arises 
most  frequently  as  a  result  of  eczema  or  impetigo,  and  is  often 
due  to  the  presence  of  pediculi,  or  to  the  action  of  irritants  used 
in  the  cure  of  ringworm.  A  subaponeurotic  abscess  usually  results 
from  a  septic  penetrating  wound,  and  is  associated  with  cellulitis. 
A  subpericranial  abscess  is  rarely  seen  except  in  connection  with 
injury  or  disease  of  the  bony  calvarium  ;  the  pus  is  limited  to  the 
affected  portion  of  bone. 

Erysipelas  and  Cellulitis  have  been  described  elsewhere  (pp.  93 
and  96). 

Tumours  occurring  in  and  under  the  scalp  may  be  considered 
according  to  whether  they  pulsate  or  not. 

Pulsating  Tumours  of  the  Scalp  arise  from  three  distinct  sources: 
1.  They  may  be  of  Extracranial  origin,  and  then  are  mainly  asso- 
ciated with  the  superficial  bloodvessels,  (a)  Ordinary  aneurisms  of 
traumatic  origin  are  not  uncommonly  seen  ;  they  rarely  attain  any 
considerable  size,  and  are  readily  dealt  with  by  excision,  (b)  A  rterio- 
venous  wounds  give  rise  either  to  an  aneurismal  varix  or  to  a  varicose 
aneurism.  They  usually  involve  the  temporal  trunk,  and  their 
symptoms  and  treatment  require  no  special  notice,  (c)  A  curious 
dilated  and  tortuous  condition  of  one  of  the  scalp  arteries,  most 
often  the  temporal,  is  occasionally  seen,  and  is  known  as  an  arterial 

45 


7o6  A  MANUAL  OF  SURGERY 


varix ;  it  may  be  treated  by  complete  excision,  (d)  A  neevus  situated 
over  the  anterior  fontanelle  may  derive  a  communicated  impulse 
from  the  subjacent  dura.  It  has  no  special  features  apart  from 
this,  and  is  to  be  treated  in  the  same  way  as  other  naevi  of  the 
scalp,  viz.,  by  excision  or  electrolysis,  (e)  A  much  more  serious 
and  interesting  phenomenon  than  any  of  the  others  is  that  known 
as  a  cirsoid  aneurism. 

Cirsoid  Aneurism  is  more  frequently  met  with  in  the  scalp  than 
elsewhere,  and  mainly  involves  the  temporal  region,  but  may  also 
spread  in  all  directions,  even  downwards  into  the  neck.  A  tumour 
of  greater  or  less  size  is  seen  under  the  skin,  consisting  of  dis- 
tended, tortuous,  pulsating,  bluish-looking  vessels,  the  arteries 
opening  directly  into  cavernous  spaces  without  the  intervention 
of  capillaries  ;  it  is  easily  emptied  by  pressure,  but  quickly  refills, 
owing  to  the  abundant  arterial  supply.  The  rate  of  growth  is 
variable,  and  the  patient  often  complains  of  headache  and  giddi- 
ness ;  the  skin  becomes  thin  and  atrophic,  the  hair  falls  out,  and 
finally  ulceration  may  occur,  the  patient  probably  dying  from 
haemorrhage.  The  Treatment  is  eminently  unsatisfactory,  com- 
plete excision  being  the  ideal  cure,  but  this  in  the  worst  cases  is 
impracticable.  If  it  be  attempted,  the  incisions  should  be  made 
wide  of  the  disease,  and  the  supplying  vessels  secured,  if  possible, 
between  double  ligatures  before  dividing  them  ;  if  this  precaution 
is  not  adopted,  frightful  haemorrhage  may  result.  It  is  necessary 
in  some  cases  to  deal  with  the  tumour  in  separate  segments, 
allowing  time  between  the  operations  for  the  patient  to  recover 
from  the  loss  of  blood.  Probably  electrolysis,  combined  with  liga- 
ture of  the  main  nutrient  vessels,  holds  out  the  best  chance  of 
success.     (For  methods  of  electrolysis,  see  p.  309.) 

2.  The  chief  pulsating  tumours  of  Cranial  origin  are  as  follows  : 
(a)  Sarcomata  arising  from  beneath  the  pericranium  or  from  the 
diploe  (p.  712).  (b)  Secondary  nodules  of  cancer  may  develop  in 
the  diploic  tissue  ;  those  due  to  the  form  known  as  thyroid  cancer 
are  specially  noted  for  their  pulsation,  (c)  Aneurism  by  anasto- 
mosis occasionally  develops  in  the  cancellous  tissue  of  the  diploe, 
and  gives  rise  to  pulsation,  which  can  be  felt  when  the  bones  are 
sufficiently  expanded  and  atrophied  (p.  537). 

3.  Pulsating  swellings  of  Intracranial  origin  include  the  following 
conditions:  Encephalocele  (vide  infra);  traumatic  cephal-hydrocele 
(p.  668) ;  hernia  cerebri  (p.  702) ;  and  sarcoma  of  the  dura  mater 
(p.  712). 

Non-pulsating  Tumours  of  the  Scalp. — Almost  any  of  the  ordinary 
connective  tissue  or  epithelial  growths  may  occur,  but  the  follow- 
ing are  the  more  important : 

Papillomata  are  not  uncommon  in  the  form  of  small  hard  warty 
outgrowths,  giving  rise  to  but  little  inconvenience,  unless  situated 
on  some  spot  where  the  hat  rests.    They  are  easily  removed. 


DISEASES  OF  THE  SCALP 


707 


Epithelioma  also  occurs,  arising  either  from  an  irritated  papil- 
loma, or  possibly  in  connection  with  a  sebaceous  cyst.  As  soon 
as  a  diagnosis  is  made,  the  growth  should,  if  possible,  be  ex- 
tirpated, and  the  resulting  raw  surface  may  either  be  left  to 
granulate,  or  dealt  with  by  Thiersch's  method  of  skin  grafting. 

Fibroma  is  either  seen  in  the  shape  of  a  localized  develop- 
ment of  hard  fibrous  tissue,  and  often  growing  on  the  forehead 
where  the  hat  crosses  it ;  or  it  may  attain  much  larger  dimensions, 
involving  perhaps  half  the  scalp,  and  giving  rise  to  an  irregular 
nodulated  outgrowth  of  soft  fibro-cellular  tissue,  which  has  some- 
times been  termed  a  pachydermatocele  (p.  163).  Either  form  may 
be  dealt  with  by  excision. 

Sarcomata  of  various  types  involve  the  scalp,  presenting  as 
large  fleshy  tumours  which  may  pulsate  or  fungate.  They  usually 
develop  rapidly,  but  are  limited  for  some  time  by  the  aponeurosis 
of  the  occipito-frontalis  ;  glandular  infection  is  uncommon.  In 
their  removal  it  is  useless  to  attempt  to  save  the  aponeurosis ; 
the  whole  thickness  of  the  scalp  must  be  sacrificed,  and  the  in- 
cisions should  be  wide  of  the  growth.  The  wound  is  allowed  to 
granulate,  or  covered  in  with  Thiersch  grafts. 

Dermoid  Cysts  are  by  no  means  uncommon  in  this  region,  their 
favourite  situation  being  near  the  outer  canthus,  the  temple,  or 
the  root  of  the  nose.  For  a  general  description,  see  p.  182. 
They  do  not  attain  any  great  size,  and  may  not  become  evident 
till  after  puberty.  The  underlying  bone  is  often  hollowed  out 
from  a  defective  development  of  the  mesoblastic  tissues  around 
them  ;  and  a  congenital  opening  may  even  exist  through  which  a 
narrow  neck  passes,  bringing  the  cyst  into  direct  connection  with 
the  dura  mater.  The  treatment  consists  in  removal  ;  but  it  is 
advisable  to  delay  this  till  after  puberty  if  the  tumour  seems  at  all 
fixed  to  the  skull,  or  if  the  bone  is  felt  to  be  defective  beneath 
it,  as  in  such  cases  the  communication  with  the  interior  of  the 
cranium  is  often  shut  off  by  that  time. 

Sebaceous  Cysts  (p.  361)  find  their  most  usual  situation  in  the 
scalp,  where  they  not  only  are  frequently  multiple,  but  also  may 
reach  a  considerable  size.  Their  removal  is  best  accomplished 
by  transfixion,  squeezing  out  the  contents,  and  picking  out  the 
cyst  wall  by  a  pair  of  forceps  without  dissection.  The  wound 
is  closed  by  one  or  two  stitches. 

Affections  of  the  Skull. 

I.  Congenital  Affections. 

r.  Meniogocele,  Encephalocele,  and  Hydrencephalocele  consist  of 
a  protrusion  of  the  dura  mater,  with  or  without  part  of  the  brain, 
through  an  opening  in  the  cranial  wall,  due  either  to  defective 
development  of  the  bones  or  to  the  non-closure  of  one  of  the 
sutures.     They  occur  most  frequently  at  the  root  of  the  nose,  and 

45—2 


7o8 


A  MANUAL  OF  SURGERY 


in  the  occipital  region  (Fig.  253),  occasionally  at  the  anterior  or 
one  of  the  lateral  fontanelles,  or  at  the  base  of  the  skull.  A 
Meningocele  is  simply  a  protrusion  of  the  brain  membranes  con- 
taining cerebro-spinal  fluid.  It  forms  a  soft,  rounded,  fluctuating 
swelling,  attached  to  the  skull  by  a  base  of  greater  or  less  size, 
and  covered  by  skin,  which  may  be  thick  and  healthy,  or  thinned, 
bluish,  and  translucent  when  the  tumour  is  large.  The  vessels 
present  in  the  skin  are  often  dilated  and  nsevoid.  It  increases  in 
size  and  tension  on  any  expiratory  effort,  such  as  coughing  or 
crying,  and  it  may  be  partially  reducible,  thus  allowing  the 
margins  of  the  opening  in  the  cranium  to  be  defined.  Symptoms 
of  cerebral  compression,  convulsions,  etc.,  are  likely  to  be  pro- 
duced by  such  manipulation.  An  Encephalocele  is  a  similar  type 
of  tumour,  but  contains  brain  substance,  and  pulsates  nearly 
synchronously  with  the  heart  ;   it  is  most  commonly  situated  at 


Fig.  253. 


-Congenital  Encephalocele  of  the  Occipital  Region. 
(Tillmanns.) 


the  back  of  the  skull.  A  Hydrencephalocele,  or  Meningo-encephalo- 
cele,  is  a  condition  in  which  the  tumour  contains  both  brain 
substance  and  fluid.  Two  varieties  have  been  described,  one  in 
which  there  is  a  small  protrusion  of  the  brain  associated  with  an 
ordinary  meningocele,  and  the  other  in  which  the  fluid  is  contained 
in  a  cavity  communicating  with  one  of  the  ventricles,  and  covered 
by  a  thin  layer  of  brain  substance.  They  are  usually  of  consider- 
able size,  and  situated  in  the  occipital  region,  either  above  the 
tentorium,  and  then  possibly  associated  with  distension  of  the 
posterior  cornu  of  one  of  the  lateral  ventricles,  or  below  that  struc- 
ture, the  osseous  defect  extending  in  some  cases  as  far  as  the  fora- 
men magnum,  and  a  portion  of  the  cerebellum  being  within  the  sac. 
The  Prognosis  of  these  conditions  is  exceedingly  grave.  For- 
tunately, many  of  the  subjects  are  born  dead,  or  die  soon  after 
birth.  In  the  more  severe  cases,  idiocy  and  microcephaly  are  not 
uncommonly  associated.    The  protrusion  may  increase  steadily  in 


AFFECTIONS  OF  THE  SKULL  709 

size  and  finally  burst,  causing  death  by  purulent  meningitis,  or  in 
more  favourable  cases  it  may  remain  stationary.  In  a  menin- 
gocele, the  subsequent  growth  of  the  cranial  bones  may  suffice 
to  close  the  communication  between  the  interior  and  the  tumour, 
which  thus  becomes  shut  off,  and  remains  as  a  cyst-like  swelling, 
with  the  base  fixed,  and  without  pulsation  or  respiratory  impulse. 
Treatment. — Most  cases  should  be  left  alone  ;  but  if  the  tumour 
is  steadily  increasing  in  size,  antiseptic  puncture  and  subsequent 
compression  may  hinder  the  process ;  a  pure  meningocele  may 
possibly  be  cured  in  this  way.  Where  the  communication  with 
the  skull  is  small,  it  may  be  feasible  to  excise  the  tumour,  taking 
special  care  to  securely  suture  the  base,  and  attempting  when 
practicable  to  make  good  the  cranial  deficiency  by  osteoplasty. 

2.  In  infants  the  ossification  of  the  bones  may  be  incomplete, 
constituting  what  is  known  as  aplasia  cranii  congenita.  It  is  said 
to  be  due  to  fcetal  rickets,  arising  from  a  cachectic  condition  of 
the  mother.  Great  care  is  needed  in  dieting  such  children  and 
protecting  them  from  injury.  Occasionally  a  similar  atrophic 
condition  of  the  bones  may  persist  through  life,  exposing  the 
patient  to  increased  risk  from  injuries  which  otherwise  would  do 
but  little  harm. 

3.  Localized  congenital  atrophy  of  the  bones  is  also  sometimes 
met  with  in  connection  with  dermoid  cysts,  as  mentioned  above. 

II.  Acquired  Affections  of  the  skull  are  atrophic,  hypertrophic, 
inflammatory,  or  neoplastic  in  nature. 

Acquired  Atrophy  of  the  skull  occurs  in  many  forms  : 

(a)  Craniotabes  is  a  condition  met  with  during  the  first  year  of 
life,  usually  as  a  result  of  inherited  syphilis  (p.  524). 

(b)  Senile  atrophy  may  affect  the  whole  cranium,  which  becomes 
thinned  and  rarefied,  the  change  commencing  from  without,  a 
similar  condition  also  occurring  in  the  jaws  from  the  loss  of  teeth, 
and  subsequent  absorption  of  the  alveoli ;  or  it  may  be  localized, 
as  pointed  out  by  the  late  Sir  G.  M.  Humphry,-  to  the  parietal 
bones,  constituting  hollow  depressions  which  extend  antero- 
posteriorly.  No  symptoms  are  caused  thereby,  but  the  patient 
runs  a  certain  increased  risk  from  injuries  to  the  head. 

(c)  Localized  loss  of  substance  may  result  from  the  pressure 
of  tumours,  such  as  Pacchionian  bodies  and  aneurisms,  or  from 
necrosis,  or  traumatic  and  operative  lesions.  If  these  are  at  all 
extensive,  the  cerebral  pulsations  can  be  felt  distinctly  through 
the  skin.  It  is  then  advisable  to  provide  the  patient  with  some 
guard  to  protect  him  from  injury.  This  may  be  accomplished  by 
means  of  a  metal  plate  worn  over  the  scalp  ;  but  where  the  lesion 
is  due  to  injury  or  operation,  surgeons  have  of  late  years  been 
endeavouring  to  remedy  the  defect  in  a  more  satisfactory  manner 
by  operation.      Autoplasty   is  the  term  applied  to  a  proceeding 

*  Med.-Chir.  Trans.,  1890,  p.  327. 


7io  A  MANUAL  OF  SURGERY 


whereby  the  defect  is  closed  by  a  plate  of  bone  removed  from  the 
patient's  own  skull.  A  suitable  scalp  flap  is  turned  down,  and 
then  a  portion  of  the  outer  table  is  chiselled  up  sufficient  in  size 
to  close  the  aperture.  The  pericranium  is  utilized  on  one  side  as 
a  pedicle,  and  by  means  of  this  it  is  stitched  down  into  the  gap, 
the  margins  of  which  have  been  previously  freshened.  By  hetero- 
plasty  is  meant  a  similar  proceeding  when  the  hole  is  closed  by  a 
plate  of  gold,  platinum,  or  vulcanite  let  in  under  the  pericranium 
or  inserted  between  the  dura  mater  and  the  cranium.  The  results 
of  these  procedures  have  been  on  the  whole  satisfactory. 

(d)  Hydrocephalus  is  always  associated  with  atrophy  and  thinning 
of  the  cranium.  It  may  be  congenital,  or  may  commence  early 
in  life,  but  is  always  a  chronic  condition.  (The  so-called  acute 
hydrocephalus  is  in  reality  tuberculous  meningitis.)  It  is  produced 
in  almost  all  cases  by  a  distension  of  the  lateral  ventricles  with 
fluid,  the  result  of  congenital  malformation,  or  of  inflammatory 
affections,  causing  exudation  from  the  choroid  plexuses,  pressure 
upon  the  veins  of  Galen  or  inferior  longitudinal  sinus,  and  possibly 
closure  of  the  foramen  of  Majendie.  The  head  becomes  more 
and  more  distended,  the  bones  expanded  and  thinned,  and  the 
sutural  areas  increased,  whilst  the  brain  is  subjected  to  such 
pressure  as  may  be  incompatible  with  life.  Fluctuation  is  dis- 
tinctly felt,  and  the  bones  may  crackle  under  the  fingers ;  the 
face  looks  abnormally  small,  and  the  eyes  protrude,  owing  to 
the  depression  of  the  orbital  plates.  Treatment. — The  ventricles 
may  be  tapped  at  a  spot  some  little  distance  from  the  median 
line,  and  a  considerable  amount  of  the  fluid  withdrawn,  whilst 
elastic  pressure  is  subsequently  maintained  ;  but  as  the  cause 
cannot  be  removed,  recurrence  is  almost  inevitable.  It  has 
recently  been  demonstrated  that  there  is  a  direct  absorption  of 
fluid  into  the  veins  from  the  subdural  space  at  any  tension  above 
the  venous  pressure,  and  hence  it  is  suggested  that,  by  establish- 
ing a  communication  between  the  ventricular  and  subdural  spaces, 
the  excess  of  fluid  in  hydrocephalus  might  be  absorbed.  This 
has  been  attempted  in  two  or  three  cases,  and  the  results  have 
been  encouraging  ;  but  of  course,  to  be  of  any  value,  it  must  be 
undertaken  before  the  cerebral  cortex  has  been  so  thinned  as  to 
interfere  with  its  functional  activity. 

(e)  By  microcephaly  is  meant  a  condition  of  diminished  size  of 
the  cranial  cavity  due  to  premature  ossification  of  the  sutures. 
It  is  usually  associated  with  idiocy,  and  possibly  with  cretinism. 
Of  late  years  attempts  have  been  made  to  relieve  this  by  the 
operation  of  linear  craniectomy  or  removal  of  portions  of  the 
cranium,  so  as  to  allow  of  the  expansion  of  the  brain.  A  broad 
strip  of  bone  is  excised  on  either  side  of  the  median  -line,  from 
back  to  front,  and  sometimes  another  transversely.  A  small 
trephine  aperture  is  first  made,  and  then  the  opening  is  prolonged 
antero-posteriorly  by  a  circular  saw  driven   by  electricity,  or  by  a 


AFFECTIONS  OF  THE  SKULL  711 

Hey's  saw,  or  by  a  bone  rongeur.  The  two  sides  of  the  skull  are 
usually  dealt  with  at  separate  times.  Temporary  improvement 
has  followed  in  many  cases  ;  but  the  final  result  is  extremely 
uncertain,  the  majority  of  the  patients  relapsing  owing  to  the 
contraction  of  the  dense  cicatricial  material  which  replaces  the 
bone.  The  proceeding  cannot  be  looked  on  as  more  than  a 
justifiable  experiment. 

Hypertrophic  Changes  of  the  Skull  result  from  simple  chronic 
inflammatory  affections,  or  from  injury,  etc.  We  have  already 
alluded  to  the  special  types  of  enlargement  seen  in  inherited 
syphilis  (p.  523),  rickets  (p.  525),  osteitis  deformans  (p.  530),  and 
acromegaly  (p.  531).  In  leontiasis  ossea  (p.  742)  the  cranium 
also  becomes  thickened  and  enlarged ;  but  the  cranial  cavity 
is  encroached  on,  constituting  what  is  known  as  concentric  hyper- 
trophy, in  contrast  to  most  of  the  other  forms,  which  are  eccentric 
in  type. 

Inflammatory  Affections  of  the  Cranial  Bones. — The  cranium  is 
liable  to  any  of  the  diseases  which  generally  occur  in  bone. 

1.  Acute  Periostitis,  or  Pericranitis,  is  usually  septic  in  origin, 
following  cellulitis  of  the  scalp  ;  it  is  likely  to  result  in  necrosis  of 
the  outer  table. 

2.  Acute  Infective  Osteomyelitis,  or  acute  necrosis,  consists  of 
an  acute  inflammation  of  the  diploe,  due  to  pyogenic  organisms, 
and  either  following  a  septic  scalp  wound  or  a  contusion  of  the 
bone  in  a  person  of  low  germicidal  powers.  The  symptoms  and 
signs  are  those  generally  characteristic  of  the  disease,  the  peri- 
cranium being  stripped  up  by  diffuse  suppuration  beneath  it,  and 
abscesses  opening  in  many  situations.  Necrosis  of  the  whole 
thickness  of  the  skull  is  likely  to  follow,  whilst  pyaomia  or 
extension  of  the  inflammation  to  the  membranes,  venous  sinuses 
or  brain,  are  the  chief  dangers  arising  from  it.  The  treatment 
consists  in  free  external  drainage  ;  but  in  addition  it  is  necessary 
to  remove  the  outer  table  with  chisel  and  mallet,  and  to  thoroughly 
scrape  away  all  the  septic  diploe,  disinfecting  the  parts  beneath 
with  pure  carbolic  acid.  If  signs  of  subcranial  suppuration 
ensue  (p.  690),  the  inner  table  must  also  be  removed. 

3.  Chronic  Periostitis  of  the  cranium  is  occasionally  met  with 
in  the  form  of  a  node.  It  is  usually  the  result  of  some  long- 
continued  irritation,  such  as  carrying  baskets  or  weights  on  the 
head.  Treatment  consists  in  the  removal  of  the  irritation,  and 
there  is  no  objection  to  chiselling  away  the  node,  if  necessary. 

4.  Tuberculous  Disease  of  the  cranial  bones  is  not  common  ;  it 
occurs  as  a  primary  phenomenon,  or  is  secondary  either  to  a 
cutaneous  lesion,  such  as  lupus,  or  perhaps  more  commonly  to 
a  meningeal  focus.  It  may  start  in  the  periosteum  or  diploe 
leading  to  the  formation  of  a  node  or  perhaps  to  expansion  of  the 


712  A   MANUAL  OF  SURGERY 


bone,  and  followed  by  suppuration  and  caries.  When  of  menin- 
geal origin,  there  is  a  considerable  amount  of  erosion  of  the  inner 
table,  and  possibly  some  necrosis;  sooner  or  later  the  outer  table 
is  perforated  and  a  subpericranial  abscess  forms.  The  amount 
of  mischief  in  the  outer  table  is  no  criterion  of  the  extent  of  the 
disease  within,  and  hence  very  thorough  exploration  is  necessary. 
The  prognosis  in  this  variety  is  not  good. 

5.  Syphilitic  Disease  of  the  cranium,  on  the  other  hand,  is 
exceedingly  common,  occurring  usually  in  the  tertiary  stage,  and 
affecting  most  frequently  the  frontal  and  parietal  bones.  It  has 
been  already  described  (p.  522). 

Tumours  of  the  Cranial  Bones. — The  chief  Tumours  affecting  the 
calvarium  are  osteomata  and  sarcomata. 

Osteoma  of  the  cranium  occurs  as  a  localized  overgrowth  either 
of  cancellous  or  of  compact  bone,  more  commonly  the  latter.  It 
grows  from  the  outer  surface  of  the  calvarium,  from  the  inner,  or 
from  both.  If  arising  externally,  a  smooth,  rounded,  globular 
swelling  is  produced,  hard  to  the  touch,  quite  painless,  and  attached 
to  the  subjacent  bone  by  a  broad  base ;  more  than  one  may  be 
present.  If  the  main  growth  is  internal,  the  early  symptoms 
will  depend  on  its  situation,  as  to  whether  evident  functional 
disturbance  of  the  cortex  will  be  produced  ;  when  very  large,  it 
gives  rise  to  compression  of  the  brain,  and  possibly  optic  neuritis. 
Osteomata  are  to  be  distinguished  from  inflammatory  hyperostoses 
(usually  of  syphilitic  origin)  by  their  sharp  limitations,  absence  of 
pain,  and  slower  progress ;  whilst  osteo-sarcomata  are  commonly 
rapid  in  growth,  painful,  and  of  unequal  consistency  in  different 
parts.  Treatment  is  rarely  possible  in  those  developing  inside  the 
skull  except  when  situated  over  the  motor  area,  since  the  disease 
has  usually  progressed  too  far  before  coming  under  observation. 
The  external  tumours  may  be  freely  chiselled  away,  but  it  must 
not  be  forgotten  that  cerebral  concussion  may  follow  the  pro- 
longed use  of  the  chisel  and  mallet  against  the  skull. 

Sarcoma  of  the  cranium  originates  either  from  the  pericranium, 
the  diploe,  or  from  the  dura  mater. 

The  extra-  or  peri-cranial  variety  consists  of  a  round  or  spindle- 
celled  tumour  growing  from  the  pericranium,  and  possibly  attain- 
ing a  considerable  size.  It  may  contain  a  certain  amount  of  ossific 
deposit,  or  the  tumour  remains  of  a  soft  consistency,  and  then  often 
pulsates.  The  subjacent  bone  is  sometimes  absorbed,  and  the  dura 
mater  affected  secondarily.   General  infection  of  the  system  follows. 

Central  sarcoma  of  the  cranium  starts  from  the  diploe  as  a 
myeloid  tumour.  It  does  not  grow  so  rapidly  as  the  other  forms ; 
it  is  single,  and  generally  covered  with  a  layer  of  expanded  bone, 
which  gives  a  sensation  of  eggshell  crackling  to  the  finger.  Later 
on  it  involves  the  dura  mater  and  skin,  and  may  fungate. 

Sarcoma  of  the  dura  mater  may  be  attributed  to  some  injury  to 


AFFECTIONS  OF  THE  SKULL  713 

the  head,  and  is  characterized  by  the  occurrence  of  severe  cerebral 
symptoms,  e.g.,  intolerable  localized  headache,  epileptic  fits,  double 
vision,  optic  neuritis,  etc.,  prior  to  any  evident  appearance  of  a 
tumour.  Gradually  the  bones  become  expanded  and  perforated, 
and  a  soft  and  exceedingly  vascular  pulsating  growth  is  felt  beneath 
the  scalp.  This  sooner  or  later  fungates,  and  possibly  the  menin- 
geal cavity  is  laid  open  by  ulceration,  death  from  septic  meningitis, 
cerebral  compression,  or  exhaustion  ending  the  chapter. 

Treatment. — These  cases  have  usually  gone  too  far  before  being 
recognised.  If  an  early  diagnosis  can  be  arrived  at,  free  removal 
may  be  undertaken  by  trephining  and  the  use  of  the  chisel,  sharp 
spoon  or  gouge. 

Affections  of  the  Frontal  Sinuses. 

These  sinuses  are  cavities  in  the  frontal  bones  lined  with  a 
mucous  membrane  continuous  with  that  of  the  nose.  They  can 
hardly  be  said  to  exist  in  children,  not  developing  much  before 
the  age  of  puberty.  In  adults  they  vary  much  in  size  and  shape, 
and  are  often  very  asymmetrical ;  the  prominence  of  the  super- 
ciliary ridges  is  no  guide  to  their  extent. 

Fracture  of  the  anterior  wall  is  not  uncommon  as  the  result  of  a 
direct  blow,  depression  of  the  fragments  being  produced,  but  with- 
out cerebral  complications.  If  the  mucous  membrane  is  torn, 
surgical  emphysema  of  the  scalp  and  face  may  follow,  and  is 
naturally  increased  on  blowing  the  nose.  In  compound  fractures, 
suppuration  usually  occurs,  leading  to  septic  osteitis  and  necrosis 
of  the  frontal  bone,  and,  if  the  posterior  wall  is  involved,  to  a  sub- 
cranial or  even  a  cerebral  abscess.  In  rare  cases,  when  the  anterior 
wall  has  been  destroyed,  a  localized  collection  of  air  may  form 
under  the  skin,  and  remain  as  a  permanent  tumour,  constituting 
what  is  known  as  a  pneumatocele  capitis ;  it  rises  and  falls  with  forced 
respirations.  A  similar  condition  may  also  result  from  a  fracture 
into  the  mastoid  cells ;  in  either  situation  it  should  be  treated  by 
compression,  or,  failing  this,  incision. 

Inflammation  of  the  frontal  sinus  is  caused  by  extension  of  catarrh 
from  the  nose,  by  penetrating  wounds  or  fractures,  by  foreign 
bodies,  or  it  may  be  secondary  to  disease  of  neighbouring  bones. 
But  little  effect  is  produced,  unless  the  infundibulum  becomes 
blocked,  and  then  distension  of  the  sinus  is  produced.  If  occupied 
by  mucus  {hydrops),  a  slowly-forming  tumour  is  noticed  without 
much  pain  or  discomfort,  but  the  bony  walls  gradually  become 
thinned,  and  may  give  a  sensation  of  eggshell  crackling.  If  dis- 
tended with  pus  {empyema),  similar  symptoms  result,  perhaps  with 
concurrent  inflammatory  disturbance  and  pain  in  the  neighbour- 
hood. In  the  more  acute  cases,  especially  the  traumatic,  the  in- 
flammation is  liable  to  extend  into  the  frontal  bone,  giving  rise 
to  an  acute  osteomyelitis,  which  may  spread  rapidly.  The  pos- 
terior wall  of  the  sinuses  is  extremely  thin  so  that  the  membranes 


714  A   MANUAL  OF  SURGERY 

are  easily  invaded,  and  an  abscess  may  develop  in  the  frontal  lobe 
of  the  brain.  Occasionally  extension  of  mischief  to  the  cavernous 
or  other  venous  sinuses  may  follow. 

The  case  must  be  treated  by  laying  the  cavity  open  and  drain- 
ing it.  F~or  this  purpose  a  curved  incision  is  made  along  or  imme- 
diately below  the  eyebrow,  and  the  soft  parts  stripped  from  the 
bone,  which  is  trephined  or  punctured  with  a  gouge,  according  to 
its  thickness,  close  to  the  middle  line ;  the  pus  or  mucus  is  removed, 
the  interior  very  gently  curetted,  and  the  passage  into  the  nose 
explored  and  dilated  so  as  to  aliow  of  free  drainage.  The  cavity 
is  syringed  out  for  some  days,  and  the  wound  usually  closes 
readily,  although  a  fistula  occasionally  remains.  A  median  vertical 
incision  is  useful  if  there  is  any  doubt  as  to  which  sinus  is  involved, 
or  if  both  are  affected.  It  has  also  been  proposed  to  deal  with  this 
condition  from  within  the  nose,  and  in  the  hands  of  skilled  rhino- 
logists  this  is  practicable,  especially  if  the  anterior  half  of  the 
middle  turbinal  is  first  removed. 

Should  acute  osteomyelitis  develop,  vigorous  measures  are 
necessary.  In  a  case  of  this  type  recently  under  treatment, 
incisions  were  made  along  each  eyebrow  from  the  middle  line,  and 
a  vertical  one  extending  from  the  hair  to  the  root  of  the  nose. 
The  flaps  thus  formed  were  thrown  back,  the  sinuses  freely  opened, 
and  their  anterior  walls  entirely  removed  :  a  large  amount  of  the 
frontal  bone  was  also  taken  away  until  healthy  diploe  free  from 
purulent  infiltration  was  reached.  During  the  process  the  posterior 
wall  of  the  right  sinus  was  removed,  and  a  large  cerebral  abscess 
opened.  The  patient  made  a  good  recovery,  although  a  consider- 
able amount  of  dead  bone  had  to  be  subsequently  taken  away. 

The  chief  Tumours  growing  from  the  frontal  sinuses  are  mucous 
cysts  or  polypi,  and  ivory  osteomata ;  they  may  also  be  involved 
in  diffuse  sarcoma  or  carcinoma,  but  the  disease  is  then  not 
limited  to  the  sinus.  The  main  symptoms  and  signs  result  from 
distension  of  the  walls  of  the  cavity,  which  may  yield  anteriorly, 
causing  a  large  frontal  swelling,  or  the  posterior  wall  is  absorbed, 
leading  to  cerebral  compression,  or  the  upper  wall  of  the  orbit 
may  be  depressed,  causing  dislocation  of  the  eyeball,  and  possibly 
blindness  (Fig.  36,  p.  167).  Tumours  which  have  attained  con- 
siderable dimensions  can  rarely  be  removed,  death  then  resulting 
from  cerebral  compression  ;  but  occasionally  bony  masses  may 
necrose,  and  become  loosened  by  suppuration  around  them,  and 
in  a  few  cases  they  have  been  taken  away  successfully. 

Cerebral  Tumours. 

The  chief  Varieties  of  new  growth  met  with  in  the  brain  are  as 
follows :  (i.)  Glioma,  or  glio-sarcoma,  which  consists  of  a  small 
round-celled  neoplasm  with  a  very  delicate  intercellular  substance, 
similar  in  character  to  the  neuroglia  ;  it  may  occur  in  any  part  of 
the  brain.     It  is  always  continuous  with  the  surrounding  cerebral 


CEREBRAL  TUMOURS  715 

tissue,  and  is  scarcely  ever  encapsuled,  so  that  to  the  naked  eye  it 
may  be  indistinguishable  from  brain  substance,  although  rather 
harder,  and  hence  its  limits  can  seldom  be  accurately  defined, 
(ii.)  True  sarcomata  also  occur,  and  occasionally  secondary  carcino- 
matous deposits,  (iii.)  Tuberculous  foci  are  met  with  apart  from  any 
meningeal  infiltration,  varying  in  size  considerably,  and  may  be 
either  firm  and  caseous,  or  with  a  diffluent  centre,  (iv.)  Gummata 
of  the  brain  usually  spring  from  the  meninges,  and  are  more 
irregular  in  shape  than  tuberculous  masses,  (v.)  Occasionally 
hydatid  cysts  are  found,  as  also  other  less  common  conditions. 

Cerebral  tumours  are  more  often  observed  in  males  than  in 
females,  and  the  different  forms  occur  at  varying  periods  of  life. 
Thus,  glioma  and  sarcoma  are  most  common  at  puberty  or  in 
middle  life  ;  tuberculous  foci,  in  children  ;  gummata,  in  the  fourth 
or  fifth  decade  ;  carcinomata,  in  middle  or  late  life  ;  and  parasitic 
tumours  in  the  second  and  third  decades. 

The  local  effects  of  a  cerebral  tumour  may  be  to  cause  some 
amount  of  sclerosis  of  the  surrounding  brain  substance,  whilst,  if 
superficial,  the  membranes  may  become  adherent  and  the  over- 
lying bone  thickened. 

The  Symptoms  of  a  cerebral  tumour  can  be  classified  as 
follows  ;  (1)  Those  due  to  increased  intracranial  pressure,  such  as 
fixed  headache,  giddiness,  epilepsy,  loss  of  memory,  and  stupor, 
finally  ending  in  coma.  The  headache  varies  much  in  character, 
but  is  usually  localized,  occurs  in  severe  paroxysmal  attacks,  and 
is  often  associated  with  tenderness  on  deep  pressure  over  the  scalp. 
It  is  increased  by  anything  that  causes  passive  congestion  of  the 
brain,  such  as  coughing,  and  it  is  most  important  to  note  that  the 
sites  of  the  maximum  pain  and  of  the  tumour  often  correspond. 
Occasionally  coma  and  a  fatal  issue  supervene  suddenly  as  a 
result  of  acute  spreading  oedema  (p.  695).  (2)  Vomiting  and 
constipation  are  also  very  marked  phenomena,  associated  with 
loss  of  appetite  and  great  emaciation.  The  vomiting  bears  no 
relation  to  the  ingestion  of  food,  and  is  not  preceded  by  nausea. 
It  often  develops  concurrently  with  the  pain,  or  may  relieve  it, 
and  is  most  common  in  subtentorial  tumours.  The  temperature 
is  usually  subnormal,  but  if  there  is  any  basal  meningitis  it  may  be 
elevated.  (3)  Optic  neuritis  is  generally  present,  and  is  supposed 
to  be  due  either  to  the  increased  intracranial  pressure  causing 
obstruction  to  the  return  of  blood  from  the  eye  to  the  cavernous 
sinus,  or  to  a  descending  neuritis,  or  possibly  to  both.  In  the 
early  stages,  the  clear  definition  of  the  disc  margin  becomes 
obscured,  and  the  retinal  veins  congested  and  tortuous  ;  the  retina 
is  ©edematous,  so  that  the  vessels  are  only  seen  at  intervals,  and 
linear  ecchymoses  may  also  occur.  If  the  patient  lives  long 
enough,  atrophy  of  the  disc  follows.  In  the  early  stages  vision 
may  be  but  little  affected,  but,  as  a  rule,  it  is  considerably  im- 
paired   towards   the    end.       In    some    cases    this    condition    may 


716  A  MANUAL  OF  SURGERY 

be  more  marked  on  the  side  of  the  lesion,  but  is  generally  bi- 
lateral. (4)  Focal  symptoms  (p.  699)  are  only  produced  when 
some  area  of  the  brain  with  definite  functions  is  involved. 
Irritative  phenomena  manifest  themselves  first ;  paralytic  symp- 
toms develop  later  on.  General  convulsions  sometimes  occur, 
but  are  without  much  significance.  We  must  refer  students  to 
text-books  of  medicine  for  a  further  consideration  of  these  lesions. 
The  surgeon  is  seldom  called  upon  to  make  a  diagnosis  in  these 
cases,  and  therefore  the  full  details  of  this  intricate  subject  will 
not  be  considered  here. 

Treatment. — In  every  case,  the  possibility  of  the  symptoms 
being  due  to  gummatous  disease  must  not  be  forgotten,  and  large 
and  increasing  doses  of  iodide  of  potassium  (even  up  to  40  or 
60  grains  three  or  four  times  a  day)  should  be  administered  before 
undertaking  operative  proceedings.  Symptoms  of  gastric  irrita- 
tion must  be  prevented  by  giving  some  alkaline  carbonate 
(especially  the  ammonium  or  soda  salts),  whilst  the  dose  should  be 
freely  diluted  with  water. 

Operation. — It  is  most  desirable  that  this  should  be  undertaken 
as  early  as  possible,  since,  even  if  no  tumour  exists,  the  patient 
runs  but  little  serious  risk,  whilst  delay  until  all  the  classical 
symptoms  are  well  marked  may  prevent  the  total  removal  of  the 
growth-  Occasionally  it  is  divided  into  two  stages,  one  consisting 
in  the  removal  of  the  bone,  and  the  other,  six  or  eight  days  later, 
involving  the  intracranial  portion  ;  but  such  a  modification  is  not 
essential,  and  is  sometimes  undesirable. 

The  scalp  should  be  entirely  shaved  a  day  or  two  previously, 
and  very  thoroughly  purified.  A  quarter  of  a  grain  of  morphia  is 
injected  about  half  an  hour  before  the  operation,  with  the  idea 
both  of  reducing  the  vascularity  of  the  brain  and  of  dulling  the 
patient's  sensations,  so  that  a  smaller  amount  of  anaesthetic  is 
subsequently  needed.  Chloroform  should  be  employed  rather 
than  ether,  as  it  produces  less  congestion  of  the  head.  The 
surgeon  marks  the  spot  selected  for  the  application  of  the  trephine 
by  drilling  the  bone  with  a  bradawl  through  the  scalp.  A  large 
semicircular  flap  is  then  turned  down,  exposing  a  considerable 
area  of  the  calvarium,  so  that  if  a  larger  amount  of  bone  than  is 
expected  needs  to  be  removed,  no  fresh  scalp  incisions  are 
required ;  moreover,  the  cicatrix  will  in  this  way  be  prevented 
from  forming  over  the  trephine  opening.  A  crucial  incision  is 
made  through  the  pericranium,  which  is  retracted  to  a  sufficient 
extent  to  allow  a  2-inch  trephine  to  be  applied,  the  centre-pin 
being  placed  in  the  hole  previously  made  by  the  bradawl.  A 
Gait's  trephine  (i.e.,  an  instrument  with  shelving  borders)  is  to  be 
preferred  to  one  of  the  ordinary  type.  The  disc  of  bone  is  care- 
fully removed,  and  placed  in  warm  and  sterilized  normal  saline 
solution,  so  that  it  may  be  subsequently  replaced  if  necessary. 
Other  methods  of  removing  the  calvarium  have  been  introduced, 


CEREBRAL  TUMOURS  717 

so  as  to  enable  a  considerable  area  of  the  brain  to  be  exposed. 
Thus,  the  bone  may  be  partially  sawn  through  in  such  a  way  as 
to  divide  the  portion  to  be  removed  into  rectangular  areas ;  then 
if  the  whole  thickness  of  the  bone  is  removed  at  one  spot  by  a 
trephine,  it  is  easy  to  cut  away  the  remainder  with  bone  pliers. 
Other  surgeons  prefer  Wagner's  osteoplastic  method,  which  con- 
sists in  turning  down  a  flap  of  skull  with  the  soft  parts.  After  the 
superficial  incision  has  been  made,  the  bone  is  divided  along  the 
same  line,  either  by  a  circular  saw  driven  by  electricity,  or  by 
one  of  the  ingenious  surgical  engines — more  or  less  resembling  a 
dental  drill — which  have  been  recently  introduced,  or  by  a  Gigli 
saw  (i.e.,  a  piano  wire  with  a  screw  thread  turned  on  it).  In 
using  the  last-mentioned  contrivance,  two  or  three  trephine  open- 
ings must  be  made  along  the  line  of  incision,  and  the  wire  carried 
through  on  a  probe  from  one  to  the  other.  Handles  are  attached 
at  each  end,  and  the  sawing  is  soon  accomplished ;  it  is  advisable 
to  bevel  the  cut  so  as  to  give  a  shelf  for  the  flap  to  rest  on  when 
replaced.  The  base  of  the  flap  is  partially  or  wholly  sawn  through, 
and  then  the  upper  portion  prised  outwards.  It  is  for  such  severe 
measures  as  these  that  the  operation  in  two  stages  is  recommended. 

The  dura  mater  when  exposed  under  normal  conditions  is  firm, 
but  yields  slightly  to  the  finger,  and  allows  the  pulsation  of  the 
subjacent  brain  to  be  felt,  if  the  latter  is  healthy  and  no  undue 
pressure  is  present  within  ;  but  if  the  intracranial  tension  is 
markedly  increased,  the  dura  mater  bulges  into  the  wound,  feels 
firm  and  unresisting,  and  the  cerebral  pulsations  are  diminished 
or  absent. 

The  dura  mater  is  next  incised  crucially,  or  a  flap  turned  down, 
care  being  taken  to  avoid,  if  possible,  the  meningeal  vessels ;  the 
brain  substance  protrudes  if  the  intracranial  pressure  is  excessive. 
The  region  is  gently  explored  by  the  finger,  and  any  areas  of 
abnormal  hardness  or  softening  noticed ;  failing  this,  a  grooved 
needle  is  inserted  in  different  directions,  or  a  fine  trocar  and 
cannula.  In  introducing  such  instruments,  care  must  be  taken 
to  make  direct  stabs,  and  never  any  lateral  movements,  which 
necessarily  lead  to  laceration  of  the  brain.  The  opening  of  the 
skull  may  be  enlarged,  if  need  be,  either  by  the  use  of  the  bone 
rongeur  or  by  additional  small  trephine  holes.  It  is  but  rarely 
that  a  cerebral  tumour  is  so  placed  that  enucleation  is  possible. 
If,  however,  a  cortical  neoplasm  is  found,  it  is  isolated  from  the 
surrounding  brain  substance  by  blunt  instruments,  e.g.,  the  handle 
of  a  scalpel,  or  a  flexible  knife,  made  of  platinum,  as  suggested  by 
Horsley,  and  the  mass  freely  removed.  Haemorrhage  is  controlled 
by  the  application  of  a  fine  ligature,  or  by  the  use  of  serrefines, 
or  by  sponge  pressure.  The  dura  mater  is  then  loosely  stitched 
together,  and  a  drainage-tube  inserted,  reaching  to  the  bottom  of 
the  wound,  and  brought  out  at  one  angle  of  the  incision  in  the  skin, 
which  may  be  closed  by  a  continuous  suture.     If  the  tumour  has 


7i8  A   MANUAL  OF  SURGERY 

been  satisfactorily  enucleated,  the  disc  of  bone  may  be  placed 
in  situ,  room,  however,  being  left  for  the  passage  of  the  tube ; 
but  if  there  is  any  doubt  as  to  its  complete  removal,  the 
opening  in  the  bone  is  left.  After  the  operation,  the  patient  must 
be  kept  absolutely  quiet,  with  the  head  slightly  raised.  The 
drainage-tube  may  be  removed  in  twenty-four  or  forty-eight  hours, 
and  the  scalp  wound  is  usually  healed  in  six  or  seven  days. 

Even  if  the  tumour  is  inaccessible  or  irremovable,  temporary 
benefit  often  results  from  an  exploratory  operation,  since  a  sub- 
cutaneous hernia  cerebri  is  thereby  allowed  to  form,  and  intra- 
cranial tension  relieved,  as  evidenced  by  an  improved  mental 
condition  and  loss  of  pain  ;  as  the  tumour  grows,  however,  the 
patient  relapses  into  his  former  state,  and  death  sooner  or  later 
follows. 

Abscess  of  the  Brain. 

Causes. — Pyogenic  infection  is,  of  course,  the  ultimate  cause  of 
all  cerebral  suppuration,  but  the  manner  in  which  the  organisms 
find  their  way  to  the  brain  varies  considerably,  (i.)  It  maybe  due 
to  traumatism,  either  in  the  early  or  late  stages  of  head  injuries. 
In  the  early,  it  is  usually  superficial,  and  connected  with  some  in- 
fective lesion  of  the  scalp,  cranium,  or  membranes,  with  or  with- 
out a  penetrating  wound  (Fig.  250).  In  the  later  stages  the  pus 
forms  deeply  in  the  white  substance.  It  may  be  due  to  a  pene- 
trating wound,  whether  a  foreign  body  is  present  or  not,  the 
microbes  finding  their  way  into  the  interior  of  the  brain  either 
through  the  track  of  the  missile,  or  along  bloodvessels  or  lym- 
phatics. Sometimes  it  occurs  apart  from  penetration,  and  then 
one  can  only  suppose  that  it  is  due  to  auto-infection  of  a  contused 
or  lacerated  area.  Chronic  abscess  of  this  type  is  most  frequently 
seen  on  the  same  side  of  the  brain  as  the  lesion,  and  the  parietal 
and  frontal  lobes  are  most  often  affected  ;  occasionally,  however, 
it  may  occur  on  the  opposite  side  in  the  same  way  as  a  contusion, 
(ii.)  It  arises  by  extension  of  an  infective  lesion  from  without,  the 
organisms  reaching  the  brain  by  direct  continuity  of  tissue  or  by 
way  of  the  bloodvessels  or  lymphatics. 

The  commonest  cause  of  all  abscesses  in  the  brain  is  chronic 
otorrhcea,  and  it  appears  that  the  cerebellum  is  more  frequently 
involved  than  the  cerebrum.  In  the  former  the  abscess  is  usually 
in  the  anterior  portion  of  the  lateral  lobe,  close  to  the  back  of  the 
petrous  bone,  whilst  in  the  latter  the  posterior  portion  of  the 
temporo-sphenoidal  lobe  is  most  frequently  affected.  The  inflam- 
mation may  spread  directly  from  the  tympanic  cavity  or  inner 
aspect  of  the  mastoid  process  through  the  bone  to  the  membranes, 
which  become  adherent  to  the  brain,  and  then  into  the  cerebral 
substance  ;  occasionally  a  direct  opening  has  been  found  through 
the  tegmen  tympani  into  an  abscess  cavity,  and  it  has  even  dis- 
charged itself  and  been  drained  in  this  way.     More  commonly  a 


ABSCESS  OF  THE  BRAIN  719 


layer  of  brain  tissue  intervenes  between  the  membranes  and  the 
pus,  and  then  infection  will  have  been  carried  along  vessels  and 
lymphatic  sheaths  running  from  the  middle  ear  to  the  brain. 

Abscesses  of  a  similar  type  occur  in  connection  with  suppura- 
tion in  the  frontal  sinus,  the  abscess  being  usually  acute  and 
secondary  to  a  frontal  osteomyelitis,  and  occupying  the  anterior 
portion  of  the  frontal  lobe  ;  it  may  also  follow  purulent  infection 
of  the  sphenoidal  and  ethmoidal  sinuses,  or  thrombosis  of  the 
cavernous  sinus. 

(iii.)  The  infective  material  may  be  brought  to  the  brain  by  the 
blood  in  pyaemia,  or  after  some  of  the  exanthemata,  such  as  scarla- 
tina, typhoid,  etc. 

(iv.)  A  chronic  abscess  of  tuberculous  origin  may  also  occur. 

A  cerebral  abscess  is  usually  single ;  occasionally  more  than 
one  is  present,  e.g.,  a  cerebral  and  cerebellar  may  co-exist  in  con- 
nection with  middle-ear  mischief.  The  course  taken  by  the  case 
is  generally  chronic,  and  then  the  pus  is  encapsuled  ;  in  acute 
cases  there  is  usually  no  limiting  membrane.  A  chronic  case  not 
uncommonly  terminates  in  an  outbreak  of  acute  symptoms,  due 
either  to  the  abscess  bursting  into  one  of  the  lateral  ventricles,  or 
to  the  supervention  of  spreading  cedema. 

The  Symptoms  vary  somewhat  with  the  method  of  onset  and 
the  characters  of  the  abscess.  If  traumatic  and  due  to  infection 
from  without,  the  case  runs  an  acute  course,  associated  with 
intense  pain  in  the  head,  recurrent  rigors,  and  rapid  development 
of  coma.  Diffuse  meningitis  is  often  present,  and  the  two  con- 
ditions can  scarcely  be  distinguished.  In  not  a  few  of  the  cases 
of  chronic  abscess,  all  that  the  patient  complains  of  is  headache, 
until  suddenly  the  temperature  rises  with  a  bound,  he  becomes 
unconscious  and  dies  within  a  day  or  two.  Such  a  course  of 
events  is  probably  due  to  the  bursting  of  the  abscess  into  the 
lateral  ventricle  or  meningeal  cavity,  and  to  the  onset  of  an  acute 
spreading  cedema. 

When  the  symptoms  are  more  characteristic,  they  may  be 
grouped  together  under  the  following  three  heads  :  (1)  Those 
resulting  from  the  presence  of  pus  within  the  body.  These  are, 
however,  not  typical,  since,  although  there  may  be  an  initial  rigor, 
the  temperature  is  usually  normal  or  subnormal,  unless  basal 
meningitis  co-exists.  (2)  Those  due  to  intracranial  pressure  and 
irritation.  Pain  in  the  head  is  usually  the  earliest  and  most 
marked  of  these  ;  at  first  it  is  often  general,  but  later  on  becomes 
fixed,  and  localized  to  the  seat  of  the  abscess.  It  varies  greatly 
in  amount,  sometimes  being  of  the  most  agonizing  type,  sometimes 
very  slight  ;  it  is  usually  continuous,  but  may  be  intermittent,  and 
entirely  disappear  for  a  time.  Anorexia,  malaise,  vomiting,  and 
constipation  are  often  present ;  the  pulse  is  usually  slow  and  inter- 
mittent, and  Cheyne-Stokes  respiration  may  occur  in  the  later 
stages.     Epileptic  seizures  may  also  be  induced,  and  the  patient 


720  A  MANUAL  OF  SURGERY 

passes  into  a  state  of  mental  torpor,  and  even  coma.  If  unrelieved, 
the  patient  dies  in  a  state  of  coma,  from  interference  with  the  vital 
centres  in  the  medulla.  Optic  neuritis,  more  marked  on  the 
affected  side,  is  another  symptom,  and  the  pupil  on  that  side  is 
dilated  and  does  not  react  to  light.  (3)  Focal  phenomena  arise  as 
in  cases  of  cerebral  tumour,  varying  necessarily  with  the  situation. 
In  most  cases  of  temporo-sphenoidal  abscesses  they  are  not  marked ; 
but  if  the  anterior  part  is  involved,  irritative  or  paralytic  symptoms 
may  be  noted  on  the  opposite  side  of  the  face,  or  aphasia  if  the 
lesion  affects  the  left  hemisphere,  whilst  if  situated  in  the  posterior 
part  symptoms  may  arise  from  pressure  on  the  cerebellum  through 
the  tentorium,  almost  exactly  simulating  those  due  to  an  abscess 
or  tumour  in  the  cerebellum. 

The  signs  connected  with  an  abscess  in  the  cerebellum  are  often 
very  indefinite  and  vague,  but  if  symptoms  develop  at  all  they 
are  very  characteristic.  The  patient  complains  of  giddiness,  and 
staggers  when  attempting  to  walk,  falling  towards  the  opposite 
side  ;  the  arm  on  the  same  side  may  be  paralyzed  ;  nystagmus 
and  lateral  deviation  of  the  eyes  towards  the  opposite  side  are  also 
present.    The  condition  is  more  common  in  adults  than  in  children. 

Diagnosis. — From  meningitis,  a  cerebral  abscess  is  usually 
recognised  by  the  fact  that  in  the  former  condition  irritative 
phenomena,  such  as  acute  and  active  delirium,  contraction  of  the 
pupil,  photophobia,  rigidity  and  spasm  of  muscles,  especially  in 
the  back  of  the  neck,  and  severe  pain,  are  more  evident  and  are 
produced  earlier.  The  temperature  is  usually  high,  and  mental 
dulness  comes  on  within  three  or  four  days  of  an  injury,  whereas 
an  abscess  rarely  forms  before  the  end  of  the  first  week.  Extra- 
dural abscess  (subcranial)  is  associated  with  a  high  temperature, 
earlier  onset  after  an  injury  in  traumatic  cases,  and  more  rapid 
compression  symptoms  ;  optic  neuritis  is  only  occasionally  met 
with,  and  the  vomiting  is  less  troublesome.  There  is  also  likely 
to  be  some  localized  cedema  or  tenderness  on  deep  pressure. 
The  diagnosis  from  thrombosis  of  the  lateral  sinus  is,  as  a  rule,  not 
difficult,  owing  to  the  fact  that  in  abscess  symptoms  of  compres- 
sion are  associated  with  a  low  temperature  and  marked  optic 
neuritis ;  whereas  in  thrombosis  the  temperature  is  high  and 
oscillating,  optic  neuritis  may  be  absent,  and  there  may  be  the 
characteristic  tenderness  in  the  neck.  It  must  not  be  forgotten 
that  the  two  conditions  may  co-exist.  It  is  often  impossible  to 
diagnose  between  a  chronic  abscess  and  a  tumour  of  the  brain  ;  the 
symptoms  in  the  latter  may,  however,  come  on  more  slowly  than 
in  the  former,  but  the  progress  is  steady  and  unrelenting ;  the 
temperature  remains  near  the  normal,  and  there  is  less  gastric 
disturbance.  The  history  of  the  case  may  throw  some  light  upon 
its  nature,  since  in  cases  of  cerebral  abscess  there  is  usually  some 
causative  septic  focus,  but  an  exploratory  operation  is  often 
necessary  to  clear  it  up.     Tumour  is  more  common  in  the  frontal 


ABSCESS  OF  THE  BRAIN  721 


and  parietal  regions,  abscess  in  the  temporo-sphenoidal  lobe. 
Optic  neuritis  is  more  marked  and  more  common  in  tumour  than 
in  abscess. 

Treatment  necessarily  follows  the  usual  rule,  viz.,  to  give  an 
exit  to  the  pus  as  soon  as  possible ;  no  delay  is  permissible  when 
once  symptoms  have  made  themselves  evident.  The  patient  is 
prepared  in  the  same  way  as  for  operation  on  a  cerebral  tumour. 
A  flap  of  scalp  tissue  is  raised,  and  in  such  a  manner  as  will  most 
effectually  serve  for  subsequent  drainage  purposes.  The  trephine 
is  applied  according  to  the  rules  given  below,  or  in  accordance 
with  the  special  indications  given  by  the  symptoms  of  the  case. 
Professor  Macewen  recommends  that,  when  the  circle  of  bone 
has  been  removed,  the  exposed  surface  and  cut  edge  should  be 
well  rubbed  over  with  powdered  iodoform  and  boracic  acid  so  as 
to  guard  them  from  infection.  The  dura  mater  is  then  carefully 
incised  in  a  crucial  fashion,  and  this  may  suffice  to  open  the 
abscess  ;  but  more  usually  the  brain  substance  protrudes.  It  is 
carefully  explored  with  a  trocar  and  cannula,  which  is  passed 
directly  into  it  in  various  directions.  In  a  temporo-sphenoidal 
abscess  the  most  likely  direction  to  explore  is  downwards  and 
inwards  towards  the  tegmen  tympani.  Pus  having  been  dis- 
covered, a  pair  of  sinus  forceps  is  gently  inserted  along  the  track 
of  the  cannula  and  opened,  so  as  to  enlarge  the  passage  and 
give  exit  to  it.  A  twin  drainage-tube  (i.e.,  two  tubes  sewn 
together  at  one  end)  is  then  inserted  so  as  to  reach  the  abscess 
cavity,  which  is  gently  irrigated  with  sterilized  salt  solution  until 
it  comes  back  clear.  The  dural  flaps  are  of  course  left  open,  and 
it  may  be  wise  to  pack  gauze  around  the  tubes  in  order  to  shut  off 
the  meningeal  cavity  by  the  formation  of  adhesions.  The  tubes 
must  not  be  dispensed  with  too  early,  as  pus  will  re-accumulate, 
and  the  wound  need  re  opening.  Possibly  it  is  well  to  remove 
one  of  the  tubes  in  twenty-four  hours  after  the  operation,  and  to 
replace  the  second  by  one  of  smaller  calibre  in  two  or  three  days ; 
in  this  matter  the  surgeon  must  be  guided  by  the  character  and 
amount  of  the  discharge.  Of  course  it  is  undesirable  to  keep  it  in 
too  long  for  fear  of  the  development  of  a  hernia  cerebri.  For  an 
abscess  in  the  temporo-sphenoidal  lobe,  the  centre  pin  of  the 
trephine  may  be  placed  ii  inches  above  Reid's  base  line,  and 
about  the  same  distance  behind  the  centre  of  the  external  auditory 
meatus  (Barker),  but  a  better  situation  is  a  spot  f  inch  above  the 
posterior  root  of  the  zygoma,  and  directly  above  the  posterior 
border  of  the  osseous  meatus  (Macewen  ;  Fig.  295,  D).  For  an 
abscess  in  the  cerebellum  the  point  selected  is  1^  inches  behind 
the  centre  of  the  external  auditory  meatus,  and  1  inch  below  the 
base  line  (Fig.  295,  E).  In  the  latter  case  the  soft  parts,  including 
the  muscles  and  periosteum,  should  be  stripped  off  the  occipital 
bone,  and  turned  downwards,  and  it  is  often  unnecessary  to  apply 

46 


722  A   MANUAL  OF  SURGERY 


a  trephine,  as  the  bone  is  very  thin,  and  may  be  broken  through 
with  a  gouge. 

When  the  diagnosis  is  doubtful,  the  mastoid  antrum  is  first 
opened  and  explored  ;  by  carefully  removing  the  bone  behind  and 
above  this  opening,  the  lateral  sinus  is  next  exposed  ;  and,  finally, 
by  working  above  or  below  it,  the  cerebrum  or  cerebellum  can 
be  examined,  and,  if  need  be,  incised.  A  similar  result  can  be 
obtained  by  applying  a  f-inch  trephine  to  a  spot  i  inch  behind 
the  meatus  and  h  inch  above  the  base  line  (H.  P.  Dean).  The 
lateral  sinus  lies  in  the  lower  portion  of  the  opening,  and  the 
dura  over  the  temporo-sphenoidal  lobe  in  the  upper  ;  by  enlarging 
the  opening  downwards  by  Hoffman's  rongeur,  the  cerebellum 
can  also  be  explored. 


CHAPTER  XXV. 
AFFECTIONS  OF  THE  LIPS  AND  JAWS. 

Affections  of  the  Lips. 

Hare-lip. — By  hare-lip  is  meant  a  congenital  fissure  of  the  upper 
lip,  which  may  extend  for  a  variable  distance  through  the  soft 
tissues  alone,  or  may  also   implicate  the   bony  alveolus  and  the 


^im^jsmkt^'. 


Fig.  254.— Single  Incomplete  Hare-  Fig.  255.— Double  Hake-lip:  com- 

lip,  involving  merely  the  tissues  plete  on  the  left  slde,  incom- 

of   the   llp,  and   not   extending  plete  on  the  rlght. 
into  the  Nose. 


.■?28+r-    P 


A  B 

Fig.  256. — Double    Complete    Hare-lip,  with   Displacement    Forwards 
of  the  Central  Portion  of  the  Intermaxilla  (Os  Incisivum). 

A,  Front  view  ;  B,  seen  in  profile. 

floor  of  the  nose,  and  extend  backwards  through  the  palate.     The 
name  is  not  a  good  one,  since  a  hare's  lip  is  cleft  in  a  Y-shaped 

46 — 2 


724 


A   MANUAL  OF  SURGERY 


manner,  the  fissure  being  central  below,  and  bifurcating  above 
into  each  nostril. 

Varieties.  —  A  hare- lip  is  complete  or  incomplete,  according  to 
whether  or  not  it  extends  into  the  nostril.  It  is  termed  simple  if 
limited  to  the  soft  parts  ;  alveolar,  if  the  bony  alveolus  is  also 
involved;  complicated,  if  associated  with  a  cleft  palate.  The  defect 
may  exist  on  one  or  both  sides  of  the  middle  line ;  if  unilateral  or 
single,  it  is  most  common  on  the  left  side,  in  the  proportion  of 
two  to  one  ;  if  double  or  bilateral,  it  is  usually,  but  not  invariably, 
alveolar,  and  accompanied  by  a  complete  cleft  of  the  palate.    The 


Fig.  257. — Head  of  Fcetus,  of  about 
Five  Weeks,  from  Ventral  Aspect 
(after  His),  showing  the  Primi- 
tive Stomod^um  bounded  above 
by  the  Undivided  Fronto-nasal 
Process,  laterally  by  the  Max- 
illary, and  below  by  the  still 
separate  Mandibular  Processes. 
(Sutton.) 

The  quinque-radiate  appearance  is 
well  represented. 


Fig.  258. — Head  of  Fcetus  of  a 
Little  Later  Date  (Six  to  Seven 
Weeks),  from  the  Ventral 
Aspect.     (Sutton.) 

The  mandibular  processes  have  now 
united  ;  the  ocular  vesicle  is  seen 
on  either  side  towards  the  upper 
end  of  the  orbito- nasal  fissure, 
and  the  fronto- nasal  process  has 
developed  internal  and  external 
nasal  processes  on  either  side  of 
the  still  unclosed  anterior  nares. 

central  portions  of  the  lip  and  alveolus  (os  incisivum)  may  either 
retain  their  normal  position,  or,  as  is  more  frequently  the  case, 
project  forwards  at  the  end  of  the  nose,  forming  a  proboscis- 
like appendage  (Fig.  256,  A  and  B).  Even  in  simple  cases  the 
nose  is  deformed,  being  broad  and  flattened,  a  condition  which 
becomes  much  more  marked  when  the  alveolus  and  floor  of  the 
nose  are  widely  fissured.  Hare-lip  is  not  uncommonly  associated 
with  other  deformities — e.g.,  spina  bifida  and  talipes — and  it  is 
frequently  transmitted  from  one  generation  to  another.  Occa- 
sionally a  thin  red  line,  as  of  a  cicatrix,  is  seen  occupying  the 
position  of  a  hare-lip  cleft,  and  is  probably  due  to  a  persistence 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


725 


of  the  raphe  of  union  of  the  labial  segments  ;  a  slight  groove  in 
the  alveolus  may  also  be  observed  at  a  corresponding  point. 

Development.  — (For  fuller  details  of  the  development  of  bare-lip  and  cleft 
palate,  we  must  refer  readers  to  'Harelip  and  Cleft  Palate,'  by  W.  Rose; 
Lewis  and  Co.,  1891.  Space  only  permits  a  very  brief  summary  here.)  The 
bony  and  fleshy  parts  of  the  face  originate  from  the  outgrowth  of  processes 
around  the  cavity  formed  by  the  bending  forward  of  the  primitive  cerebral 
vesicle  over  the  end  of  the  notochord.  At  about  five  weeks  after  conception 
the  primitive  buccal  cavity  or  stomodaeum  has  a  quinque-radiate  appearance, 
due  to  the  manner  in  which  these  processes  are  formed  (Fig.  257).  A  broad 
median  lappet  (fronto-nasal  process)  descends  from  above  ;  this  is  separated 
by  a  fissure  on  each  side  from  the  symmetrically-placed  maxillary  processes, 
and  these  again  below  from  the  more  prominent  mandibular  processes,  which 
early  unite  across  the  middle  line,  to  form  the  lower  jaw.  The  fronto-nasal 
process  soon,  however,  changes,  developing  four  rounded  buds,  the  relations 
of  which  are  indicated  in  Fig.  258.  On  either  side  of  a  slight  depression  in 
the  median  line  is  placed  the  internal  nasal  process,  from  which  are  produced 


Fig.  259. — Diagram  to  represent  the  Albrecht  Theory  of  Hare-lip, 
showing  the  situation  of  the  cleft  in  the  alveolus  between 
the  Inner  and  Outer  Segments  of  the  Intermaxilla. 

EG,  Endognathion  ;   MG,  mesognathion  ;  XG,  exognathion  ;  ix,  central 
incisor;  »a,  lateral  incisor;  c,  canine;  mlt  m„,  first  and  second  molars. 


superficially  the  central  portion  of  the  upper  lip,  and  from  its  deeper  aspect 
the  inner  segment  of  the  intermaxilla  (endogathion,  Fig.  259,  EG),  carrying 
the  central  incisor.  Separated  from  this  by  a  hollow,  which  subsequently 
forms  the  anterior  nares,  is  the  rounded  external  nasal  process,  from  which 
develop  the  side  of  the  cheek,  the  ala  nasi,  and  from  its  deep  side  the  outer 
segment  of  the  intermaxilla  (mesognathion,  MG)  and  probably  the  lateral 
incisor.  External  to  this  a  fissure  runs  up  to,  and  even  beyond,  the  primitive 
eye  (naso-orbital  fissure),  and  this  is  later  on  closed  by  amalgamation  of  the 
internal  and  external  nasal  processes  on  the  inner  side  with  the  adjacent 
maxillary  process  on  the  outer,  except  in  the  deepest  part,  which  constitutes 
the  nasal  duct.  The  integrity  of  the  upper  lip  is  obtained  by  the  union  of 
the  lower  parts  of  the  internal  nasal  and  maxillary  processes,  which  thus 
exclude  the  external  nasal  from  participation  in  its  free  border.  It  is  doubtless 
owing  to  this  arrangement  that  the  sulcus  or  depression  around  the  ala  nasi 
constitutes  such  a  distinct  and  characteristic  feature  of  the  face.  At  the  same 
time  the  deeper  parts  of  these  nasal  processes  are  uniting  with  one  another 
and  with  the  palatal  plates,  which  grow  horizontally  inwards  from  the  under 
side  of  the  maxillary  processes,  uniting  in  a  Y-shaped  suture,  the  point  of 
junction  of  the  limbs  being  situated  at  the  anterior  palatine  canal.     The  union 


726  A   MANUAL  OF  SURGERY 

of  all  these  elements  is  taking  place  from  the  sixth  to  the  tenth  week,  and  by 
that  date  even  the  uvula,  the  last  part  to  unite,  should  be  complete. 

Ordinary  hare-lip  is  due  to  a  failure  of  union  of  the  internal  nasal  process 
with  the  structures  in  external  relation  with  it;  if  limited  to  the  soft  parts 
(simple  hare-lip),  the  cleft  runs  between  the  internal  nasal  and  maxillary- 
processes  ;  if  complete  or  alveolar,  between  the  same  two  below  and  super- 
ficially, but  in  addition  between  the  internal  and  external  nasal  processes 
above  and  on  the  deep  side.  The  cleft  in  the  alveolus  passes  between  the 
inner  and  outer  segments  of  the  intermaxilla  (Fig.  259),  and  is  thus  bounded 
on  the  inner  side  by  the  central  incisor,  on  the  outer  side  by  the  lateral  incisor. 
Occasionally  two  teeth  are  found  growing  from  the  endognathion,  the  outer  of 
the  two  being  an  accessory  tooth,  whilst  the  lateral  incisor,  and  presumably 
the  outer  segment  of  the  intermaxilla,  are  often  undeveloped,  or  exist  in  a  very 
rudimentary  condition  attached  to  the  maxilla. 

The  os  incisivum,  or  projecting  portion  of  the  intermaxilla,  consists  of 
two  segments  of  bone,  the  two  endognathia,  united  in  the  median  line,  and 
in  a  child  contains  two  milk  central  incisors,  and  the  rudiments  of  the  two 
permanent  ones;  occasionally,  as  we  have  just  stated,  there  may  be  an 
accessory  tooth  developed  on  one  or  both  sides  of  the  process. 

A  simple  hare-lip  does  not  interfere  seriously  with  the  infant's 
nutrition,  but  when  double,  and  especially  if  associated  with  a 
cleft  palate,  considerable  trouble  may  arise,  thus  necessitating 
surgical  treatment  as  a  life-saving  measure  at  a  very  early  date. 
It  must  also  be  remembered  that  all  movements  of  the  face — 
e.g.,  in  crying  or  laughing — exaggerate  the  deformity  from  the 
unbalanced  action  of  the  divided  orbicularis  oris  and  other 
muscles. 

As  to  the  period  at  Avhich  to  operate,  it  is  better  to  allow  the 
infant  to  get  over  the  shock  of  its  entrance  into  the  world  and 
become  acclimatized  to  an  independent  existence,  whilst  at  the 
same  time  the  operation  should  be  performed  before  the  troubles 
of  dentition  begin.  From  six  weeks  to  three  months  is  perhaps 
the  best  age  for  operation — in  well-nourished  and  healthy  children 
at  the  earlier  date,  in  poorly-fed  and  weakly  children  at  the  later, 
unless  the  inanition  is  due  to  the  difficulty  of  giving  nutrition 
owing  to  the  deformity.  Under  such  circumstances  the  operation 
may  have  to  be  undertaken  within  the  first  three  weeks. 

Operation  for  Single  Hare-lip. — The  child  should  be  laid  on  an 
operating-table  with  its  arms  bound  to  the  body.  The  surgeon 
stands  behind  it,  the  anaesthetist  and  assistant  one  on  each  side. 
The  operation  may  be  described  in  three  stages : 

1.  The  lip  is  thoroughly  dissected  up  from  the  maxilla  and  alveoli 
by  cutting  through  the  reflections  of  mucous  membrane  and  the 
attachment  of  the  muscles  and  other  soft  parts.  This  is  mainly 
needed  on  the  outer  side,  and  where  there  is  much  flattening  of 
the  nose  the  ala  nasi  will  also  require  to  be  separated.  This 
may  cause  some  amount  of  bleeding,  but  sponge  pressure  easily 
controls  it. 

2.  The  edges  of  the  cleft  are  then  pared.  Many  different  methods 
have  been  employed  to  accomplish  this,  but  it  is  only  necessary 
to  mention  two.     The  object  to  be  attained  is  the  union  of  the 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


727 


cleft  lip  by  means  of  a  cicatrix,  which  shall  be  as  unobtrusive 
as  possible,  whilst  the  red  margin  must  be  continuous,  and  the 
section  such  that  the  raw  surfaces  are  larger  than  are  absolutely 
necessary,  so  as  to  allow  for  subsequent   cicatricial  contraction 


Fig.  260. — Rose's  Operation  for  Single  Hare-lip. 

On  the  left  side  the  semilunar  incisions  are  seen  extending  as  far  as  the  free 
borders  of  the  lip.  The  right-hand  figure  shows  the  parts  drawn  into 
position  ;  the  wide  cross  lines  represent  the  wire  sutures,  the  narrow  ones 
the  catgut  or  horsehair  stitches. 

without  the  development  of  a  notch.    The  methods  recommended 
are  as  follows : 

(a)  The  incision  extends  from  the  apex  of  the  cleft,  or  from 
within  the  nostril,  in  a  crescentic  manner  (Fig.  260),  so  that  a 
slight   angular   projection   is  formed    to  constitute  a  prolabium. 


Fig.  261. — Mirault's  Operation  for  Hare-lip. 

In  the  right-hand  figure  the  prolabial  flap  is  shown  ready  to  be  implanted 
on  the  prepared  inner  side. 

This  is  done  on  each  side,  and  where  the  nose  is  much  flattened, 
more  tissue  is  removed  on  the  outer  than  on  the  inner  side,  so 
that  when  the  parts  are  sutured  together  the  nostrils  become  as 
nearly  as  possible  symmetrical.  By  this  means  the  depth  of  the 
lip  is  increased  to  allow  of  subsequent  contraction,  whilst  the  red 
margin  can  be  made  continuous. 


728  A  MANUAL  OF  SURGERY 


(b)  Miraulfs  Operation  (Fig.  261). — -The  inner  margin  and  apex 
of  the  cleft  are  pared,  so  as  to  leave  a  raw  surface  ;  a  flap  of  red 
marginal  tissue,  as  thick  as  possible,  is  then  cut  from  the  outer 
side,  and  implanted  on  the  bevelled  raw  surface  of  the  red  margin  on 
the  inner  side,  the  upper  portions  of  the  cleft  being  also  apposed. 

3.  Sutures  are  now  inserted  to  maintain  the  lip  in  the  position 
into  which  it  can  be  drawn  by  the  fingers  without  tension.  Two 
deep  silver- wire  sutures  should  be  introduced,  one  just  above  the 
red  margin,  and  one  close  to  the  nose,  to  draw  into  position  and 
steady  the  nostril,  which  should  be  left  smaller  than  that  on  the 
other  side,  so  as  to  allow  for  subsequent  dilatation,  which  is  certain 
to  occur.  Horsehair  or  catgut  stitches  are  used  to  bring  the  exact 
margins  together,  the  continuity  of  the  muco-cutaneous  line  being 
accurately  preserved,  and  the  cut  edges  of  the  mucous  membrane 
upon  the  deeper  aspect  being  sutured,  each  stitch,  after  it  is  tight- 
ened, being  used  to  elevate  and  evert  the  lip  and  thus  assist  the 
insertion  of  the  next.  The  wound  is  dressed  with  a  small  piece 
of  gauze,  and  secured  by  another  dry  piece  cut  in  the  shape  of  a 
butterfly,  so  that  the  narrow  body  shall  fit  over  the  lip,  and  the 
wings  spread  over  the  cheeks ;  this  is  fixed  by  collodion,  and 
maintained  for  some  days  after  the  stitches  are  removed,  the  deep 
ones  on  the  fourth  day,  and  the  superficial  ones  about  the  eighth 
or  tenth.  Careful  feeding  by  the  spoon  is  necessary,  the  mother's 
milk  being  drawn  off  and  given  in  this  way,  if  possible.  In  simple 
cases  the  child  may  be  returned  to  the  breast  about  the  fifth  day. 
In  order  to  prevent  the  child  from  picking  at  the  lip  or  disturbing 
the  dressing,  it  is  well  to  put  a  splint  on  the  flexor  side  of  each 
arm  to  control  the  elbow-joint. 

The  Treatment  of  Double  Hare-lip  may  be  discussed  under  two 
headings,  viz.,  the  treatment  of  the  os  incisivum,  and  that  of  the 
soft  parts. 

The  os  incisivum  need  not  be  touched  if  it  retains  its  normal 
position,  and  the  labial  clefts  are  then  alone  dealt  with  ;  but  if  it 
projects  forwards,  as  is  often  the  case,  it  must  be  either  removed 
or  replaced,  (a)  In  the  former  case  the  central  portion  of  the 
upper  lip  is  freed  from  it  by  dissection,  and  the  base  of  the  process 
divided  with  cutting  pliers  ;  a  small  artery  in  the  bone  will  spurt 
vigorously,  and  may  need  an  application  of  the  cautery  to  stop  it. 
The  operation  on  the  lip  is  deferred  till  ten  days  later,  (b)  Re- 
position may  be  effected  by  several  methods,  the  best  of  which 
is  Bardeleben's,  who  incises  the  lower  border  of  the  septum, 
strips  off  the  muco-periosteum  from  either  side,  and  then  bends 
or  breaks  the  bone  back  into  position,  fixing  it  by  silver  wires, 
and  uniting  the  lip  at  once  to  form  a  splint  to  maintain  it  in  situ. 
The  advantages  claimed  for  reposition  are  that  the  patient  retains 
his  own  central  incisor  teeth,  and  that  the  normal  contour  of  the 
jaw  and  face  is  not  interfered  with.  Against  this  plan,  however, 
must  be  placed  the  facts  that  the  bone  rarely  becomes  firmly 
united,  that  the  teeth  are  stunted  and  erupt  obliquely  backwards 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


729 


from  rotation  of  the  process,  and  that  its  presence  prevents  the 
maxillae  from  falling  together  and  increases  the  difficulties  of 
subsequently  closing  the  palatal  cleft.     Personally  we  recommend 


Fig.  262. — Rose's  Operation  for  Double  Hare-lip. 

The  central  tubercle  is  pared  in  a  V-shaped  manner,  and  the  lateral  segments 
by  curved  incisions,  extending  to  the  red  margin,  and  then  inwards.  Only 
the  apex  of  the  central  portion  is  included  in  the  completed  lip.  The  long 
cross  lines  represent  the  position  of  the  wire  stitches,  the  shorter  ones  of 
the  catgut  sutures. 

extirpation  in  bad  cases,  since  the  disfigurement  can  to  a  large 

measure  be  removed  by  adding  a  projecting  cheek-plate  to  that 

which  carries  the  artificial  incisors,  thus  pushing  the  upper  lip 

forwards,      (c)  Where,  however, 

the  projection  is  not  great,  it  is 

possible  to  diminish  the  size  of 

the    os     incisivum    by    gouging 

away  the  teeth  contained  within 

it,  so  that  the  lip  can  be  closed 

over  it. 

The  soft  parts  of  the  lip  are 
dealt    with   in    much    the    same 
way  as  in  single  hare-lip.     They  ^ 
are    freely    detached    from    the  \ 
maxillse,    and   the    edges   pared,     ^fc 
as  shown  in  Fig.  262,  the  central        ^ 
portion  being  cut  into  a  V,  and 
no  attempt  made  to  incorporate 
it  into  the  free  margin  for  fear  of     Fig 
depressing  the  tip  of   the  nose, 
whilst  the  lateral   segments   are 
pared  as  in  the  single  operation. 

These  latter  are  now  drawn  together  and  united  in  the  middle  line 
below  the  central  portion,  so  that  a  Y-shaped  cicatrix  results.  One 
of  the  deep  silver  stitches  should  fix  the  apex  of  the  V ;  the  other 
should  be  inserted  just  above  the  red  margin.  The  dressing  and 
after-treatment  are  as  in  the  single  operation.  For  a  time  the  child 
may  have  difficulty  in  breathing  owing  to  the  diminution  in  the 
size  of  the  oral  aperture,  but  this  is  obviated  by  the  nurse  drawing 


263. — Median  Hare-lip. 
(Pitts'  Case.) 


730 


A   MANUAL  OF  SURGERY 


down  the  lower  lip  with  the  fingers,  or  by  painting  it  in  a  vertical 
direction  with  collodion. 

Other  congenital  abnormalities  of  the  lip  are  met  with,  which,  however,  can 
only  be  briefly  mentioned  here. 

Median  Hare-lip  may  occur  in  one  of  two  forms  :  either  a  simple  cleft  exists 
in  the  middle  line  (Fig.  263),  or  there  may  be  an  absence  of  the  intermaxilla 
and  nasal  septum,  causing  flattening  of  the  bridge  of  the  nose,  and  a  broad 
median  defect,  flanked  by  the  maxillary  portions  of  the  lip. 

Oblique  Facial  Cleft  is  an  uncommon  deformity,  characterized  by  a  cleft  or 
sulcus  in  the  face,  starting  from  the  usual  situation  of  a  hare-lip  below,  but 
running  up  outside  the  nostril  to  the  inner  side  of  the  lower  lid  (Fig.  264). 
Coloboma  of  the  iris  or  choroid  is  sometimes  associated  with  this  rare  defect. 
The  deformity  is  due  to  non-closure  of  the  naso-orbital  fissure,  and  runs  along 


WITH 

(Fer- 


Fig.  264 — Oblique  Facial  Cleft,  or, 
rather,    Cicatricial    Deformity 

along  the  llne  usually  traversed  fig-     2^5  •       macrostoma 

by  such  a  Cleft.     (Kraske's  Case.)  Auricular  Appendages. 

GUSS(5N.) 

the  line  of  the  nasal  duct.  It  may  be  limited  to  the  soft  parts,  or  may  involve 
the  bones,  even  laying  open  the  antrum. 

Macrostoma  (Fig.  265)  is  characterized  by  an  abnormal  width  of  the  mouth, 
and  is  due  to  non-union  of  the  maxillary  and  mandibular  processes.  It  may 
be  uni-  or  bi-lateral,  and  is  usually  associated  with  anomalies  of  development 
of  the  ear,  accessory  auricles  being  often  present.  As  a  rule,  a  small  papilla 
on  the  upper  and  lower  margins  will  indicate  the  true  limits  of  the  mouth, 
being  constituted  by  the  points  of  attachment  of  the  orbicularis.  The  existence 
of  these  is  of  great  importance  as  indicating  the  extent  to  which  the  cleft 
must  be  pared  in  order  to  restore  the  mouth  to  its  normal  size. 

Mandibular  Clefts  are  exceedingly  rare.  They  are  due  to  non-union  of  the 
mandibular  processes  in  the  middle  line,  and  involve  either  the  soft  tissues  of 
the  lower  lip  alone,  or  may  extend  to  the  bone,  and  even  the  tongue.  Treat- 
ment is  as  for  ordinary  hare-lip. 

Microstoma  is  the  term  applied  to  a  condition  in  which  the  fusion  of  the 
parts  entering  into  the  formation  of  the  lips  progresses  to  a  greater  extent 
than  usual,  so  that  the  oral  orifice  is  contracted.  It  may  be  associated  with 
defective  development  of  the  lower  jaw.  In  the  more  severe  cases,  where  the 
mouth  is  extremely  narrowed,  a  transverse  cut  should  be  made  outwards  on 
each  side,  and  the  mucous  membrane  stitched  to  the  skin. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


731 


Macrocheilia,  or  hypertrophy  of  the  lip,  occurs  in  three  forms  : 
1.  The  congenital  variety,  a  condition  analogous  to  macroglossia, 
and  due  to  a  congenital  distension  of  the  lymphatic  spaces,  or 
chronic  lymphangiectasis,  accompanied  by  overgrowth  of  the 
connective  tissue.  The  lower  lip  is  most  often  involved,  and  is 
firm,  thickened,  and  everted,  causing  considerable  deformity. 
The  treatment  consists  in  the  removal  of  a  V-shaped  portion  from 
the  centre.  2.  An  acquired  form  occurs  in  children  and  young 
people  with  a  tuberculous  inheritance,  constituting  the  so-called 
'  strumous  lip.'  Either  lip  may  be  affected,  but  perhaps  more 
frequently  the  upper ;  the  thickening  is  probably  of  a  chronic 
cedematous  nature,  maintained  by  the  persistent  irritation  of  cracks 
and  fissures.  If  these  can  be  healed,  and  the  general  health 
improved,  diminution  in  the  size  of  the  lip  soon  follows.  3.  In 
adults,  macrocheilia  is  in  almost  all  cases  due  to  tertiary  syphilis. 
The  lower  lip  is  most  often  enlarged,  and  becomes  thick  and  hard. 
It  is  due  to  the  diffuse  sclerosis  characteristic  of  tertiary  mischief. 
General  treatment,  and  not  local,  is  needed. 

Syphilitic  Affections  of  the  lip  are  not  uncommon.  A  primary 
chancre  may  be  caused  by  kissing,  or  by  smoking  an  infected  pipe, 
or  drinking  from  a  glass  with  an 
infected  rim.  It  usually  presents 
a  smooth  ulcerated  surface,  dis- 
charging a  small  amount  of  sero- 
pus,  resting  on  a  mass  of  infil- 
trated tissue  which  may  extend 
over  the  whole  lip  (Fig.  266). 
The  induration  is  not  so  great 
as  in  chancres  upon  the  genital 
organs,  but  the  infiltration  is 
much  more  extensive.  An  indo- 
lent enlargement  of  one  or  more 
of  the  submaxillary  lymphatic 
glands  occurs  very  early,  and 
the  disease  usually  runs  an  acute 
course.  Ordinary  specific  treat- 
ment is  all  that  is  needed.  A 
labial  chancre  may  closely  re- 
semble epithelioma,  but  is  dis- 
tinguished from  it  by  its  rapid 
development  up  to  a  certain 
point,  by  the  early  implication 
of  the  glands,  which  soon  be- 
come very  large,  by  the  absence 

of  typical  cachexia,  by  the  age  of  the  patient,  and  the  course 
taken  by  the  case,  as  well  as  by  the  local  appearances.  The 
surface  is  usually  flattened,  and  less  warty  and  irregular  than  in 


Fig.  266. — Chancre  of  Upper  Lip. 
(From  a  Photograph.) 

The  enlargement  of  the  submaxil- 
lary lymphatic  glands  is  very 
evident. 


732  A  MANUAL  OF  SURGERY 

epithelioma,  whilst  the  skin  is  more  involved  than  the  mucous 
membrane.  Should  the  chancre  have  existed  for  any  time,  the 
presence  of  a  rash  or  sore  throat  may  materially  assist  in  forming 
a  diagnosis.  Moreover,  it  is  said  to  be  more  common  on  the 
upper  lip,  whilst  epithelioma  is  usually  seen  on  the  lower  (com- 
pare Figs.  266,  267).  In  the  secondary  stage  mucous  tubercles  are 
frequently  met  with,  involving  the  inner  side  of  the  lip  and  the 
angle  of  the  mouth.  In  the  tertiary  period  serpiginous  ulceration 
and  gummata  may  occur,  or  the  diffuse  induration  described 
above.  In  inherited  syphilis,  cracks  and  mucous  tubercles  are  con- 
stantly present,  and  may  be  so  extensive  as  to  leave  cicatrices 
radiating  from  the  mouth,  which  are  very  characteristic  (Fig.  17). 

Cracked  Lips  (or,  as  they  are  often  called,  chapped  lips)  are 
usually  the  result  of  cold  weather,  a  central  crack  or  fissure 
forming  which  is  extremely  painful,  and  liable  to  bleed  very 
readily  on  everting  or  stretching  the  part.  The  lower  lip  is  that 
generally  affected.  In  tuberculous  children  more  than  one  may 
occur,  and  by  their  persistence  they  give  rise  to  a  considerable 
degree  of  induration  and  infiltration,  and  perhaps  lead  to  glandular 
trouble.  All  that  is  needed  in  the  shape  of  treatment  is  the  appli- 
cation of  a  little  lanoline  or  cold  cream,  but  if  they  persist,  it  may 
be  advisable  to  touch  them  with  nitrate  of  silver. 

Herpes  Labialis  is  a  condition  usually  associated  with  catarrh, 
and  not  unfrequently  with  pneumonia  or  other  fevers.  Either 
lip  may  be  affected,  and  the  herpetic  eruption  is  quite  limited  in 
extent.  It  consists  of  a  number  of  little  vesicles  situated  on  a 
hyperaemic  and  painful  base  ;  after  a  few  days  the  vesicles  become 
transformed  into  pustules,  and  these  in  turn  burst  and  dry  up, 
the  whole  affection  lasting  perhaps  a  week  or  ten  days.  No 
special  treatment  is  required.  If  the  inner  aspect  of  the  lip  is 
affected,  the  epithelium  early  becomes  sodden  and  is  shed,  so  that 
the  vesicular  stage  is  much  shorter. 

Mucous  Cysts  occur  on  the  inner  side  of  the  lip  in  the  form 
of  small  rounded  swellings,  which  are  translucent  and  contain  a 
glairy  fluid.  They  are  often  due  to  trauma,  whereby  the  opening 
of  a  mucous  gland  is  blocked.  The  whole  cyst  wall  should  be 
dissected  out,  and  the  wound  closed  by  stitches. 

Nsevi  are  frequently  met  with  in  the  lip.  If  confined  to  the 
inner  aspect  they  may  be  dissected  out,  but  when  large  and 
involving  the  whole  thickness,  they  should  be  dealt  with  by 
electrolysis. 

Warty  Growths  are  often  seen  on  the  lower  lip,  especially  near 
the  angle,  and  may  then  simulate  epithelioma.  They  are  dis- 
tinguished, however,  by  the  fact  that  ulceration  is  not  often  pre- 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


733 


sent,  that  the  lymphatic  glands  are  not  involved,  and  that  there 
is  but  little  infiltration  of  the  base.  They  should,  however,  be 
removed  as  early  as  possible,  since  malignant  disease  often  starts 
from  them. 

Epithelioma  of  the  lip  usually  occurs  in  men  of  the  working 
classes,  and  is  commonly  stated  to  be  due  to  the  irritation  pro- 
duced by  smoking  a 
short  clay  pipe,  which 
is  allowed  to  rest  on 
one  or  the  other  side 
near  the  angle.  A 
semicircular  notch  will 
frequently  be  noticed 
in  the  teeth  of  the 
upper  and  lower  jaw, 
corresponding  to  the 
situation  of  the  growth 
on  the  lip,  and  caused 
by  the  constant  fric- 
tion of  the  pipe-stem. 
It  may  also  start 
opposite  the  site  of 
some  projecting  rough 
or  carious  tooth.  It  is 
but  rarely  met  with 
in  women,  occurring 
in  England  in  not  more 
than  5  to  6  per  cent,  of 
the  cases,  and  of  these, 
according  to  Hutchin- 
son, half  are  clay-pipe 
smokers,  whilst  in 
Warren's  female  cases, 
amongst  the  Irish    in 

Glasgow,  three-quarters  were  smokers.  It  is  also  more  common 
amongst  country  folk  who  use  the  short  clay  pipe  than  amongst 
the  cigarette  and  cigar  smokers  in  towns. 

The  disease  may  start  as  an  induration  around  a  crack  or 
fissure,  which  gradually  extends,  forming  a  typical  malignant 
ulcer  ;  or  as  a  wart-like  growth,  which  fungates  and  ulcerates  ;  or 
as  a  chronic  infiltration  leading  to  an  irregular  nodular  thickening 
of  the  lip  (Fig.  267). 

If  allowed  to  run  its  course  unchecked  by  treatment,  the  disease 
steadily  progresses,  forming  an  ulcerated  mass  of  greater  or  less 
size,  and  even  involving  the  jaw.  The  submental  and  sub- 
maxillary glands  are  early  implicated,  and  secondary  deposits  are 
also  found  in  the  glandulae  concatenatae.     Beyond  this,  however, 


Fig.  267. — Chronic  Epithelioma  of  Lower 
Lip.     (From  a  photograph.) 


734 


A   MANUAL  OF  SURGERY 


the  disease  rarely  extends,  visceral  complications  being  uncommon. 
When  a  fatal  issue  results,  it  is  generally  caused  by  the  secondary 
growths  in  the  neck,  which  attain  considerable  dimensions  and 
then  ulcerate,  this  stage  being  possibly  preceded  by  one  of  cystic 
degeneration.  From  these  ulcerating  surfaces  a  variable  amount 
of  discharge  escapes,  varying  with  the  septicity  or  not  of  the 
wounds.  Haemorrhage  is  also  likely  to  follow  from  erosion  of 
some  of  the  vessels  in  the  neck. 

The  Diagnosis  of  epithelioma  is  rarely  doubtful,  but  occasionally 
warty  growths,  or  even  a  primary  chancre  (p.  731),  may  be  mis- 
taken for  it.  The  clinical  history  generally  suffices  to  determine 
the  nature  of  the  mass,  as  also  the  character  of  the  base  and  the 
appearance  of  the  parts  ;  but  in  uncertain  cases  the  removal  of  a 
small  portion  under  cocaine,  and  its  microscopic  examination,  are 
required  to  set  doubts  at  rest. 

Treatment. — The  primary  growth  can  almost  always  be  excised 
completely  without  much  difficulty  ;  if  glands  are  also  enlarged, 

these  should  be  removed 
where  such  is  feasible, 
but  when  once  the  con- 
catenate group  has  been 
attacked,  they  often  con- 
tract such  adhesions  as 
to  render  their  extirpa- 
tion impracticable.  If 
the  growth  is  limited  to 
one  part  of  the  lip,  a 
V-shaped  wedge  extend- 
ing half  an  inch  beyond 
it  in  all  directions  may 
be  taken  away  (Fig.  268), 
and  the  wound  closed,  as 
in  a  case  of  hare-lip,  with- 
out much  deformity  re- 
sulting. When  it  is  more  extensive  considerable  ingenuity 
must  be  exercised  in  order  to  make  good  the  defect.  One  plan 
that  often  gives  good  results  is  to  excise  the  growth  by  a  some- 
what larger  V-shaped  incision,  and  then  to  extend  the  labial 
fissure  transversely  to  one  or  the  other  side,  or  to  both,  dissecting 
up  these  segments  from  the  bone ;  the  flaps  can  then  usually  be 
brought  together,  whilst  the  mucous  membrane  is  united  to  the 
skin  along  the  margin  of  the  new  lip. 

When  the  whole  lower  lip  requires  removal,  Symes'  opevation 
may  be  performed  with  advantage.  It  consists  first  of  all  in  the 
complete  excision  of  the  diseased  lip.  Two  curved  incisions  are 
then  made,  starting  from  the  middle  line  of  the  wound,  and  ex- 
tending downwards  under  the  chin,  to  terminate  below  the  angles 
of  the  jaw,  an  inverted  V-shaped  portion  of  skin  between  them 


Fig. 


268. — V-shaped   Incision  for  Removal 
of  Epithelioma  of  Lip. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  735 

remaining  fixed  to  the  symphysis  menti  to  form  a  base  of  support 
for  the  new  lip.  The  lateral  flaps  are  now  dissected  up,  raised, 
and  united  one  to  the  other  in  the  middle  line,  so  as  to  constitute 
the  new  lip,  an  inverted  Y-shaped  cicatrix  resulting.  The  elasticity 
of  the  skin  in  this  region  allows  this  to  be  accomplished,  and  the 
whole  wound  closed,  without  leaving  any  part  to  granulate.  The 
mucous  membrane  should  be  finally  stitched  to  the  skin  over  the 
upper  free  margin.     Healing  by  first  intention  usually  follows. 

If  the  whole  of  the  upper  lip  needs  to  be  removed,  it  may  be 
restored  in  a  variety  of  ways.  Perhaps  one  of  the  best  consists 
in  making  incisions  which  skirt  the  alae  nasi  on  each  side,  and 
then  extend  outwards  into  the  cheeks  sufficiently  to  allow  the 
tissues,  when  they  have  been  freed  from  the  maxillae  by  under- 
cutting, to  be  drawn  together  in  the  middle  line.  In  such  cases 
care  must  be  taken  not  to  encroach  on  Stenson's  duct. 

Affections  of  the  Gums  and  Alveolar  Processes. 

Spongy  Gums  are  not  unfrequently  met  with  as  a  result  of  the 
administration  of  mercury,  or  from  scurvy.  They  are  characterized 
by  being  soft  and  congested,  bleeding  readily  on  pressure,  and 
perhaps  showing  signs  of  ulceration.  All  that  is  necessary  is  the 
correction  of  the  determining  cause  and  the  use  of  an  alum 
mouth- wash. 

Alveolar  Abscess  (Fig.  269)  is  almost  always  associated  with 
suppuration  around  the  fang  of  a  carious  tooth.  The  alveolar  walls 
become  expanded,  and  the  pus  finds  its  way  over  the  edge  of  the 
bone  (C,  D),  or  even  through  the  osseous  tissue  (A),  under  the 
external  periosteum.  If  limited  in  extent,  it  perforates  the  gum 
directly,  and  is  then  known  as  a  gum-boil ;  but  it  occasionally 
burrows  beneath  the  periosteum,  which  is  stripped  from  the  bone, 
and  may  thus  lead  to  an  abscess  of  larger  size,  possibly  resulting  in 
necrosis  of  the  jaw.  The  formation  of  an  alveolar  abscess  is  almost 
always  associated  with  a  considerable  amount  of  pain  of  a  very 
irritating  nature,  and  when  extensive  may  give  rise  to  serious  con- 
stitutional disturbance.  Occasionally  graver  complications  ensue  ; 
thus,  in  the  upper  jaw  the  antrum  may  be  opened,  and  suppura- 
tion in  this  cavity  follow,  whilst  in  the  lower  the  abscess  may 
travel  downwards  and  burst  externally,  either  close  to  the  lower 
margin  of  the  bone  or  in  the  neck.  A  troublesome  sinus  results, 
which  can  only  be  cured  by  the  removal  of  the  tooth,  and 
even  then  a  depressed  and  adherent  cicatrix  ensues,  which  is 
very  unsightly.  The  most  essential  point  in  the  treatment  neces- 
sarily consists  in  the  removal  of  the  offending  tooth.  Often 
this  is  quite  sufficient,  and  possibly  the  tooth  may  come  away 
with  an  abscess  cavity  attached  to  one  of  the  fangs.  When 
suppuration  occurs  beneath  the  periosteum,  the  pain  can  at  first 
be  relieved  in  measure  by  fomentations,  but  as  soon  as  fluctua- 


736 


A   MANUAL  OF  SURGERY 


tion  is  detected  an  incision  should  be  made  through  the  mucous 
membrane,  and  the  cavity  emptied.  Possibly  it  may  be  wise  to 
keep  a  small  piece  of  stuffing  in  for  a  few  hours,  but  if  a  large 
enough  opening  has  been  made,  all  that  is  subsequently  required 
is  repeated  and  frequent  irrigation,  preferably  with  peroxide  of 
hydrogen.  If  a  small  sinus  persists  after  removal  of  the  tooth,  it 
must  be  opened  up,  and  any  carious  or  necrosed  bone  removed. 

Pyorrhoea  Alveolaris  (or  Riggs's  Disease)  consists  in  an  inflam- 
matory condition  of  the  margins  of  the  gums,  accompanied  by 
a  muco-purulent  discharge,  which  arises  from  pockets  or  pouches 
which  may  extend  a  greater  or  less  distance  along  the  roots  of 
the  teeth.  In  consequence  of  this  the  tissues  of  the  gums  shrink, 
and,  together  with   the  alveolar  border,  become  atrophic ;    the 


Fig.  269. — Diagram   of   Alveolar  Abscess,  resulting  from   Disease  of 
Molar  Tooth.     (After  the  American  System  of  Dentistry.) 

A,  Abscess  arising  from  escape  of  septic  material  from  the  pulp  chamber, 
B,  through  the  foramen  at  apex  of  the  fang ;  it  has  burrowed  directly 
through  the  alveolar  process  and  burst  through  the  gum  ;  C,  similar 
abscess,  which  has  tracked  down  between  the  tooth  and  the  alveolus,  and 
spread  out  beneath  the  alveolar  periosteum  at  D,  constituting  the  t)'pical 
alveolar  abscess  ;   E,  cheek  ;  F,  antrum  ;  G,  nasal  cavity. 

fangs  are  thereby  uncovered,  and  the  teeth  loosened,  so  that  after 
a  while  the  patient  is  likely  to  become  edentulous.  The  process 
is  limited  to  a  few  teeth,  or  may  involve  many.  It  is  always  pre- 
ceded by  an  excessive  deposit  of  tartar,  beneath  which  bacterial 
infection  occurs,  the  inflammation  spreading  down  along  the  peri- 
odontal membrane.  Treatment  consists  in  the  removal  of  the 
tartar  and  the  application  of  astringents  and  antiseptics,  prefer- 
ably peroxide  of  hydrogen,  not  only  to  the  exposed  mucous 
membrane,  but  also  into  the  pouches  and  pockets  where  pus 
collects.     Treatment  is  often  prolonged  and  tedious,  but  must  be 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  737 

persisted  in,  not  only  to  save  the  teeth,  if  possible,  but  also 
to  prevent  or  remedy  the  toxaemic  and  dyspeptic  symptoms  which 
are  due  to  the  absorption  of  the  pus.  In  many  cases,  however, 
the  teeth  have  to  be  sacrificed. 

Hypertrophy  of  the  Gums  is  met  with  in  the  form  of  a  sessile  over- 
growth, sometimes  almost  cauliflower-like,  around  and  between 
the  teeth  ;  it  occurs  most  frequently  in  children,  but  occasionally 
in  older  subjects.  It  is  sometimes  associated  with  carious  teeth, 
and  should  be  cut  away  with  a  scalpel. 

Dental  Cysts  are  by  no  means  uncommon,  resulting  from  the 
irritative  effects  of  dental  caries  ;  hence  they  follow  the  distribution 
of  that  affection,  and  are  most  frequently  seen  in  connection  with 
the  upper  first  molars  and  bicuspids.  They  develop  at  the  roots 
of  the  teeth,  causing  a  painless  regular  expansion  of  the  bone, 
free  from  inflammatory  phenomena,  unless  infected  secondarily 
with  bacteria.  After  a  time  the  centre  of  the  swelling  softens, 
and,  as  the  bony  wall  is  absorbed,  parchment-like  crackling  can 
be  felt  ;  finally,  the  condition  presents  as  a  rounded  tense  elastic 
swelling,  around  the  margins  of  which  the  remains  of  the  ex- 
panded bone  can  be  detected.  The  tooth  which  is  the  cause  of 
the  trouble  is  always  dead,  and  frequently  merely  a  septic  root  is 
present. 

The  cause  of  these  cysts  is  probably  the  proliferation  of  certain 
embryonic  remains  of  the  enamel  organ,  brought  about  by  the 
irritation  of  septic  matter  which  has  escaped  from  the  pulp  cavity. 
These  fcetal  residues  are  lighted  up  into  activity,  develop  into 
masses  or  cylinders  of  epithelial  tissue,  and  then  undergo  cystic 
degeneration.  Their  pathogenesis  is  practically  identical  with 
that  of  the  epithelial  odontome,  but  merely  one  cyst  develops 
here  instead  of  many.  The  fluid  contained  therein  is  thick  and 
mucoid  in  character,  and  broken-down  epithelial  cells  and  choles- 
terine  are  seen  in  it  on  microscopical  examination. 

Treatment. — The  cyst  must  be  laid  freely  open  into  the  mouth, 
the  septic  tooth  or  stump  removed,  and  the  anterior  wall  of  its 
alveolus  cut  away.  The  alveolus  and  cyst  thus  laid  into  one 
cavity  are  scraped  so  as  to  remove  all  the  epithelial  lining,  and 
packed  with  gauze  so  as  to  ensure  healing  by  granulation. 

Epulis. — By  this  term  is  meant  a  tumour  growing  from  the 
alveolar  periosteum.  Two  varieties  are  described,  viz.,  the  simple 
and  the  malignant. 

A  Simple  Epulis  is  usually  of  a  fibromatous  nature,  and  may 
grow  from  either  jaw,  though  more  commonly  from  the  lower.  It 
is  generally  due  to  the  irritation  of  diseased  teeth,  and  although 
most  marked  on  the  outer  aspect,  it  burrows  between  the  teeth,  and 
is  also  found  on  the  inner  side.  It  appears  as  a  red  fleshy  mass, 
smooth,  or  perhaps  lobulated  (Fig.  270),  of  an  elastic  consistency, 
and  possibly  associated  with  a  little  superficial  ulceration.      It  is 

47 


738 


A   MANUAL  OF  SURGERY 


covered  with  mucous  membrane,  and  may  contain  a  few  spicules 
of  bone.  The  treatment  consists  in  removing  the  growth  together 
with  the  teeth  or  stumps  with  which  it  is  connected.  If  small,  it 
will  suffice  to  cut  away  and  scrape  the  bone  from  which  it  arises ; 
but  if  large,  or  if  it  recurs  after  such  treatment,  the  portion  of 
the  alveolus  from  which  it  springs  must  also  be  excised.  This 
is  best  accomplished  by  extracting  a  tooth  on  either  side  of  the 
tumour,  and  cutting  vertically  through  each  socket  with  a  saw,  the 
two  incisions  being  united  below  with  a  chisel,  so  as  to  remove 
a  quadrangular  portion  of  bone  without  interfering  with  the  con- 
tinuity of  the  jaw. 

Malignant  Epulis. — This  title  is  applied  to  a  myeloid  sarcoma 

growing  from  the 
medullary  substance  of 
the  alveolar  process. 
It  forms  a  soft  rapidly 
increasing  mass  of  a 
dusky  purple  colour, 
which  runs  on  to 
ulceration  or  fungation. 
The  deeper  portions  of 
the  growth  may  contain 
an  ossific  deposit.  As 
with  all  forms  of 
myeloid  growth,  it  is 
only  locally  malignant. 
Treatment  consists  in 
free  removal  of  the 
mass  and  of  the  portion 
of  alveolus  from  which 
it  arises.  In  the  upper 
jaw  this  usually  neces- 
sitates excision  of  the 
complete  palatal  seg- 
ment of  the  maxilla, 
but  in  the  lower  jaw  it  is  generally  possible  to  maintain  the  con- 
tinuity of  the  mandible  by  removing  merely  a  quadrilateral  portion 
in  the  same  way  as  for  a  simple  epulis. 

Epithelioma  and  Sarcoma  (round  or  spindle-celled),  arising  from 
the  gum,  are  both  occasionally  met  with.  Epithelioma  in  this 
situation  rarely  fungates,  but  rather  tends  to  invade  the  bony 
tissues,  and  in  the  upper  jaw  extends  upwards  to  the  antrum  ; 
hence,  it  is  sometimes  termed  a  '  creeping  or  burrowing  epithe- 
lioma.' The  ordinary  signs  of  this  disease  become  evident, 
lymphatic  glands  are  enlarged,  and  typical  ulceration  of  the  gum 
follows.  The  only  possible  treatment  consists  in  free  excision  of 
the  growth,  together  with  the  portion  of  bone  affected. 


Fig.  270. — Simple  Epulis. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  739 


Necrosis  of  the  Jaw. — Causes  :  (1)  Subperiosteal  alveolar  abscess, 
connected  with  dental  caries.  (2)  Traumatism,  such  as  blows 
.  on  the  jaw,  with  or  without  fracture,  in  the  latter  instance  being 
due  to  septic  periostitis  or  osteomyelitis,  owing  to  the  lesion 
becoming  compound.  It  is  also  not  uncommonly  caused  by 
the  use  of  dirty  forceps  or  elevators  in  extracting  a  tooth.  (3)  In 
tertiary  syphilis  necrosis  also  occurs,  affecting  most  frequently  the 
palate  or  alveolar  borders.  (4)  It  occasionally  results  from  mer- 
curial poisoning,  bu<  such  is  rarely  seen  at  the  present  day.  (5)  Phos- 
phorus necrosis  is  met  with  amongst  those  who  work  in  lucifer- 
match  factories,  but  only  when  ordinary  phosphorus  is  used  ;  the 
amorphous  form  is  harmless.  The  fumes  are  supposed  to  gain 
access  to  the  jaws  through  carious  teeth,  giving  rise  to  a  somewhat 
acute  inflammation,  which  terminates  in  necrosis.  A  considerable 
amount  of  new  bone  forms  beneath  the  periosteum,  and  the  seques- 
trum, which  is  curiously  grey  and  porous,  like  dirty  pumice-stone, 
is  always  slow  in  separating.  Either  jaw  may  be  affected,  but  per- 
haps the  lower  a  little  more  commonly  than  the  upper.  (6)  Necrosis 
may  follow  one  of  the  exanthemata,  arising  as  an  infective  idio- 
pathic or  embolic  osteomyelitis,  and  then  probably  affecting  a 
considerable  extent  of  bony  tissue,  possibly  the  whole  mandible. 
(7)  Tubercle  is  occasionally  responsible  for  this  condition. 

The  symphysis  menti  in  children  is  occasionally  the  seat  of  a 
pyogenic  or  tuberculous  infection,  previous  to  the  eruption  of  the 
permanent  incisors.  An  abscess  forms,  and  caries,  or  a  limited 
necrosis  results.  In  a  case  of  this  type  an  opening  is  required  in 
the  submental  region,  through  which  the  diseased  tissue  can  be 
thoroughly  scraped  away.  The  teeth  are  of  course  lost,  but  a 
good  result,  and  with  but  little  scarring,  may  be  anticipated. 

The  Clinical  Phenomena  associated  with  necrosis  of  the  jaw  are 
necessarily  much  the  same  whatever  the  cause.  In  the  acute 
form,  inflammatory  symptoms  are  well  marked,  the  face  becoming 
swollen,  red  and  shiny,  and  severe  pain  is  experienced.  Sooner 
or  later  an  abscess  forms,  which  may  point  either  in  the  mouth  or 
on  the  face,  or  the  pus  may  burrow  downwards  for  some  distance 
into  the  neck.  Sinuses  persist,  discharging  the  most  offensive 
pus  ;  a  new  case  of  bone  sometimes  forms  in  the  lower  jaw,  enclos- 
ing the  sequestrum,  but  in  the  upper  this  is  rarely  noticed,  and  even 
in  the  lower  it  is  not  unusual  to  see  a  considerable  amount  of  bare 
or  dead  bone  absorbed  without  the  formation  of  an  involucrum. 

Treatment. — In  the  early  stage  the  mouth  should  be  fomented, 
and  as  soon  as  there  is  any  suspicion  of  pus  a  free  incision  is  made 
down  to  and  along  the  bone.  When  necrosis  is  present,  it  must 
be  treated  in  the  ordinary  way.  the  sinuses  being  flushed  out  with 
an  antiseptic  solution  three  or  four  times  a  day  until  the  sequestrum 
is  loose ;  it  is  then  removed,  if  possible,  from  within  the  mouth. 
Drainage  by  means  of  an  external  opening  is  often  absolutely 
necessary. 

47—2 


74o  A   MANUAL  OF  SURGERY 


Affections  of  the  Antrum. 

Suppuration  within  the  Antrum  frequently  arises  from  disease 
connected  with  the  fangs  of  the  first  or  second  molar  or  bicuspid 
teeth  ;  it  not  uncommonly  extends  from  the  nasal  cavities  in  con- 
nection with  disease  of  the  middle  turbinated  bone,  or  may  be 
secondary  to  suppuration  within  the  frontal  sinus  ;  it  is  occasion- 
ally lighted  up  by  injury.  In  chronic  cases  it  is  not  unusual  to 
find  the  antrum  filled  with  soft  polypi. 

The  Symptoms  produced  are  often  extremely  equivocal,  and  the 
condition  may  be  present  for  some  time  without  being  recognised. 
In  the  chronic  forms  there  is  usually  a  little  local  tenderness  over 
the  antrum,  and  perhaps  some  swelling  of  the  mucous  membrane 
or  of  the  cheek,  whilst  there  is  an  intermittent  discharge  of  pus 
into  and  from  the  nose.  This  varies  considerably  in  amount  and 
character,  being  sometimes  extremely  offensive.  It  is  stated  by 
Heath  that,  although  the  patient  notices  the  fcetor  himself,  it  is 
not,  as  a  rule,  discerned  by  other  people,  thus  differing  from 
ozaena.  On  holding  the  patient's  head  forwards,  it  can  be  demon- 
strated that  there  is  an  overflow  of  pus  into  the  nostril,  and  some- 
times when  the  patient  reclines  it  flows  back  into  the  pharynx. 
Should  the  opening  into  the  nose  become  blocked,  all  the  symp- 
toms are  aggravated,  the  pain  becoming  more  marked  and  the 
swelling  increasing.  Signs  of  distension  of  the  cavity  may  also  be 
produced  in  this  way ;  such  are  manifested  in  four  directions  : 
(a)  Inwards,  causing  obstruction  to  nasal  respiration,  and  possibly 
epiphora,  from  compression  of  the  nasal  duct ;  (b)  upwards,  lead- 
ing to  protrusion  of  the  eyeball  or  exophthalmos  ;  (c)  downwards, 
resulting  in  depression  of  the  side  of  the  palate,  and  possibly 
irregularity  in  the  line  of  the  teeth  ;  and  (d)  outwards,  giving  rise 
to  a  somewhat  characteristic  projection  of  the  cheek  beneath  the 
malar  eminence.  Under  these  circumstances,  a  finger  inserted 
into  the  mouth,  between  the  cheek  and  the  bone,  will  detect  a  loss 
of  resistance  in  the  anterior  wall  of  the  antrum,  and  if  the  disten- 
sion has  lasted  long,  eggshell  crackling  may  be  noticed,  or  the 
whole  anterior  wall  may  be  absorbed  and  an  elastic  swelling  take 
its  place.  Infraorbital  neuralgia  is  often  a  marked  feature  in 
these  cases. 

In  acute  cases  all  the  above  phenomena  may  be  present  in  an 
accentuated  degree,  accompanied  by  severe  tensive  pain  and  some 
amount  of  febrile  disturbance.  Necrosis  of  the  lining  bony  walls 
may  also  be  induced,  owing  to  the  fact  that  the  mucous  mem- 
brane is  closely  adherent  to  the  periosteum. 

The  Diagnosis  of  suppuration  within  the  antrum  is  by  no  means 
readily  made,  since  there  are  many  conditions  which  simulate 
it  somewhat  closely.  Perhaps  the  most  important  sign  is  the 
periodic  discharge  of  pus  from  the  nose,  and  if  this  can  be  induced 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  741 


by  change  of  position  of  the  head,  it  is  pathognomonic  of  disten- 
sion with  pus  of  one  of  the  accessory  sinuses  connected  with  the 
nose,  probably  of  the  antrum.  The  association  of  such  a  pheno- 
menon with  a  dead  or  painful  first  molar  or  bicuspid  is  also  a 
most  suggestive  occurrence.  Another  method  which  has  been 
recommended  is  that  known  as  transillumination  of  the  antrum.  A 
small  electric  lamp  is  placed  within  the  mouth,  and  if  the  patient 
is  in  a  dark  room,  and  his  antra  are  normal,  the  cheeks,  lips,  and 
lower  margins  of  the  orbits  become  of  a  rosy-red  colour.  If, 
however,  the  cavities  are  occupied  by  pus,  blood,  or  a  growth,  the 
parts  remain  dark.  Transillumination  does  not  answer  in  every 
individual,  and  hence  the  value  of  the  test  is  much  diminished.  The 
presence  of  illumination  excludes  intra-antral  growths  or  abscess, 
but  its  absence,  unless  unilateral,  is  not  of  much  significance. 

The  Treatment  of  this  affection  consists  in  freely  opening  and 
curetting  the  antrum  from  the  mouth,  so  that  the  cavity  may  be 
washed  out  and  drained.  Various  methods  have  been  adopted  to 
mttain  this  end,  and  perhaps  the  most  satisfactory  consists  in 
making  an  incision  through  the  anterior  wall  above  the  first  molar 
after  dividing  the  mucous  membrane.  This  tooth,  the  fangs  of 
which  encroach  upon  the  cavity,  should  also  be  drawn,  and  the 
anterior  wall  of  its  socket  cut  or  gouged  away.  In  bad  cases  a 
good  opening  must  also  be  established  into  the  nasal  cavity  so  as 
to  allow  a  thorough  flushing  of  the  antrum  two  or  three  times  a 
day.  To  prevent  the  opening  from  closing  too  quickly,  a  tube 
made  of  gold,  silver,  or  platinum,  and  fitted  to  a  small  tooth- 
plate,  should  be  inserted.  It  is  taken  out  and  cleansed  night  and 
morning,  and  plugged  during  meals.  In  those  cases  secondary 
to  intranasal  disease,  the  first  essential  is  to  deal  with  the  origin 
of  the  mischief  in  the  nose  by  scraping  away  all  granulation  tissue 
and  diseased  bone.  The  antrum  is  often  opened  in  this  way 
from  the  nose,  and  in  the  majority  of  cases  this  will  suffice  to 
enable  the  cavity  to  be  irrigated  and  drained.  In  old-standing 
cases  where  chronic  suppuration  persists,  the  cavity  should  be 
freely  opened  up  from  the  mouth,  examined  by  the  finger,  scraped, 
flushed,  and  stuffed  with  gauze. 

Hydrops  Antri  is  the  term  applied  to  a  chronic  distension  of 
the  antrum  with  a  glairy  mucoid  fluid,  somewhat  similar  in 
character  to  that  contained  in  a  ranula.  The  condition  is  pain- 
less, and  free  from  inflammatory  phenomena,  and  as  the  ex- 
pansion increases,  eggshell  crackling  of  the  anterior  wall,  or  even 
distinct  fluctuation,  may  be  observed.  It  was  formerly  supposed 
to  arise  from  obstruction  to  the  aperture  into  the  nose  and  re- 
tention of  secretion,  but  it  is  in  reality  due  to  a  cystic  tumour 
forming  from  the  mucous  membrane  and  the  glandular  elements 
contained  therein,  or  to  a  dental  cyst  (p.  737)  which  has  en- 
croached on  the  antral  cavity.  The  treatment  required  is  to 
thoroughly  open  the  antrum  from  the  mouth  after  dividing  the 


742  A   MANUAL  OF  SURGERY 

mucous  membrane,  subsequently  removing  a  sufficient  portion  of 
the  anterior  wall  to  enable  it  to  be  washed  out  and  drained. 

Various  Tumours  may  originate  in  the  antrum,  e.g.,  mucous 
polypi,  fibromata,  odontomata,  osteomata,  sarcomata,  and  cancers. 
If  limited  to  the  cavity,  they  produce  no  definite  symptoms, 
except  when  large  enough  to  cause  expansion  of  its  walls. 
Malignant  growths,  however,  usually  pass  beyond  the  limits  of 
the  antrum,  and  lead  to  the  usual  signs  of  malignant  disease  of 
the  upper  jaw.  Treatment  consists  in  removing  simple  growths, 
if  possible,  without  interfering  with  the  integrity  of  the  maxilla. 
This  may  be  accomplished  by  reflecting  the  overlying  cheek,  as 
in  incision  of  the  upper  jaw.  For  malignant  tumours,  removal 
of  the  whole  bone  is  the  only  possible  remedy. 


Tumours  of  the  Upper  Jaw. 

Many  of  the  Simple  Tumours  springing  from  the  upper  jaw 
have  been  already  described  amongst  those  involving  the  alveolar 
border  and  antrum.     Only  a  few  remain  to  be  dealt  with. 

Osteoma  occurs  either  in  the  form  of  a  tumour  composed  of 
compact  tissue,  then  usually  growing  within  the  antrum,  or  it  is 
occasionally  met  with  as  a  diffuse  symmetrical  overgrowth,  con- 
stituting the  condition  known  as  Icontiasis  ossea. .  A  few  cases  of 
Chondroma  have  also  been  repeated. 

By  Leontiasis  Ossea  is  meant  a  disease,  fortunately  very  rare, 
characterized  by  the  formation  of  diffuse  hyperostoses  from  either 
the  cranial  or  facial  bones,  or  from  both.  It  usually  commences 
in  young  adult  life,  and  both  rickets  and  syphilis  have  been 
suggested  as  playing  some  part  in  its  causation,  although  really 
nothing  definite  as  to  its  origin  is  known.  Nodular  outgrowths 
of  soft  spongy  bone  are  gradually  developed,  increasing  slowly 
in  size,  and  giving  rise  to  irregular  bony  protuberances  projecting 
beneath  the  skin,  and  when  affecting  the  maxillae  and  mandibles 
leading  to  an  extremely  repulsive  appearance  of  the  individual. 
Sometimes  merely  the  cranial  bones  are  affected,  at  other  times 
only  the  jaws,  whilst  occasionally  the  whole  skull  participates  in 
the  change,  which  is  almost  always  symmetrical.  As  growth  pro- 
gresses, the  new  bone  tends  to  encroach  on  the  cavities  contained 
within  the  skull,  so  that  the  antrum  may  be  obliterated,  the  eyes 
may  protrude  owing  to  the  contraction  of  the  intra-orbital  space, 
and  even  coma  and  death  may  supervene  from  cerebral  compres- 
sion. Prior  to  this,  however,  a  variety  of  symptoms,  especially 
neuralgia,  may  be  induced  by  pressure  on  the  cranial  nerves. 
Treatment  is  only  occasionally  possible,  and  consists  in  the  removal 
of  the  projecting  masses  of  bone  by  the  chisel.  A  few  fairly  satis- 
factory results  of  such  a  procedure  have  been  recorded. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  743 


Malignant  Disease  of  the  Upper  Jaw  occurs  in  the  form  of 
sarcoma  or  cancer. 

Sarcoma  is  perhaps  the  more  common,  and  originates  either 
from  the  anterior  wall,  from  the  cavity  of  the  antrum,  or  from  the 
spheno-maxillary  fossa  behind  the  bone.  Sarcomatous  naso- 
pharyngeal polypi  also  spread  from  the  nose,  and  involve  the 
maxilla  secondarily.  Not  unfrequently  these  growths  have  a  con- 
siderable ossific  deposit  within  them,  and  this  is  occasionally  so 
extensive  as  to  obliterate  the  antral  cavity,  and  convert  the  bone 
into  a  solid  mass. 

Cancer  develops  in  the  form  of  squamous  epithelioma,  springing 
from  the  gums  ;  or  as  a  columnar  or  acinous  cancer  starting  in 
the  glandular  tissue,  found  both  in  the  nasal  and  antral  cavities. 

The  Clinical  Features  of  all  forms  of  malignant  disease  are 
practically  identical. 

If  arising  from  the  anterior  aspect  of  the  bone,  a  tumour  is  pro- 
duced which  projects  under  the  cheek,  the  tissues  of  which  are 
invaded  by  it  ;  it  tends  to  travel  down  towards  the  mouth,  and  is 
readily  detected  through  the  mucous  membrane.  It  may,  how- 
ever, spread  deeply,  and  in  time  involve  the  cavity  of  the  antrum. 
It  causes  no  obstruction  to  nasal  respiration,  and  no  epiphora 
except  in  the  later  stages. 

If  it  originates  within  the  antrum,  the  usual  signs  of  distension 
of  that  cavity  are  produced,  associated  with  a  foul,  and  often 
blood-stained,  discharge  from  the  nose,  within  which  the  ulcerated 
surface  of  the  growth  may  be  seen.  Epiphora  is  caused  by 
pressure  on  the  nasal  duct,  whilst  the  growth  has  been  known  to 
burrow  upwards  along  this  passage  and  project  near  the  inner 
canthus.  The  passage  of  air  through  the  nose  on  that  side  is  also 
impeded. 

If  the  growth  commences  behind  the  maxilla,  it  usually  springs 
from  one  of  the  walls  of  the  spheno-maxillary  fossa,  or  from  the 
base  of  the  skull,  and  is  then  characterized  by  a  great  tendency 
to  spread  or  burrow  in  all  directions.  Thus,  it  may  perhaps  push 
the  whole  bone  bodily  forwards  without  encroaching  upon  the 
antrum  ;  sometimes  it  finds  its  way  outwards  to  the  pterygoid 
fossa  through  the  pterygo-maxillary  fissure,  or  inwards  to  the 
nose  through  the  spheno-palatine  foramen,  or  even  up  into  the 
orbit ;  whilst  more  rarely  it  spreads  downwards  along  the  posterior 
palatine  canal,  so  as  to  appear  at  the  postero-external  corner  of 
the  palate  ;  in  the  later  stages  it  is  not  uncommon  to  find  the 
antral  cavity  also  involved,  and  even  the  base  of  the  skull  is  not 
exempt  from  the  ravages  of  the  disease. 

The  General  Signs  of  a  malignant  growth  of  the  superior 
maxilla  consist  in  the  appearance  of  a  tumour  which,  according 
to  its  origin,  produces  various  effects,  but  finally  tends  to  destroy 
the  bones  and  occupy  the  whole  of  the  maxillary  region.  It 
is    usually    accompanied    by   nasal    obstruction,   epiphora,    and 


744  A   MANUAL  OF  SURGERY 


frequently  by  a  discharge  of  blood  or  pus  from  the  nares.  Severe 
pain  sometimes  accompanies  the  process,  especially  affecting 
the  second  division  of  the  trigeminal.  Neighbouring  lymphatic 
glands  become  enlarged,  more  especially  in  the  carcinomata ; 
those  in  the  submaxillary  region  are  first  involved,  and  afterwards 
those  in  the  anterior  triangle  ;  secondary  deposits  in  the  viscera 
may  also  occur  somewhat  later.  The  tumour  follows  a  typical 
malignant  course,  and,  owing  to  the  great  vascularity  of  the  parts, 
its  onward  progress  is  very  rapid. 

The  Diagnosis  of  malignant  disease  of  the  jaw  from  a  simple 
tumour  should  be  readily  made  ;  the  later  age  at  which  it  appears, 
the  rapidity  of  its  growth,  the  greater  pain  and  more  abundant 
discharge  from  the  nose,  the  associated  enlargement  of  the 
lymphatic  glands,  and  the  tendency  to  spread  and  to  encroach 
upon  surrounding  structures,  all  point  to  malignant  disease.  In 
some  cases,  however,  an  exploratory  incision  must  be  made  into 
the  antrum,  in  order  to  make  certain  of  the  diagnosis.  More 
frequently  the  existence  of  a  tumour  at  all  is  for  some  time 
entirely  overlooked,  some  one  prominent  symptom,  such  as 
neuralgia  or  epiphora,  being  treated  without  ascertaining  the 
cause. 

Treatment  consists  in  free  removal  of  the  growth,  if  such  be 
practicable,  together  with  total  or  partial  ablation  of  the  superior 
maxilla.  Where,  however,  the  tissues  of  the  cheek  have  been 
invaded,  or  where  the  growth  has  spread  beyond  the  limits  of  the 
antrum,  the  surgeon  may  well  hesitate  before  recommending  an 
operation,  since  complete  eradication  is  always  a  matter  of  un- 
certainty and  difficulty,  and  often  secured  only  at  the  expense  of 
terrible  mutilation  and  considerable  risk  to  the  patient's  life.  Of 
course,  in  those  cases  which  spring  from  behind  the  maxilla, 
operative  treatment  should  never  be  lightly  undertaken. 

Excision  of  the   Superior  Maxilla. 

The  operation  is  performed  for  the  purpose  of  removing  new 
growths,  simple  or  malignant,  either  originating  in  the  upper  jaw, 
or  extending  into  it,  whilst  it  is  also  sometimes  employed  as  a 
preliminary  in  dealing  with  tumours  of  the  base  of  the  skull. 
Naturally  the  exact  steps  vary  considerably  in  different  cases 
according  to  the  character  and  extent  of  the  disease. 

Operation. — The  patient's  head  and  shoulders  are  well  raised, 
and  anaesthesia  is  maintained  by  means  of  chloroform  given  by 
Junker's  apparatus.  Some  surgeons  undertake  a  preliminary 
tracheotomy,  and  plug  the  pharynx,  in  order  to  prevent  the 
entrance  of  blood  into  the  air  passages,  but  such  is  scarcely 
necessary  or  desirable  if  good  assistance  is  to  hand,  since  it 
increases  to  a  certain  extent  the  risks  of  the  operation.  The 
proceeding  may  be  described  in  stages  as  follows  : 


AFFECTIONS  OF  THE  LIPS  AND  yAWS 


745 


Stage  I. :  Incision  and  Reflection  of  the  Soft  Structures  of  the 
Cheek. — The  central  incisor  tooth  of  the  affected  side  having 
been  extracted,  the  upper  lip  is  divided  in  the  middle  line 
as  high  as  the  columna  nasi ;  the 
incision  is  now  carried  round  the 
ala  and  along  the  side  of  the  nose, 
to  a  point  half  an  inch  below  the 
inner  canthus  ;  it  thence  extends 
on  the  same  level  along  the  lower 
orbital  margin  to  a  point  below  its 
outer  border,  or  even  to  the  zygoma 
(Fig.  271,  A).  The  flap  thus  marked 
out  is  raised  from  the  bone,  and 
reflected  outwards  so  as  to  clear  the 
zygomatic  eminence,  the  knife  being 
carried  as  near  to  it  as  is  considered 
wise,  and  the  more  important  arteries 
secured,  as  they  are  divided,  by 
Spencer  Wells'  forceps. 

Stage  II.  :  Division  of  the  Bony 
Attachments. — A  keyhole-saw  is  now 
passed  into  the  nose,  and  the  alve- 
olus and  hard  palate  divided  from 
before  backwards  through  the 
empty  socket  of  the  central  incisor 
tooth.  There  is  no  need  to  incise 
the  muco-periosteum  previously,  as  is  sometimes  recommended  ; 
division  by  the  saw  causes  less  bleeding  than  the  use  of  the  knife. 
The  side  of  the  nose  is  then  freed  from  its  bony  attachments,  and 
the  periosteum  stripped  from  the  floor  of  the  orbit,  the  eyeball 
being  protected  by  a  spatula.  It  is  most  desirable  that  the  orbital 
periosteum  should  be  preserved  intact,  so  as  to  prevent  septic 
invasion  of  the  orbit.  The  nasal  process  of  the  superior  maxilla 
is  now  cut  through  with  a  saw,  and  also  the  malar  bone  divided  so 
as  to  open  into  the  spheno-maxillary  fissure.  The  surgeon  then 
takes  a  pair  of  long-handled  cutting  pliers,  and  completes  the 
division  of  each  of  these  bony  attachments,  but  reversing  the 
order,  dealing  with  the  malar  bone  first,  next  with  the  nasal  attach- 
ments, and  finally  with  the  palate.  The  cutting  pliers  must 
always  be  applied  with  the  smooth  surface  towards  the  tissues 
which  are  to  be  left,  and  the  bevelled  surface  towards  the  part 
which  is  to  be  removed  (Fig.  272).  When  the  section  of  the 
palate  is  completed,  the  cutting  pliers  are  used  as  a  lever  to  prise 
the  bone  out  of  its  bed,  the  sound  bone  acting  as  a  fulcrum, 
the  posterior  attachments  being  thus  fractured.  The  pterygoid 
processes  are  broken  through  close  to  their  origin  from  the 
sphenoid,  and  the  lateral  mass  of  the  ethmoid  yields  along  the 
inner  orbital  margin. 


Fig.  271. — A,  Incision  for  Re- 
moval of  Superior  Maxilla  ; 
B.  for  Removal  of  Lower 
Jaw;  C.  for  Kocher's 
Operation  for  Removal  of 
Tongue. 


746 


A   MANUAL  OF  SURGERY 


Stage  III :  Removal  of  the  Bone  and  Tumour. — The  bone  is  now 
seized  by  lion  forceps,  one  blade  holding  the  alveolus,  and  the 
other  the  infra-orbital  border,  and  twisted  out ;  the  mouth  is 
gagged  open,  and  the  soft  palate,  if  free  from  disease,  is  divided 
from  its  attachment  to  the  hard  by  a  transverse  incision,  and  all 
other  muscular  connections  severed.  Some  care  is  needed  in  the 
removal  of  the  projecting  hamular  process.  Considerable  haemor- 
rhage may  occur  at  this  stage  from  some  of  the  branches  of 
the  internal  maxillary  artery,  especially  the  infra-orbital  and 
posterior  palatine ;  it  is  checked  temporarily  by  plugging  the 
wound  firmly  with  a  sponge,  and  subsequently  the  chief  vessels 


Excision  of  the  Superior  Maxilla. 


are  secured  by  ligature,  whilst  smaller  bleeding  points  may  be 
touched  with  the  cautery.  Any  outlying  portions  of  the  tumour 
are  now  dealt  with,  and  the  cavity,  after  being  dabbed  over  with 
a  solution  of  chloride  of  zinc  (40  grains  to  the  ounce),  is  plugged 
with  strips  of  cyanide  gauze  soaked  in  the  iodoform  glycerine 
emulsion.  The  wound  in  the  cheek  is  closed,  the  greatest  care 
being  taken  to  obtain  accurate  apposition  of  the  flap,  especially  at 
the  lip  margin,  and  dressed  with  gauze  secured  with  collodion. 

In  the  majority  of  cases  there  is  comparatively  little  shock,  and 
the  patients  do  remarkably  well — at  any  rate,  for  a. time — although, 
unfortunately,  recurrence  is  only  too  likely  to  follow.  The  plug 
in  the  nose  is  left  in  situ  for  twenty-four  hours,  and  then  removed 
through  the  mouth,  and  the  wound  irrigated  with  some  antiseptic 
solution.     The  plug  may  be  replaced,  but  can  usually  be  dispensed 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  747 

with  if  the  patient  washes  out  the  cavity  several  times  a  day. 
Healing  is  effected  by  granulation,  and  of  course  a  large  gap 
communicating  with  the  mouth  remains.  This  can  be  sub- 
sequently remedied  by  an  obturator,  to  which  is  attached  a  cheek- 
plate  to  prevent  falling  in  of  the  cheek.  The  patient  is  fed  for 
the  first  few  days  by  the  rectum,  or  by  a  tube  passed  into  the 
pharynx,  but  soon  acquires  the  knack  of  swallowing  fluids, 
especially  when  the  soft  palate  has  been  left  intact. 

Partial  Operations. — Many  modifications  of  the  above  may  be 
undertaken  in  order  to  minimize,  as  far  as  possible,  the  amount 
of  tissue  removed,  and  to  prevent  any  unnecessary  scarring. 
When  the  alveolus  alone  needs  removal,  the  external  incision 
may  be  limited  to  division  of  the  lip,  the  soft  tissues  of  the  cheek 
being  stripped  up  as  far  as  necessary  from  the  bones.  If  part  of 
the  body  of  the  bone  requires  removal  as  well  as  the  alveolus,  only 
the  nasal  half  of  the  incision  need  be  made,  and  indeed,  wherever 
it  is  possible,  the  orbital  plate  should  be  left  in  order  to  prevent 
displacement  downwards  of  the  eye  and  subsequent  diplopia.  In 
such  cases  a  saw  is  carried  from  the  anterior  nares  across  the  front 
of  the  antrum  to  the  malar  bone.  The  alveolus  and  palate  are 
now  divided,  and  the  growth  with  this  portion  of  bone  detached 
from  its  posterior  connections.  The  upper  part  can  also  be  re- 
moved separately,  the  palate  and  alveolus  being  left  intact;  the 
operation  should,  in  fact,  never  be  looked  upon  as  a  fixed  and 
definite  proceeding,  but  may  be  modified  to  suit  the  particular 
exigencies  of  the  case. 

Various  forms  of  osteoplastic  resection  of  the  superior  maxilla 
required  for  the  treatment  of  tumours  of  the  naso-pharynx  are 
mentioned  later  (p.  766). 

Tumours  of  the  Lower  Jaw. 

These  are  similar  in  character  to  those  met  with  in  the  upper 
jaw.  Thus,  Chondroma,  Osteoma,  Fibroma,  and  the  simple  and 
malignant  forms  of  Epulis,  have  been  already  described. 

Dentigerous  Cysts  form  around  teeth  which  are  so  misplaced 
that  they  cannot  erupt ;  though  occasionally  seen  in  the  upper 
jaw,  they  are  much  more  common  in  the  lower.  Their  characters 
and  nature  have  been  already  described  under  the  title  of  follicular 
odontomes  at  p.  171.  They  are  met  with  in  young  people,  and 
give  rise  to  expansion  of  the  jaw  (Fig.  273)  ;  the  tumour  thus 
formed  is  at  first  hard  and  solid  to  the  touch,  but  later  on  egg- 
shell crackling  and  even  true  fluctuation  are  observed  when  the 
encasing  wall  has  become  thin  or  absorbed.  Irregularity  in 
the  line  of  the  permanent  teeth  may  sometimes  be  noted,  but 
not  necessarily,  since  the  milk  tooth  corresponding  to  that  which 
is  misplaced  is  not  always  shed,  owing  to  the  absence  of  pressure 
from  below.  Occasionally  suppuration  within  the  cavity  may  be 
caused  by  an  extension  of  inflammation  from  the  fang  of  a  neigh- 


748 


A   MANUAL  OF  SURGERY 


bouring  tooth,  or  by  the  cyst  being  opened  during  its  extraction. 

A    sinus    discharging     offensive    pus   will    then    form,    and    the 

surrounding  tissues  become  red 
and  congested.  Treatment  con- 
sists in  freely  opening  the  cyst 
through  the  mucous  membrane, 
and  removing  a  sufficient  por- 
tion of  the  bony  wall  to  allow 
of  the  removal  of  the  misplaced 
tooth.  The  cavity  is  left  open 
and  allowed  to  heal  by  granu- 
lation, during  which  process 
strict  attention  to  cleanliness 
must  be  observed. 

Fibrocystic  Disease  of  the 
Jaw  (epithelial  odontome,  p.  171) 
has  been  already  mentioned  as 
characterized  by  the  formation 
of  a  tumour,  often  of  great  size, 
which  consists  of  spaces  lined 
with  cuboidal  epithelium,  and 
supposed  to  originate  from  the 
enamel  organ  (Fig.  274).  It 
occurs  most  frequently  in  young 
people,  and,  as  a  rule,  runs  a 
perfectly  benign  course,  although 
when  of  large  size  it  may  lead  to 

„  serious  results.    The  only  Treat- 
Fig.  273.  —  Dentigerous  Cyst,  show-  ,  ...  ,    . 

ing   Expanded  Condition  of   the  mmt    consists    in     complete     re- 

Lower  Jaw,  and  Unerupted  Tooth  moval  of  the  affected  portion  of 

LYING      HORIZONTALLY       WITHIN      IT.     the  jaW. 

(College  of  Surgeons'  Museum.)        Myeloid  Sarcoma  is  met  with 

in  the  lower  jaw,  not  only  in  the 
form  of  a  malignant  epulis,  but  also  occasionally  as  a  central 
growth,  usually  attacking  the  median  portion  of  the  bone,  which 
becomes  expanded  in  the  same  way  as  when  a  similar  disease 
invades  the  end  of  a  long  bone.  It  presents  but  slight  evidences 
of  malignancy,  and  may  be  treated  in  the  first  place  by  opening 
the  outer  shell  of  bone  and  scraping  away  the  soft  contents,  the 
cavity  thus  formed  being  swabbed  out  with  pure  carbolic  acid, 
and  plugged  with  gauze.  Should  it  recur,  the  affected  portion  of 
the  bone  must  be  removed.  Whenever  possible,  a  bridge  of 
osseous  tissue  is  left  so  as  to  connect  the  two  segments  of  the 
jaw  ;  if  this  is  not  attended  to,  they  are  likely  to  fall  together,  and 
lead  to  considerable  trouble.  If  the  whole  thickness  of  the  bone 
is  excised,  a  wire  frame  or  splint  should  at  once  be  introduced 
between  the  fragments  with  the  same  object.  It  is  replaced  later 
on  by  a  suitable  plate  carrying  artificial  teeth. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


749 


Round-  or  Spindle-Celled  Sarcoma  also  occurs,  usually  springing 
from  the  periosteum,  the  deeper  parts  undergoing  ossification. 
The  course  is  typically  malignant,  and  free  removal  of  the  affected 
portion  of  the  bone  must  be  undertaken. 

Epithelioma  invades  the  lower  jaw  as  an  extension  of  a  similar 
affection  arising  either  from  the  gum,  lips,  or  tongue.  Excision 
of  a  portion  of  the  bone  together  with  the  primary  disease  is 
always  required,  unless  it  has  extended  so  far  as  to  render  extir- 
pation impracticable. 

Excision  of  the  Lower  Jaw  is  employed  in  the  treatment  of 
various  tumours  arising  from  that  bone,  as  also  sometimes  for 
extensive  necrosis.  In  the  latter  case  it  may  be  possible  to  deal 
with  it  from  the  mouth,  but  when  required  for  the  treatment  of 
malignant  disease  an  external  incision  is  absolutely  essential. 


u 


Fig.  274. — Fibro-Cystic  Disease  of  the  Lower  Jaw. 
(By  kind  permission  of  the  Council  of  the  Royal  College  of  Surgeons.) 

If  the  whole  of  one  side  is  to  be  removed,  an  incision  is  made, 
reaching  from  just  below  the  red  margin  of  the  lip  downwards  to 
a  point  immediately  below  the  symphysis,  and  thence  along  the 
under  surface  of  the  body  of  the  jaw  as  far  as  the  angle ;  it  is 
then  prolonged  upwards  as  far  as  the  posterior  border  of  the 
vertical  ramus,  not  extending  further  than  the  attachment  of  the 
lobule  of  the  ear,  so  as  to  avoid  the  facial  nerve  (Fig.  271,  B). 
When  a  large  tumour  is  being  dealt  with,  the  whole  thickness  of 
the  lip  should  be  divided,  and  the  flap  thus  marked  out  dissected 
off  the  bone,  and  turned  outwards.  Where,  however,  the  upper 
portion  of  the  lip  is  left,  the  incisions  are  carried  down  to  the 
bone,  the  facial  vessels  being  secured  above  and  below  before 
division.  The  soft  parts  are  then  freed  from  the  outer  aspect  of 
the  bone,  and  the  cavity  of  the  mouth  opened.  The  central  incisor 
tooth  is  drawn,  and  the  jaw  divided  through  the  empty  socket 
with  a  saw  and  cutting  pliers.  By  this  means  the  genial  tubercles 
and  their  attached  muscles  are  not  encroached  on,  and  the  move- 


75o  A  MANUAL  OF  SURGERY 


ments  of  the  tongue  are  left  unimpaired.  The  bone  is  seized  and 
drawn  outwards,  so  that  its  internal  connections  as  far  as  the 
angle  may  be  divided.  It  must  then  be  firmly  depressed,  and  the 
muscular  attachments  of  the  masseter  on  the  outer  side,  and  of  the 
internal  pterygoid  on  the  inner,  cut  through.  The  inferior  dental 
nerve  and  artery  will  also  be  met  with  at  this  stage.  By  still 
further  depressing  the  bone,  the  temporal  tendon  is  exposed  and 
should  be  divided  by  successive  touches  of  the  knife,  which  is  kept 
close  to  the  bone.  Finally,  the  condyle  is  freed  after  division  of 
the  external  pterygoid  muscle  and  of  the  ligaments  of  the  temporo- 
maxillary  articulation.  The  proximity  of  the  internal  maxillary 
artery  to  the  inner  aspect  of  the  neck  of  the  bone  must  be  remem- 
bered, and  hence  it  is  important  to  keep  the  blade  of  the  knife 
directed  towards  the  bone.  After  haemorrhage  has  been  arrested, 
the  wound  is  stitched  together  and  dressed  with  collodion  and 
gauze ;  possibly  a  drainage-tube  may  be  inserted  with  advantage 
for  a  few  days  through  the  floor  of  the  mouth.  Considerable 
deformity  usually  results  from  this  operation,  owing  to  the  remain- 
ing half  of  the  bone  being  drawn  across  the  middle  line. 

Diseases  of  the  Temporo-Maxillary  Articulation. 

Acute  Synovitis  may  supervene  in  the  course  of  an  attack  of 
rheumatic  fever,  and  is  evidenced  by  pain  on  movement  of  the 
jaw,  with  swelling  due  to  a  serous  effusion  into  and  around  the 
joint.  Resolution  usually  follows,  but  fibroid  thickening  of  the 
ligaments  and  impairment  of  movement  may  result. 

Acute  Arthritis  arises  from  pyaemic  infection  after  the  ex- 
anthemata, or  from  gonorrhoea,  but  may  be  caused  by  direct  ex- 
tension of  inflammation  from  the  middle  ear,  as  in  scarlatina.  It 
occurs  in  children,  and  is  due  'to  the  persistence  of  a  hiatus  in 
that  part  of  the  tympanic  plate  which  forms  the  floor  of  the  meatus 
and  the  roof  of  the  articulation  '  (Barker).  It  is  characterized  by 
the  usual  signs  of  a  severe  localized  inflammation,  with  the  forma- 
tion of  abscesses,  and  results  commonly  in  ankylosis.  Rest  and 
the  antiseptic  opening  of  abscesses  constitute  the  only  early  treat- 
ment, although  excision  of  the  condyle  is  sometimes  required  at 
a  later  date. 

Osteo-arthritis  is  by  no  means  a  rare  affection  of  this  joint. 
It  is  often  symmetrical,  and  characterized  by  an  enlargement 
of  the  condyle,  which  can  be  felt  distinctly  in  front  of  the  tragus, 
especially  on  opening  the  mouth,  when  crepitus  is  also  noticed. 
The  pain  is  worse  at  night  and  in  wet  weather,  and  the  jaw 
becomes  deflected  to  the  sound  side  if  the  disease  is  unilateral ; 
when  both  sides  are  affected,  the  jaw  is  pushed  forwards,  and 
the  chin  prcjects.  The  articular  cartilage  undergoes  the  usual 
changes,  the  inter-articular  cartilage  disappears,  and  the  glenoid 
cavity  becomes  enlarged   and   flattened,   so  that  the  eminentia 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  751 

articularis  is  relatively  less  marked,  thus  permitting  the  external 
pterygoid  muscle  to  draw  the  condyle  forwards.  After  a  time, 
considerable  difficulty  is  experienced  in  opening  the  mouth,  even 
amounting  to  ankylosis.  Ordinary  medical  treatment  may  be  used 
in  the  early  stages,  but  in  the  later  the  condyle  of  the  jaw  should 
be  excised,  a  proceeding  followed  by  excellent  results. 

Tuberculous  Disease  may  arise  either  in  the  bone  or  synovial 
membrane,  perhaps  spreading  to  it  from  neighbouring  lymphatic 
glands.  It  runs  the  usual  course  of  the  disease,  terminating  in 
caries  of  the  condyle,  and  ankylosis  after  protracted  suppuration  ; 
to  prevent  this,  excision  of  the  condyle  is  indicated. 

Immobility  or  Closure  of  the  Jaw  may  be  caused  by  a  variety 
of  conditions : 

1.  True  ankylosis  of  the  temporo-maxillary  joint,  fibrous  or 
osseous,  as  the  result  of  any  of  the  diseases  mentioned  above. 

2.  Cicatricial  contraction  of  the  soft  structures  either  within  or 
without  the  mouth,  as  from  burns,  lupus,  or  extensive  operations 
in  the  pterygoid  regions  upon  the  roots  of  the  fifth  nerve,  from 
cancrum  oris,  or  very  rarely  from  myositis  ossificans. 

3.  Spasm  of  the  muscles  of  the  jaw  (or  trismus),  due  to  reflex 
irritation,  as  from  carious  teeth,  or  an  unerupted  wisdom-tooth, 
or  some  other  local  lesion.  It  is  occasionally  hysterical,  and  is 
one  of  the  early  symptoms  of  tetanus. 

4.  Local  inflammatory  conditions  often  render  opening  of  the 
mouth  impossible,  both  from  the  pain  and  swelling — e.g.,  in  mumps, 
parotid  abscess,  acute  alveolar  periostitis — whilst  in  epithelioma 
and  various  forms  of  tumour  the  size  of  the  growth  may  seriously 
impair  the  mobility  of  the  jaw. 

The  term  ankylosis  can  only  be  applied  to  the  conditions  men- 
tioned in  the  first  two  groups.  In  the  others  appropriate  treat- 
ment must  be  instituted  according  to  the  character  of  the  affection. 
Where  the  closure  of  the  jaw  is  permanent,  it  may  be  due  to 
osseous  ankylosis,  the  bony  masses  extending  not  only  between 
the  articular  surfaces,  but  also  between  the  alveoli,  or  to  fibrous 
adhesions  within  the  joint,  or  to  extra-articular  contraction  of  the 
soft  parts,  the  skin  and  mucous  membrane  being  not  only  involved, 
but  also  frequently  the  muscles  and  deeper  structures. 

Division  of  the  neck  of  the  bone  or  excision  of  the  head  may 
thus  be  impracticable,  or,  even  if  possible,  is  useless,  since  the 
muscles  of  the  jaw  hold  the  surfaces  in  such  good  apposition  as 
to  bring  about  a  recurrence  of  bony  union,  unless  obviated  by 
implanting  a  flap  of  the  temporal  muscle  or  a  vulcanite  plate 
between  the  bony  surfaces.  Division  of  the  intra-  or-  extra-buccal 
cicatrices  is  unsatisfactory,  owing  to  their  rapid  re-formation.  The 
best  treatment  in  most  cases  is  either  removal  of  the  vertical  ramus 
of  the  jaw  down  to  the  level  of  the  alveolus,  or  the  plan  suggested 
by  Esmarch,  viz.,  excision  of  a  wedge  of  bone,  with  its  apex 
towards  the  alveolar  border,  from  the  neighbourhood  of  the  angle, 


752  A   MANUAL  OF  SURGERY 


and  the  establishment  of  an  artificial  joint  at  that  spot.  The 
incision  should  be  made  below  and  behind  the  angle  down  to  the 
bone,  from  which  the  periosteum  is  stripped  up,  and  division  is 
accomplished  by  means  of  the  saw. 

Excision  of  the  Condyle  of  the  Jaw  is  not  always  a  simple 
operation,  since  the  space  at  the  surgeon's  disposal  is  very  limited, 
owing  to  the  presence  of  the  zygoma  above,  of  the  facial  nerve 
below,  of  the  parotid  gland  in  front,  and  the  external  ear  behind. 
The  best  incision  is  a  curvilinear  one,  commencing  over  the  middle 
of  the  zygoma,  and  passing  downwards  in  front  of  the  tragus.  It 
should  merely  divide  the  skin  and  subcutaneous  tissue,  and  the 
flap  thus  marked  out  is  turned  forwards.  A  transverse  incision 
is  now  made  through  the  deep  fascia  immediately  below  the 
posterior  extremity  of  the  zygoma,  extending  down  to  the  neck  of 
the  bone,  which  is  cleared  by  a  raspatory  and  divided  by  cutting 
pliers ;  the  condyle  is  then  grasped  by  necrosis  forceps,  and 
twisted  out.  But  little  bleeding  occurs,  and  the  wound  heals  by 
first  intention  except  along  the  track  of  the  drainage-tube,  which 
should  always  be  employed. 


CHAPTER  XXVI. 

AFFECTIONS  OF  THE  NOSE  AND  NASOPHARYNX. 

Affections  of  the  Outer  Nose. — Several  forms  of  Injury,  including 
fracture  of  the  nasal  bones  and  separation  of  the  cartilages,  have 
been  already  noticed  (p.  439). 

Depression  or  Flattening  of  the  Bridge  of  the  Nose  is  either  a 
result  of  traumatism,  such  as  a  fracture  of  the  nasal  bones,  or 
may  arise  from  defective  growth  of  the  ethmo- vomerine  septum, 
due  to  disease  either  of  syphilitic  or  tuberculous  origin  early  in 
life,  whilst  it  may  also  result  from  similar  conditions  occurring  in 
the  course  of  tertiary  syphilis.  If  caused  by  injury,  and  dealt 
with  promptly,  it  may  be  remedied ;  but  when  once  acquired,  and 
especially  if  the  consequence  of  disease,  treatment  is  well-nigh 
impracticable.  Several  cases  have  been  lately  recorded,  however, 
in  which  bone-grafting  has  been  successful.  An  incision  is  made 
down  the  middle  line  of  the  nose,  the  soft  parts  are  reflected  on 
either  side,  and,  after  making  a  comfortable  bed  for  it,  the  bone- 
graft  is  introduced,  and  kept  in  position  partly  by  sutures,  but 
mainly  by  closing  up  the  wound  in  the  soft  tissues.  In  one  case 
the  patient's  own  fourth  metatarsal  bone  was  utilized  with  success, 
whilst  platinum,  gold,  or  celluloid  frames  have  also  been  employed 
in  the  same  way. 

Expansion  of  the  Bridge  of  the  Nose  is  always  the  outcome 
of  some  long-continued  intranasal  pressure,  especially  from  the 
growth  of  polypi.  It  rarely  follows  the  development  of  mucous 
polypi,  except  when  they  are  very  large  and  chronic,  but  it  is  not 
an  uncommon  accompaniment  of  the  fibrous  or  fibro-sarcomatous 
variety.  The  bridge  is  flattened  and  bulged  out  on  either  side, 
giving  the  face  an  appearance  justifying  the  name  'frog-nose' 
which  has  been  applied  to  it. 

It  is  impossible  to  discuss  all  the  different  affections  of  the  skin 
of  the  nose.  Many  of  them  are  associated  with  the  sebaceous 
glands,    which    in    this    region    are    very    large    and    abundant. 

48 


754 


A  MANUAL  OF  SURGERY 


Thus,  acne  is  commonly  met  with,  arising  from  an  inflammation 
of  the  glands  after  obstruction  to  their  ducts.  It  is  especially 
frequent  in  drinkers  and  dyspeptics,  women  addicted  to  tea- 
drinking  often  suffering  severely.  When  the  superficial  capillaries 
become  markedly  dilated  and  the  face  readily  flushes  on  the 
imbibition  of  hot  or  stimulating  fluids,  the  term  rosacea  is  attached 
to  it,  whilst  if  acne  pustules  are  also  present,  it  is  known  as  acne 
rosacea.  Sometimes  the  spots  become  much  enlarged,  and  there 
is  a  considerable  amount  of  infiltration  of  the  base,  a  condition 
described  as  acne  hypcrtrophiaim.  In  the  most  exaggerated  stage 
the  sebaceous  glands  become  overgrown  and  form  large  protu 
berant  nodular  masses  projecting  from  the  end  of  the  nose,  and 
covered  with  red  greasy  skin,  in  which  the  dilated  orifices  of  the 
glands  are  very  evident,   and  with   dilated    capillaries  coursing 

freely  over  them.  This  condition  is 
generally  known  as  lipoma  nasi,  rhino- 
phyma, or  hammer -nose  (Fig.  275). 
The  treatment  of  simple  acne  con- 
sists in  correcting  the  dyspepsia,  and 
limiting  the  amount  of,  or  interdicting 
entirely,  alcohol  or  tea.  Capsules  of 
ichthyol  (3  to  10  minims),  may  also 
be  administered  thrice  daily,  and 
soothing  applications  should  be  used 
locally,  such  as  a  lotion  consisting 
of  calamine,  oxide  of  zinc  and  pre- 
cipitated sulphur,  held  in  suspension 
with  glycerine  and  lime  -  water. 
Dilated  and  unsightly  capillaries 
may  be  dealt  with  by  puncturing 
them  with  the  galvano- cautery  or  an 
electrolytic  needle.  Rhinophyma  requires  operative  proceedings  ; 
the  protuberant  mass  should  be  freely  dissected  away  from  the 
cartilages,  and  the  raw  surface  either  left  to  cicatrize,  or  dealt 
with  by  Thiersch's  method  of  skin-grafting. 

Partial  or  Total  Destruction  of  the  Nose  may  result  from  trau- 
matism, but  usually  from  some  chronic  inflammatory  or  malignant 
growth,  such  as  lupus,  tertiary  syphilis,  or  rodent  ulcer.  Epi- 
thelioma sometimes  attacks  it,  and  requires  total  removal  of  the 
nose  for  its  cure.  In  any  of  these  conditions  the  resulting  de- 
formity is  so  repulsive  that  the  surgeon  is  certain  to  be  asked  to 
undertake  some  proceeding  to  remedy  it.  Indian  surgeons  have 
had  a  good  deal  of  experience  in  this  direction,  since  in  that 
country  cutting  off  the  nose  is  often  resorted  to  as  a  means  of 
avenging  some  real  or  fancied  wrong.  Various  plastic  operations 
have  been  devised,  which,  however,  we  can  only  indicate  briefly 
here,  referring  students  to  larger  works  of  operative  surgery  for 
fuller  details. 


Fig.    275.  —  Rhinophyma,     or 

Hammer-nose,     (Tillmans.) 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYN.X 


755 


The  chief  methods  of  Rhinoplasty  are  as  follows  : 

i.  The  so-called  Indian  method*  consists  in  the  formation  of  a  nose  from  a 
flap  of  skin  obtained  from  the  forehead.  The  flap  (Fig.  276)  is  more  or  less 
pyriform,  with  the  pedicle  so  placed  as  to  contain  one  of  the  frontal  arteries 
and  the  supratrochlear  nerve.  Necessarily  its  exact  shape  and  size  vary  with 
the  character  of  the  defect  and  with  the  type  of  nose  desired.  Keegan,  who 
has  done  some  excellent  work  in  this  direction,  advises  that  the  skin  covering 
the  nasal  bones,  as  high  as  the  level  where  the  bridge  of  spectacles  would  rest, 
should  first  be  turned  down  in  two  flaps,  using  their  attachment  to  the  nasal 
mucosa  as  a  hinge,  so  that  the  cutaneous  surface  shall  look  inwards  and  the  raw 
surface  outwards.  Over  these  the  forehead  flap  is  placed,  and  there  should  be 
sufficient  tissue  in  the  nasal  flaps  to  enable  their  free  ends  to  be  stitched  below 
to  the  forehead  flap  on  either  side  of  the  columna,  thus  completing  the  anterior 
nares.  The  columna  itself  is  formed  by  the  free  end  of  the  forehead  flap. 
Drainage-tubes  are  inserted  through  the  anterior  nares  and  kept  in  position  for 
ten  to  fourteen  days.  The  lateral  margins  of  the  flap  are  carefully  sutured  to 
the  freshened  edges  of  the  defect.  When  the  union  of  the  lower  portion  is 
sufficiently  firm,  the  nose  is  made  more  shapely  by  partially  dividing  the 
twisted  pedicle,  but  if  possible  the  integrity  of  the  frontal  artery  should  still 
be  retained.  The  wound  in  the  forehead  is  drawn  together  as  far  as  possible 
by  sutures,  and  healing  promoted  later  by  skin- 
grafting. 

2.  In  the  Tagliacozzian  or  Italian  operation  (so 
called  from  Tagliacozzi,  the  surgeon  who  first 
proposed  it)  a  flap  of  skin  is  taken  from  the 
arm.  The  pedicle  must  always  be  broad,  and  is 
left  attached  to  the  upper  part  of  the  inner 
aspect  of  the  arm  ;  it  must  be  so  placed  that  it 
can  be  brought  into  apposition  with  the  nasal 
defect  without  tension,  the  forearm  and  hand 
being  fixed  by  a  suitable  apparatus  above  the 
head,  and  retained  there  until  good  union  has 
been  accomplished,  when  the  pedicle  is  gradually 
divided.  Absolute  fixation  of  the  arm  is  an 
essential,  and  as  this  may  need  to  be  maintained 
for  two  or  three  weeks,  the  patient  needs  a  con- 
siderable amount  of  pluck  and  perseverance 
When  the  pedicle  has  been  detached,  subse- 
quent plastic  measures  are  required  to  mould  p 
the  new  tissue  to  the  shape  of  the  nose. 

3.  The  cheeks  have  also  been  made  use  of  in 
what  is  known  as  the  French  method  to  supply 
material  for  the  nose,  flaps  being  dissected  up 
from  either  side,  and  united  in  the  middle  line. 

4.  The  above  operations  have  the  great  objec- 
tion that  the  new  nose  only  consists  of  soft 
tissues,  and  hence  is  very  likely  to  shrivel  up 
and  contract,  so  that  all  that  is  finally  obtained 
is  a  covering  for  the  defect,  which  is  often  quite  flush  with  the  surface.  To 
obviate  this,  and  to  secure  a  bony  basis  for  the  nose,  attempts  have  been  made 
to  utilize  a  finger  for  the  purpose,  and  Mr.  Astley  Bloxam  has  had  one  or 
more  successful  cases.  The  terminal  phalanx  is  removed,  the  soft  parts  split 
down  the  middle  line  on  the  palmar  aspect,  and  the  divided  segments  united 
by  suture  to  the  margins  of  the  nasal  defect.  When  union  is  secured,  the 
amputation  of  the  finger  is  completed. 

Naturally,  where  only  a  portion  of  the  nose  is  destroyed,  partial  operations 
can  be  devised  to  meet  the  requirements  of  the  case. 

*  For  full  details  of  this  plan  we  would  refer  to  Keegan's   '  Rhinoplastic 
Operations.'     Bailliere,  Tindall  and  Cox,  1900. 

48—2 


276. — Indian  Method 
of  Rhinoplasty,  showing 
the  Shape  andPosition  of 
the  Forehead  Flap. 

The  points  A  and  B  are 
brought  down  to  A1  and  B1 
when  the  flap  is  twisted 
into  position. 


756  A  MANUAL  OF  SURGERY 

Examination  of  the  Nose  and  Naso-Pharynx.  In  order  to  under- 
stand fully  the  diseases  of  the  nose,  it  is  essential  that  the  interior 
of  the  organ  be  efficiently  examined,  and  to  do  this  three  chief 
methods  are  resorted  to. 

1.  Anterior  rhinoscopy  consists  in  the  illumination  of  the  front  of 
the  nasal  cavity  through  the  anterior  nares.  A  good  light  is 
required,  such  as  that  derived  from  an  electric  head-lamp,  and 
some  form  of  nasal  speculum.  Perhaps  Thudichum's  speculum 
is  one  of  the  best ;  it  consists  of  two  unfenestrated  blades,  con- 
nected by  a  U-shaped  spring,  which  is  held  in  the  hand,  whilst 
the  blades  are  inserted  into  the  nostril,  the  nasal  vibrissas  being 
thus  held  aside  ;  the  ring  and  index  fingers  are  placed  one  on 
each  limb,  so  as  to  regulate  the  amount  of  tension,  and  prevent 
painful  overstretching.  By  this  or  similar  means  one  is  enabled 
to  see  the  anterior  part  of  the  nasal  fossae,  including  the  inferior 
turbinated  bone  and  the  erectile  tissue  at  its  anterior  extremity. 
The  amount  of  distension  of  the  latter  limits  the  view  of  other 
structures;  if  greatly  swollen,  it  feels  soft  and  even  fluctuating,  but 
collapses  entirely  on  the  application  of  a  5  per  cent,  solution  of 
cocaine,  allowing  the  free  convex  border  of  the  middle  turbinated 
bone  to  come  into  view,  as  also  the  cleft  or  olfactory  fissure 
between  it  and  the  septum.  The  septum  can  also  be  examined, 
frequently  showing  deviations  from  the  middle  line,  and  thickenings 
or  spurs  of  bone  or  cartilage,  which  run  in  an  antero-posterior  or 
vertical  direction.  A  certain  amount  of  erectile  tissue  is  also 
present  on  the  septum. 

The  introduction  of  a  sterilized  probe  under  the  guidance  of  the 
eye  is  of  the  greatest  value  in  examining  the  nose.  It  not  only 
serves  to  distinguish  the  different  qualities  of  growth  that  can  be 
seen,  but  will  also  give  information  concerning  regions  beyond  the 
surgeon's  eye. 

2.  By  posterior  rhinoscopy  is  meant  an  examination  of  the  pos- 
terior nares  by  a  mirror  placed  behind  the  uvula  and  soft  palate. 
It  is  by  no  means  easy  to  accomplish,  and  requires  some  dexterity 
and  practice.  The  tongue  should  be  depressed,  and  a  small 
mirror,  previously  warmed  to  prevent  condensation  of  moisture, 
is  then  passed  behind  the  uvula,  without  touching  it  or  the 
posterior  wall  of  the  pharynx,  and  by  shifting  its  angle  and 
position  a  view  should  be  obtained  of  the  structures  exposed 
posteriorly.  If  not  successful,  and  it  is  absolutely  necessary  to 
obtain  a  view,  the  fauces  should  be  cocainized  and  the  velum  held 
up  by  some  form  of  palate  retractor,  such  as  White's.  The 
posterior  nares  (or  choanae)  are  seen,  separated  by  the  vertical 
posterior  free  margin  of  the  septum,  and  within  each  cavity  the 
rounded  ends  of  the  turbinated  bones  with  the  meatuses  inter- 
vening. The  inferior  meatus  often  looks  very  small  owing  to 
the  prominence  of  the  velum  palati,  whilst  the  middle  meatus 
may  be  encroached  on  by  the  tumefaction  of  the  erectile  tissue 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX  757 

at  the  back  of  the  inferior  spongy  bone.  Outside  the  choanae 
are  seen  the  yellowish  openings  of  the  Eustachian  tubes,  whilst 
above  and  between  them  Luschka's  tonsil,  a  raised  collection 
of  lymphoid  tissue  in  the  roof  of  the  pharynx,  is  occasionally 
observed. 

3.  Palpation  of  the  Posterior  Nares,  with  the  index  finger,  pre- 
viously disinfected,  will,  however,  give  better  results  in  the 
majority  of  cases  to  those  who  are  not  specially  practised  in  the 
above  method.  The  index  finger  is  passed  behind  the  uvula  and 
velum,  and  the  nares  can  then  be  well  explored,  and  the  existence 
of  adenoids  or  other  growths  determined. 

Foreign  Bodies  are  rarely  impacted  in  the  nasal  passages  except 
in  children,  in  whom  the  condition  is  not  uncommon.  Any  uni- 
lateral purulent  discharge  from  a  child's  nose  should  suggest  the 
likelihood  of  such  an  occurrence,  peas,  beads,  or  buttons,  being 
the  substances  usually  introduced.  A  certain  amount  of  unilateral 
obstruction  to  nasal  respiration  is  caused  thereby,  followed  by  a 
catarrhal  or  even  suppurative  rhinitis,  and  in  old-standing  cases 
a  rhinolith  or  nasal  calculus  may  be  caused  by  the  deposit  of 
inspissated  mucus  upon  the  outer  surface  of  a  foreign  body. 
Removal  is  often  effected  by  syringing  out  through  the  unaffected 
nostril,  the  lotion  rushing  back  through  the  other  side,  and 
carrying  the  intruding  body  before  it.  Failing  this,  the  child 
should  be  anaesthetized  and  a  forceps  or  scoop  employed,  the 
surgeon's  manipulations  being  guided  by  a  rhinoscope  and  frontal 
illumination.  Necessarily,  all  instruments  used  for  this  purpose 
should  be  thoroughly  sterilized.  After  the  removal,  the  nostrils 
are  carefully  washed  out  for  a  few  days  with  a  weak  alkaline 
antiseptic  lotion,  such  as  salt  and  water  to  which  a  little  sanitas 
has  been  added. 

Acute  Rhinitis. — Several  distinct  varieties  of  this  affection  are 
described. 

1.  The  Catarrhal  form  is  extremely  common,  constituting  what 
is  popularly  known  as  a  '  cold  in  the  head.'  Not  only  is  the 
nasal  mucosa  involved,  but  the  inflammation  often  extends  to  the 
frontal  or  maxillary  sinuses,  causing  brow-ache  and  face-ache, 
whilst  if  it  spreads  to  the  mucous  lining  of  the  Eustachian  tube, 
temporary  deafness  may  ensue.  In  infants  great  dyspnoea  often 
results  owing  to  the  extreme  narrowness  of  the  nasal  passages, 
and  this  may  be  so  marked  as  to  interfere  for  a  time  with  breast 
feeding.  Apart  from  the  usual  domestic  remedies  directed  to  in- 
creasing the  action  of  the  bowels,  kidneys,  and  skin,  considerable 
relief  can  often  be  obtained  by  washing  out  the  nasal  cavities  three 
or  four  times  a  day  with  a  weak  warm  alkaline  lotion  containing 
borax  and  possibly  a  little  menthol. 

2.  A  Suppurative  form  arises  not  unfrequently  as  a  result  of  acute 


758  A  MANUAL  OF  SURGERY 


suppuration  in  one  of  the  accessory  sinuses  (acute  empyema),  and 
then  treatment  must  be  mainly  directed  to  the  sinus.  Occa- 
sionally it  is  due  to  gonorrheal  infection  either  in  adults  or 
infants,  but  perhaps  more  commonly  in  the  latter.  The  discharge 
is  abundant,  and  causes  much  obstruction  to  nasal  respiration, 
whilst  ulceration  is  likely  to  occur.  The  passages  must  be  well 
cleansed  with  a  solution  of  boric  acid  several  times  daily,  and  the 
interior  sprayed  or  painted  with  a  weak  solution  of  nitrate  of 
silver  (gr.  5  to  1  ounce)  once  every  day  as  long  as  the  suppuration 
continues. 

3.  True  diphtheria  also  occurs  in  the  nasal  fossae,  usually  as  a 
complication  of  the  same  disease  elsewhere,  and  requiring  a  similar 
form  of  treatment. 

Chronic  Rhinitis. — So  many  distinct  types  of  chronic  inflamma- 
tion of  the  interior  of  the  nose  have  been  differentiated  of  late 
years  that  it  is  impossible  for  us  to  give  more  than  the  barest 
outline  of  them.  For  fuller  details  we  would  refer  readers  to 
Dr.  Greville  Macdonald's  excellent  work  on  diseases  of  the 
nose.* 

One  of  the  forms  most  commonly  met  with  is  characterized  by 
engorgement  of  the  erectile  tissue  covering  the  inferior  turbinated 
bone,  causing  considerable  obstruction  to  nasal  respiration  and  an 
abundant  discharge  of  muco-pus.  It  usually  occurs  in  patients 
with  long,  prominent  noses  of  the  Jewish  type,  where  the  nasal 
passages  are  narrow,  and  in  consequence  the  air  pressure  is 
diminished  ;  it  may  be  lighted  up  by  some  slight  local  irritant, 
such  as  a  sudden  change  of  temperature.  The  anterior  end  of 
the  inferior  turbinated  bone  is  swollen,  red,  and  rounded,  the 
mucous  covering  being  cedematous,  and  the  mass  feeling,  on 
touching  it  with  a  probe,  like  a  sac  full  of  fluid.  The  local  appli- 
cation of  a  5  per  cent,  solution  of  cocaine  causes  its  complete, 
though  temporary,  collapse  in  a  few  moments.  If  it  is  allowed  to 
persist,  hypertrophy  of  the  mucous  membrane  follows,  and  in  the 
most  marked  types  a  projecting  papillomatous-like  mass,  almost 
resembling  a  polypus,  results.  It  is,  however,  merely  an  inflam- 
matory hyperplasia,  and  not  a  new  growth  ;  true  papillomata  of 
the  nose  are  extremely  rare.  The  posterior  end  of  the  bone  may 
be  similarly  affected,  and  the  mucous  covering  of  the  middle 
turbinated  may  participate  in  the  same  process.  A  certain 
amount  of  pharyngitis  or  laryngo-tracheitis  may  also  be  present. 

Treatment. — In  the  early  stages  all  that  is  required  is  to  wash 
out  the  nasal  cavity  night  and  morning  with  some  simple  nose 
lotion,  such  as  borax  or  bicarbonate  of  soda  (5  grains  to  1  ounce). 
This  may  be  accomplished  either  by  sniffing  the  solution  from 
the  palm  of  the  hand,  or  by  using  some  form  of  nasal  douche ; 
Basdon's  douche  is  perhaps  ihe  best  for  this  purpose.     If  such  is 

*  '  Diseases  of  the  Nose.'     Alex.  P.  Watt  and  Son.     Second  edition,  1892. 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX  759 


insufficient  to  give  relief,  or  if  collapse  is  not  produced  by  cocaine, 
the  surface  may  be  swabbed  over  with  some  diluted  caustic,  or, 
better  still,  a  point  of  galvano-cautery  at  a  red  heat  may  be  run 
along  the  length  of  the  bone.  In  the  later  stages  removal  of  the 
hypertrophied  excrescences  by  the  cold  wire  snare,  or  by  the 
galvano-ecraseur,  is  required. 

Another  group  of  cases  of  chronic  rhinitis  is  associated  with 
collapse  of  the  erectile  tissue,  and  then  there  is  but  little  discharge, 
since  the  exudation  dries  within  the  nasal  cavities  and  forms 
inspissated  crusts  or  scabs  which  are  often  difficult  to  remove 
(rhinitis  sicca).  The  nasal  fossae  are  in  this  case  more  patulous 
than  usual,  and  a  dry  pharyngitis  and  chronic  laryngitis  are  often 
present.  Both  nostrils  may  be  involved,  but  occasionally  the 
affection  results  from  deviations  of,  or  cartilaginous  excrescences 
(spurs)  from,  the  septum,  and  then  is  unilateral,  the  discharge 
coming  from  that  side  which  is  most  patulous,  whilst  the  narrowed 
side  remains  healthy.  When  symmetrical,  the  disease  is  rather 
due  to  constitutional  than  to  local  causes,  occurring  in  weakly, 
anaemic  women,  and  is  to  be  treated  by  general  rather  than  local 
measures.  In  the  unilateral  form,  deviations  of  the  septum  from 
the  middle  line  must  be  rectified,  or  the  spur  removed  by  the 
saw.  In  this  way  the  inspired  air  is  made  to  pass  more  freely 
along  the  narrowed  healthy  side,  and  the  other  nostril  is  dealt 
with  by  the  use  of  weak  alkaline  lotions.  It  may  be  also  advisable 
to  plug  the  dilated  side  with  cotton-wool  for  some  time  daily,  so 
as  to  enforce  respiration  through  the  other  nostril.  Treatment 
is  always  likely  to  be  prolonged,  and  it  is  possible  that  a  daily 
alkaline  nose  lotion  may  be  needed  permanently.  Stimulating 
applications  are  never  borne  well,  and  hence  should  rarely  be 
ordered. 

Ozsena. — This  term  was  formerly  applied  to  any  offensive  muco- 
purulent discharge  from  the  nostrils,  whatever  the  cause,  and  thus 
was  made  to  include  such  conditions  as  tuberculous  or  syphilitic 
disease  of  the  turbinated  bones  or  of  the  septum,  suppuration  in 
the  accessory  sinuses,  the  impaction  of  foreign  bodies,  or  the 
ulceration  of  malignant  growths.  Improvements  in  differential 
diagnosis  have  reduced  the  cases  of  ozaena  to  a  very  small  number, 
and  the  term  is  now  limited  to  one  particular  affection,  and  that  a 
special  form  of  rhinitis  sicca. 

The  disease  is  usually  met  with  in  young  females,  and  may 
sometimes  originate  from  traumatism,  or  after  one  of  the  exanthe- 
mata, oris  associated  with  inherited  tuberculosis  or  syphilis.  The 
nose  is  almost  always  wide  and  roomy,  and  may  be  of  the  special 
strumous  type ;  the  lips  are  often  thick  and  everted,  and  the 
mouth  is  usually  held  open  owing  to  the  impediment  to  nasal 
respiration  caused  by  inspissated  mucus.  The  fcetor  of  the 
breath  is  the  special  feature  that  calls  attention  to  the  complaint ; 


76o  A  MANUAL  OF  SURGERY 

it  is  peculiarly  searching  and  objectionable,  but  the  patient 
fortunately  is  not  cognizant  of  it.  It  is  due  to  the  decomposition 
of  the  muco-pus  collecting  in  the  nasal  cavity,  and  although 
Lowenberg's  diplococcus  is  constantly  present,  the  causative 
organism  has  not  been  determined  with  certainty.  There  is  not 
much  discharge,  but  at  varying  periods  large  crusts  come  away, 
giving  relief  both  to  the  nasal  respiration  and  to  the  fcetor.  Both 
nostrils  are  usually  involved. 

On  examination,  the  shape  and  size  of  the  nares  are  the  first 
things  that  claim  attention  ;  vibrissae  are  scanty,  and  on  inserting 
a  speculum  the  unusual  patency  becomes  evident ;  in  fact,  after 
clearing  away  all  the  dried  mucus  and  scabs,  it  is  often  possible 
to  see  the  posterior  pharyngeal  wall,  and  even  the  orifices  of  the 
Eustachian  tubes.  The  mucous  membrane  over  the  turbinated 
bones  is  dry,  collapsed,  and  pale,  and  crusts  may  be  found  cover- 
ing any  or  every  part  of  them.  The  pharyngeal  wall  is  also  dry, 
and  may  be  coated  with  a  film  of  inspissated  mucus.  No  ulcera- 
tion is  present,  although  the  removal  of  the  crusts  may  be 
associated  with  a  slight  amount  of  bleeding  owing  to  their  close 
attachment  to  the  mucous  membrane.  The  examination  of  a 
case  of  suspected  ozaena  should  also  include  the  accessory  cavities 
of  the  nose,  since  many  cases  in  which  crust-formation  is  a 
prominent  symptom  are  really  due  to  an  empyema  of  one  or  more 
of  the  sinuses. 

As  to  etiology,  it  is  important  to  note  that  ozaena  is  never  seen 
in  patients  with  stenosed  and  narrow  nostrils,  and  is  almost  always 
associated  with  wide,  roomy  noses.  In  consequence,  it  is  difficult 
to  obtain  sufficient  air  pressure  within  them  to  expel  the  exudation 
arising  from  any  ordinary  rhinitis,  and  hence  the  discharge  tends 
to  collect  and  necessarily  to  putrefy.  The  irritation  thus  induced 
is  likely  in  weakly  children  to  lead  to  suppuration.  For  the  same 
cause  the  mucous  membrane  becomes  dry  and  the  erectile  tissue 
collapses,  so  that  an  atrophic  form  of  rhinitis  sicca  results,  followed 
in  time  by  sclerosis  and  shrinking  of  the  turbinated  bones.  It  is 
always  a  prolonged  process,  although  in  the  course  of  years  it 
improves  and  gradually  disappears. 

Treatment. — The  first  essential  is  to  keep  the  nose  clean  and 
free  from  putrefying  masses  of  dried  secretion.  This  must  be 
accomplished  by  irrigating  the  cavity  once  or  twice  daily,  and 
preferably  with  warm  water,  to  which  a  little  alkali,  such  as 
common  salt,  and  an  unirritating  antiseptic,  such  as  sanitas,  has 
been  added.  At  first  it  is  well  for  the  surgeon  to  see  to  this  him- 
self, but  after  a  while  the  patient  or  her  friends  can  be  entrusted 
with  the  task.  Every  portion  of  scab  ought  to  be  removed  daily, 
and  the  surface  lubricated  with  some  such  application  as  a  spray 
of  menthol  and  paroleine  (10  grains  to  i  ounce).  The  nose  should 
then  be  partially  plugged  with  a  tampon  of  cotton-wool,  especially 
along  the  lower  meatus,  and  if  thought  desirable  the  wool  may  be 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX  761 

medicated  with  some  antiseptic.  By  this  means  a  flow  of  mucus 
from  the  membrane  is  determined,  and  the  discharge  is  thus 
rendered  more  fluid,  and  inspissation  prevented.  A  similar  end 
may  also  be  obtained  by  partially  plugging  the  nostril  with  an 
indiarubber  tube,  so  as  to  diminish  its  size.  The  general  health 
must  be  attended  to,  and  patience  and  perseverance  will  generally 
be  crowned  with  success.  Operative  measures  are  scarcely  ever 
required  in  this  disease,  although  they  have  frequently  been 
resorted  to  most  unnecessarily. 

Disease  of  the  Middle  Turbinated  Bone  and  Ethmoid  is  sometimes 
the  cause  of  an  offensive  purulent  discharge  from  the  nose,  which 
is  often  wrongly  called  ozaena.  It  occurs  in  individuals  of  all 
ages  and  classes,  arising  from  syphilitic  or  tuberculous  disease,  but 
is  perhaps  most  commonly  due  to  septic  infection  from  without, 
the  result  of  meddlesome  and  careless  surgery.  It  must  be 
remembered  that  the  upper  part  of  the  nose  is  normally  sterile, 
and  the  introduction  of  dirty  instruments  is  often  responsible  for 
this  affection.  It  commences  as  a  submucous  infiltration,  usually 
of  the  middle  turbinal,  and  thence  spreads,  with  or  without 
ulceration,  to  the  periosteum  covering  the  bone,  which  becomes 
carious  or  necrosed.  Various  parts  of  the  ethmoid,  including  the 
cribriform  plate,  may  also  be  involved,  and  adjacent  bony  cavities 
(antrum,  frontal  and  ethmoidal  sinuses,  etc.)  are  filled  with  pus. 
In  bad  cases  the  venous  channels  in  the  base  of  the  skull — e.g., 
the  cavernous  sinus — may  be  thrombosed  and  infected,  and  even 
abscess  of  the  brain  has  followed.  The  disease  affects  one  or 
both  sides  of  the  nose,  perhaps  most  frequently  but  one.  On 
examining  the  interior  of  the  nostril,  there  is  no  patency  of  the 
cavity,  as  in  ozaena,  but  a  large  polypoid  mass  of  granulation 
tissue  may  be  seen  blocking  the  middle  meatus  and  covered  with 
a  half-dried  scab,  w"hilst  pus  can  be  seen  to  exude  from  it  when 
pressed  upon  ;  this  usually  comes  from  the  antrum  or  frontal 
sinus,  the  mass  of  granulation  tissue  lying  both  above  and  below 
the  entrance.  A  probe  passed  into  the  mass  always  impinges  on 
diseased  or  bare  bone. 

When  due  to  syphilis,  distinct  sequestra  are  usually  present, 
sometimes  involving  the  septum  and  hard  palate,  but  the  accessory 
cavities  are  not  generally  invaded. 

The  Diagnosis  from  ozaena  is  made  by  remembering  that  in  the 
latter  the  characteristic  features  are  the  abnormal  width  of  the 
nasal  fossae,  the  bilateral  symmetry,  the  collapse  of  the  erectile 
tissue,  the  more  complete  inspissation  of  the  secretion,  and  the 
pathognomonic  stench,  which  are  all  absent  in  these  cases.  A 
certain  amount  of  odour  is  present,  but  it  is  mainly  noticed  by  the 
patient,  not  so  much  by  outsiders. 

Treatment  consists  in  the  removal  of  all  dead  and  carious  bone 
that  can  be  safely  dealt  with,  together  with  the  destruction  of  all 


762 


A   MANUAL  OF  SURGERY 


fungating  granulation  tissue,  and  the  drainage  of  such  accessory 
cavities  as  can  be  reached,  whilst  attention  is  given  to  maintain 
cleanliness  and  asepsis  as  far  as  possible.  Thus,  the  middle 
turbinated  bone  and  its  accompanying  mass  of  granulation  tissue 
may  be  removed  by  the  sharp  spoon,  snare,  or  polypus  forceps. 
The  antrum  must,  if  necessary,  be  opened  and  drained,  and  the 
walls  of  the  ethmoidal  cells  may  be  broken  down,  and  exit  thus 
given  to  pus.  The  greatest  gentleness  and  care  must  be  exercised 
when  any  attempt  is  made  to  deal  with  the  roof  of  the  nose. 

Nasal  Polypi. — Two  forms  of  nasal  polypus  are  described,  viz., 
the  simple  or  mucous  polyp  and  the  fibrous  or  fibro-sarcomatous. 
Other  malignant  tumours  occur  in  the  nasal,  fossae,  to  which, 
however,  the  term  polypus  can  scarcely  be  extended  ;  they  mainly 
originate  from  the  superior  maxilla. 

The  Mucous  Polypus  consists  of  a  soft  gelatinous  mass,  which 
on  microscopic  examination  much  resembles  myxomatous  tissue, 

covered  by  ciliated  columnar 
epithelium,  and  supplied  freely 
with  bloodvessels.  There  has 
been  a  good  deal  of  discussion 
as  to  whether  or  not  these  polypi 
are  really  of  a  myxomatous 
nature,  but  the  general  opinion 
of  rhinologists  is  in  favour  of  the 
view  that  they  are  inflammatory 
in  origin,  consisting  merely  of 
cedematous  hypertrophic  tissue. 
The  growths  are  usually  situated 
on  the  middle  and  superior  tur- 
binated bones  ;  they  rarely  start 
from  the  roof  of  the  nasal  fossae, 
occasionally  in  the  sinuses,  or  at 
the  orifices  leading  into  them  ; 
they  hardly  ever  involve  the 
septum  or  inferior  turbinated  bone.  The  polypoid  masses  are 
generally  multiple,  a  large  one  projecting  downwards  and  forwards 
towards  the  anterior  nares,  and  covering  or  hiding  a  whole  series 
of  smaller  ones,  which  readily  spring  into  prominence  when  that 
in  front  is  removed.  They  are  sometimes  dependent  on,  and  kept 
up  by,  suppuration  in  one  of  the  adjacent  sinuses.  They  are 
usually  attached  by  a  small  pedicle,  and  when  developing  in  the 
nasal  fossa  are  pyriform  and  laterally  compressed.  When  of  large 
size,  they  may  protrude  through  the  nostrils,  and  then  the  epithe- 
lium covering  the  anterior  portion  becomes  squamous,  and  the 
whole  mass  firmer  in  texture  and  papillomatous  in  appearance. 
Sometimes  they  project  backwards  into  the  pharynx,  and  are  then 
more   distinctly  globular  and   usually  single.     Occasionally  they 


Fig.  277. — Mucous  Polypi  of  Nose, 
springing  from  the  back  and 
Front  of  the  Middle  Turbinated 
Bone. 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX  763 


are  the  starting-point  of  a  myxo-sarcomatous  growth,  which 
develops  rapidly,  and  early  tends  to  invade  the  surrounding 
bones. 

The  main  Symptom  arising  from  nasal  polypi  is  obstruction  to 
the  passage  of  air  along  one  or  both  sides  of  the  nose,  according  to 
the  location  of  the  growths.  This  is  always  of  gradual  onset,  and 
is  invariably  worse  in  wet  weather,  on  account  of  the  hygroscopic 
property  of  mucoid  tissue.  There  is  often  a  thin,  watery  discharge 
from  the  nose,  which  may  perhaps  be  blood-stained.  The  patient 
is  unable  to  blow  the  nose,  and  his  articulation  becomes  nasal  in 
quality.  On  rhinoscopic  examination  one  finds  a  greyish  semi- 
translucent  glistening  mass  occupying  the  nostril,  and  attempts  to 
blow  the  nose  render  this  more  obvious.  Its  pedunculated  nature 
can  be  easily  demonstrated  by  passing  a  probe  around  it.  When 
of  large  size,  some  flattening  or  expansion  of  the  bridge  of  the 
nose  may  be  caused  thereby,  and  possibly  epiphora  from  pressure 
on  the  opening  of  the  nasal  duct. 

The  Diagnosis  should  present  no  difficulty  to  one  who  knows 
how  to  employ  the  nasal  speculum.  Abscess,  a  spur,  or  deviation 
of  the  septum,  though  causing  unilateral  obstruction,  is  recognised 
by  the  exercise  of  a  very  small  amount  of  intelligence.  (Edema- 
tous masses  of  granulation  tissue,  associated  with  tuberculous  or 
syphilitic  disease  of  the  bones,  are  recognised  by  usually  involving 
the  septum  as  well  as  the  turbinals,  by  the  purulent  discharge, 
by  the  absence  of  superficial  epithelium,  and  by  not  being  dis- 
tinctly pedunculated  ;  carious  bone  can  usually  be  felt  by  a 
probe  through  the  granulation  tissue.  From  hypertrophy  of  the 
mucous  membrane  over  the  inferior  turbinated  bone,  a  polypus 
is  known  by  the  fact  that  it  scarcely  ever  springs  from  this  region, 
whilst  the  former  condition  is  sessile,  red,  and  diminished  con- 
siderably in  size  by  the  application  of  cocaine. 

The  Treatment  of  mucous  polypi  consists  in  their  removal  either 
by  forceps  or  the  snare.  The  former  plan  is  usually  condemned 
by  rhinologists  as  unscientific  and  barbarous,  and  as  utilized  by 
many  of  the  old  class  of  surgeons,  such  it  certainly  was :  but  if 
employed  in  the  way  described  below,  it  is  just  as  efficient  as  the 
snare,  and  gives  the  patient  very  little,  if  any,  more  pain.  Person- 
ally, we  must  plead  guilty  to  a  very  distinct  preference  for  the 
forceps. 

In  undertaking  avulsion  by  forceps,  the  patient  is  seated  in  a 
chair,  and  the  surgeon  sits  or  stands  in  front  of  him.  The  nasal 
cavities  are  fully  cocainized,  and  the  situation  of  the  pedicle  ascer- 
tained, as  clearly  as  possible,  by  illuminating  the  interior  and  by 
the  use  of  a  probe.  The  forceps  employed  should  be  long,  with 
delicate,  though  strong,  blades,  which  are  deeply  serrated  on 
either  side  of  a  median  groove.  They  are  introduced  open,  with 
a  blade  placed  horizontally  on  either  side  of  the  growth,  and  are 
gently  pressed  upwards  until  the  pedicle  is  grasped  as  close  to  the 


764  A  MANUAL  OF  SURGERY 


turbinated  bone  as  possible.  The  blades  are  then  closed  firmly, 
and  the  polyp  twisted  off  and  removed,  a  certain  amount  of 
haemorrhage  resulting.  The  same  process  is  repeated  to  the 
smaller  tumours  until  the  nostril  is  clear.  It  may  be  plugged 
with  a  strip  of  boric  lint  if  the  bleeding  continues,  but  such  should 
never  be  left  unchanged  longer  than  twenty-four  hours.  The  plug 
is  then  removed,  and  the  base  of  the  growth  carefully  examined 
and  cauterized  with  the  galvano-cautery  by  the  aid  of  a  nasal 
speculum.  This  cannot  be  so  accurately  accomplished  immedi- 
ately after  removal,  as  the  bleeding  interferes  with  clear  vision. 
The  cauterization  of  the  base  is  a  most  important  item  in  the 
treatment,  as  without  it  the  growths  are  sure  to  recur.  The 
patient  should  be  again  examined  after  a  short  interval,  so  that 
any  smaller  polypi  which  have  commenced  to  develop  may  be 
suitably  dealt  with. 

To  remove  polypi  with  the  galvanic  ecraseur  or  snare,  a 
speculum  is  inserted,  and  the  wire  loop  passed  round  the  growth 
so  as  to  encircle  its  base,  and  gradually  tightened  until  it  has  cut 
through.  This  plan  is  specially  adapted  to  large  masses  which 
project  downwards  behind  the  palate. 

Whichever  method  is  adopted,  recurrences  are  not  uncommon, 
and  the  treatment  may  in  consequence  be  very  prolonged  ;  but  if 
the  surgeon  will  persevere  in  the  way  described  above,  the  disease 
can  in  time  be  eradicated  without  having  recourse  to  such  a  muti- 
lating procedure  as  removal  of  the  turbinated  bones  ;  indeed,  after 
such  an  operation,  considerable  trouble  may  arise  from  the  nasal 
cavity  being  too  patulous. 

A  Fibrous  Polypus  is  the  term  applied  to  a  fibroma,  which  tends 
sooner  or  later  to  become  sarcomatous,  springing  from  the  base 
of  the  skull,  especially  from  the  basi-sphenoid  or  basi- occipital. 
It  is  at  first  distinctly  pedunculated,  and  is  usually  firm,  smooth, 
and  fleshy  in  character  ;  when  of  large  size,  it  may  be  lobulated. 
The  early  symptoms  are  almost  limited  to  those  of  obstruction 
to  nasal  respiration,  but  to  this  is  not  unfrequently  added  severe 
epistaxis,  owing  to  the  vascularity  of  the  capsule  and  of  the  over- 
lying mucous  membrane.  As  it  increases  in  size,  ulceration 
occurs,  leading  to  a  foetid  sanious  discharge,  and  the  growth  rarely 
remains  limited  to  the  nasal  fossae.  If  pushing  forwards,  it  may 
lead  to  expansion  of  the  bridge  of  the  nose  and  separation  of  the 
eyes,  which  may  even  be  made  to  diverge  ;  but  if  backwards,  it 
may  depress  the  velum,  and  hang  downwards  as  a  naso-pharyngeal 
tumour.  In  other  cases  it  may  force  its  way  into  the  orbit  or 
any  of  the  other  surrounding  cavities,  or  may  even  erode  the  base 
of  the  skull,' and  encroach  upon  the  cranium.  It  is  rare  for  any 
of  these  latter  manifestations  to  occur  until  after  the  tumour  has 
taken  on  a  distinct  sarcomatous  type. 

The  disease  usually  attacks  young  people,  and  mainly  those 
in  the  second  decade  of  life.     It    progresses  with   considerable 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX  765 


rapidity,  and  the  fatal  issue  may  be  due  to  haemorrhage,  asphyxia, 
or  cerebral  complications. 

Treatment. — Unfortunately  this  condition  is  but  rarely  recog- 
nised in  the  early  stages,  owing  to  the  fact  that  the  majority  of 
practitioners  are  quite  unable  to  use  the  rhinoscope.  We  would 
impress  upon  students  the  immense  importance  of  thoroughly 
exploring  both  by  the  mirror  and  the  finger  passed  behind  the 
velum  every  case  of  nasal  obstruction  or  of  chronic  discharge 
from  the  nose.  When  the  growth  is  small  and  polypoid,  it  can 
often  be  dealt  with  from  the  anterior  nares  by  means  of  a  galvano- 
ecraseur.  The  wire  loop  is  inserted  from  the  front,  and  hitched 
over  the  tumour,  so  as  to  encircle  its  base,  by  the  assistance  of 
the  right  index  finger  passed  behind  the  velum.  The  pedicle  must 
be  divided  as  near  the  skull  as  possible,  as  otherwise  recurrence  is 
almost  certain  to  follow.  Nelaton's  operation,  described  below 
(p.  766),  will  in  some  instances  assist  the  surgeon  to  reach  the 
base  of  the  skull  and  deal  with  the  tumour. 

In  the  more  severe  cases,  where  the  growth  has  become  diffuse, 
it  is  very  doubtful  whether  much  good  can  be  done  by  operation, 
since  the  base  of  the  skull  is  sure  to  be  gravely  affected.  If  treat- 
ment is  attempted,  one  or  other  of  the  many  plans  for  exploring 
the  nose  or  naso-pharynx  must  be  resorted  to,  and  the  operative 
measures  must  be  modified  according  to  the  peculiar  requirements 
of  the  case.  Probably  total  ablation  of  the  superior  maxilla  will 
give  the  best  approach  to  the  mass. 

Other  forms  of  Malignant  Disease  of  the  Nose  are  met  with, 
and  may  originate  in  any  part  of  the  nasal  fossae.  Squamous 
epithelioma  is  that  which  occurs  most  frequently  ;  the  symptoms 
consist  in  the  presence  of  a  blood-stained  discharge,  and  a  certain 
amount  of  respiratory  obstruction,  together  with  pain  and  cachexia. 
The  lymphatic  glands  at  the  angle  of  the  jaw  are  early  enlarged, 
and  the  course  of  the  disease  is  usually  rapid  owing  to  the  great 
vascularity  of  the  part.  Up  to  within  quite  a  recent  period  such 
growths  have  been  almost  always  looked  on  as  inoperable,  but 
within  the  last  ten  years  attempts  have  been  made  to  remove 
them,  and  although  necessarily  the  mortality  is  great,  and  the 
liability  to  recurrence  considerable,  yet  the  results  have  been  such 
as  to  encourage  the  practice  of  attacking  the  disease,  even  in  such 
a  difficult  region  to  explore  as  the  interior  of  the  nose. 

Sarcoma  may  also  commence  in  the  nose  itself,  quite  apart  from 
that  which  originates  in  the  superior  maxilla.  It  gives  rise  to 
the  usual  signs  of  an  intranasal  growth,  and  may  be  dealt  with 
in  a  satisfactory  manner  by  local  means,  such  as  curetting  and 
the  application  of  caustics.  Not  a  few  cases  are  on  record  in 
which  such  treatment  has  proved  efficacious  in  curing  the  disease. 

The  operations  which  have  been  devised  for  dealing  with  disease  of  the  nose 
and  naso-pharynx  are  so  numerous  and  complicated  that  it  is  impossible  for  us 
to  mention  more  than  a  few  of  the  most  useful  and  important 


766  A   MANUAL  OF  SURGERY 


(a)  In  many  cases  of  intranasal  disease  considerable  assistance  can  be 
derived  by  opening  up  the  anterior  naves,  especially  when  one  is  operating  for 
caries  or  necrosis  of  the  turbinated  bones.  It  may  suffice  merely  to  divide  one 
ala  nasi  and  the  attachments  of  the  cartilages  to  the  maxilla  ;  but  where  both 
sides  are  involved,  Rouge's  operation  is  advisable.  This  consists  in  the  detach- 
ment of  the  mask  of  the  face  from  the  maxillae  by  everting  the  upper  lip  and 
incising  the  mucous  membrane  and  subjacent  tissues  until  the  nasal  cavities 
are  opened.  The  septum  nasi  is  divided  by  cutting  pliers,  and  the  nasal 
cartilages  completely  separated.  The  soft  tissues  of  the  face  can  then  be 
retracted  upwards,  and  the  nasal  fossae  fully  exposed.  The  bleeding  is  always 
considerable,  and  the  space  gained  in  children  is  but  slight.  When  the  opera- 
tion is  completed,  the  mask  of  the  face  is  allowed  to  fall  back  again  into  posi- 
tion, union  occurring  without  difficulty,  although  no  sutures  are  employed. 

When  the  upper  and  anterior  portion  of  the  nasal  cavity  is  to  be  dealt  with, 
Langenbeck's  plan  can  sometimes  be  utilized  with  advantage.  An  incision 
down  to  the  bones  is  made  along  the  outer  border  of  the  nose  from  the  root 
downwards  and  outwards  towards  the  ala.  The  soft  parts  are  retracted  on 
either  side  so  as  to  expose  the  nasal  bone  and  the  nasal  process  of  the  superior 
maxilla,  a  wedge-shaped  portion  of  which  can  be  divided  by  cutting  pliers  and 
prised  upwards,  but  left  with  their  superior  connections  untouched,  so  that 
after  the  operation  they  can  be  replaced. 

When  the  septum  alone  is  involved  in  malignant  disease,  it  is  possible  to 
deal  with  it  by  an  operation,  which  consists  in  splitting  the  upper  lip  in  the 
middle  line,  and  carrying  the  incision  round  the  ala  nasi  on  each  side  so  that 
the  lower  portion  of  the  nose  can  be  turned  upwards  after  dividing  the  septum. 
A  wedge-shaped  portion  is  then  removed  from  the  front  of  the  palate  after 
detaching  the  muco-periosteum  from  its  buccal  aspect.  An  excellent  approach 
is  thus  obtained  into  the  nasal  cavity,  and  the  entire  septum  can  in  this  way 
be  removed  without  difficulty.  The  parts  can  be  afterwards  brought  together 
quite  naturally,  and  the  deformity  is  very  slight. 

(b)  When  the  disease  is  located  further  back,  originating  rather  in  the 
naso-pharynx  than  in  the  nose  itself,  the  palatine  route  may  be  used  with 
advantage.  Perhaps  the  best  of  the  several  suggested  operations  is  that  of 
Nelaton.  This  consists  in  a  median  section  of  the  velum  and  of  the  mucous 
membrane  covering  the  posterior  half  of  the  hard  palate.  A  transverse 
incision  is  then  made  on  either  side  of  the  anterior  extremity  of  this,  and  two 
muco-periosteal  flaps  reflected,  exposing  a  quadrilateral  area  of  bone  which 
is  removed  by  chisel  and  mallet.  If  need  be,  part  of  the  vomer  is  also  taken 
away,  and  thus  the  naso-pharynx  is  opened  sufficiently  to  allow  of  the  removal 
of  the  polypus  or  growth.  The  reflected  segments  of  the  palate  are  subse- 
quently sutured  together. 

(e)  Various  methods  of  osteoplastic  section  of  the  superior  maxilla  have  been 
practised,  and  Langenbeck's  name  has  been  associated  with  one  or  two 
different  plans,  which  are,  however,  only  suited  to  particular  cases  of  disease, 
and  at  best  give  but  poor  access  to  the  parts  behind  or  above  the  superior 
maxilla,  whilst  they  usually  leave  extremely  ugly  cicatrices.  Perhaps  the  best 
plan  to  adopt  is  to  temporarily  detach  the  superior  maxilla  from  its  bed,  turning 
it  outwards  together  with  the  cutaneous  and  subcutaneous  tissues  overlying  it, 
and  then,  after  completing  the  operation,  replacing  the  bone  and  suturing  the 
soft  parts  into  position.     The  results  of  such  practice  have  been  encouraging. 

Adenoids. — Although  it  is  only  twenty  years  ago  since  Meyer 
first  drew  attention  to  this  condition,  it  is  not  too  much  to  say 
that  at  the  present  time  a  large  proportion  of  our  children  and 
young  people  are  subject  to  it  in  a  more  or  less  aggravated  form. 
Adenoids  are  very  common  in  children  with  an  inherited  tuber- 
culous history,  and  are  of  considerable  importance  from  the 
results  to  which  they  give  rise. 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX 


767 


It  has  been  already  mentioned  that  the  naso-pharynx  is  the 
seat  of  a  large  amount  of  lymphoid  tissue,  similar  to  that  met 
with  in  the  tonsil,  which  may  either  be  distributed  widely  over 
the  whole  mucous  membrane,  or  may  be  gathered  into  a  special 
mass  on  the  roof,  known  as  the  pharyngeal  or  Luschka's  tonsil. 
Adenoids  consist  in  a  hyperplasia  of  this  tissue,  exactly  analo- 
gous to  the  chronic  hypertrophic  form  of  tonsillitis,  with  which, 
indeed,  it  is  often  associated.  They  may  occur  in  the  form  of 
broad,  cushion-like  masses  springing  mainly  from  the  roof  or 
posterior  walls,  or  occasionally  as  pedunculated  tumours  hanging 
down  into  the  posterior  nares.  Fig.  278  represents  such  a  condi- 
tion as  seen  by  posterior 
rhinoscopy.  The  tumours 
are  extremely  soft  and 
vascular,  bleeding  very 
readily.  In  the  recesses 
or  folds  between  the  dif- 
ferent portions  of  the  mass 
bacteria  lodge  and  give 
rise  to  various  inflam- 
matory troubles,  both 
locally,  and  in  neighbour- 
ing lymphatic  glands.  Not 
uncommonly  isolated 
masses  similar  in  structure 
to  the  above  are  also  to  be 
seen  on  the  posterior  wall  of  the  pharynx,  and  a  certain  amount 
of  chronic  rhinitis  and  laryngitis  may  be  associated. 

The  Symptoms  induced  by  adenoids  are  mainly  due  to  obstruc- 
tion to  nasal  respiration.  The  mouth  is  generally  held  half  open, 
so  as  to  allow  the  child  to  breathe  through  it,  thereby  exposing 
the  upper  central  incisors  (Fig.  279) ;  for  a  similar  cause  he  snores 
during  sleep,  and  usually  wakes  with  the  mouth  and  tongue  dry. 
The  nostrils  are  drawn  in,  and  the  nose  is  thin  and  pinched,  the 
whole  aspect  being  very  characteristic  ;  the  children  often  look 
sleepy  and  half  silly,  and  indeed  may  be  very  backward  in  their 
studies.  Not  uncommonly  there  is  a  certain  amount  of  semi- 
purulent  discharge  from  the  nose,  or  it  may  be  hawked  up  from 
the  pharynx,  perhaps  mixed  with  blood.  Deafness  also  results 
from  extension  of  the  catarrhal  condition  to  the  mucous  lining  of 
the  Eustachian  tubes,  and  acute  or  chronic  otitis  media  may  be 
thereby  induced  ;  both  taste  and  smell  are  sometimes  impaired. 
The  palate  also  becomes  high  and  arched,  owing  to  the  defective 
intranasal  air  pressure,  and  as  the  patient  grows  up,  the  incisor 
1eeth  may  project  forwards,  giving  a  curious  rabbit-like  expression 
to  the  face.  The  cervical  glands  are  sympathetically  enlarged, 
and  often  the  seat  of  tuberculous  disease.  In  bad  cases  which 
have  been  allowed  to  persist  throughout  adolescence  considerable 


Fir,   27S  — Adenoids  as  seen  by  Posterior 
Rhinoscopy.     (Tillmanns.) 


768 


A   MANUAL  OF  SURGERY 


deformity  of  the  thoracic  parietes  is  induced,  owing  to  the  inability 
of  the  child  to  take  a  really  deep  inspiration,  the  ribs  in  conse- 
quence being  drawn  in,  and  the  spine  kyphotic  (Fig.  280). 

Physical  Examination  consists  in  posterior  rhinoscopy,  by  means 
of  which  the  growths  can  be  seen,  or  in  palpation  of  the  posterior 
nares,  a  process  more  suitable  to  children,  who  rarely  have  suffi- 
cient control  to  permit  of  the  former.  On  passing  the  finger 
behind  the  velum,  the  naso-pharynx  is  found  to  be  occupied  by  a 
soft  mass  of  tissue  which  readily  bleeds,  and  more  or  less  obstructs 
the  openings  of  the  posterior  nares. 


jwt*^S|  Bfe> 

w- 

Mm.    *"       '" 

pPP^^ 

I 

Fig    279. — Adenoid  Facies.     (From  a  Photograph  kindly  lent  by 
Dr.  St.  Clair  Thomson.) 

This  illustration  shows  well  the  sleepy  look,  the  pinched  nostrils,  the  open 
mouth  and  projecting  upper  central  incisors  so  characteristic  of  this 
condition. 

Treatment  consists  in  the  great  majority  of  cases  in  removal  of 
the  adenoids  by  operation.  If  left  alone,  there  is  a  tendency  for 
these  growths  to  gradually  disappear,  but  during  this  interval 
development  may  be  considerably  hindered,  and  hence  a  cure  by 
natural  processes  in  children  should  never  be  relied  on.  Much 
may  be  done  in  milder  cases,  however,  by  enforcing  respiratory 
exercises  with  the  mouth  shut ;  and  in  young  adults  attention  to 
the  general  health,  combined  with  irrigation  of  the  nose  with  salt 
and  water,  and  perhaps  the  local  application  of  a  weak  solution  of 
nitrate  of  silver  (5  grains  to  1  ounce)  to  the  naso-pharynx,  may 
suffice  to  bring  about  an  amelioration  of  the  condition. 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX 


-69 


Operation. — Much  diversity  of  opinion  exists  as  to  the  character 
and  extent  of  the  operation  ;  some  authorities  consider  that  all 
that  is  required  is  to  scrape  the 
growths  away  with  the  finger-nail, 
and  undertake  this  proceeding  either 
under  nitrous  oxide  gas,  or  even  with- 
out an  anaesthetic.  Such  a  measure 
is,  to  our  minds,  unsatisfactory,  in 
that  the  adenoids  cannot  possibly  be 
entirely  removed,  and  recurrence  may 
ensue.  As  a  general  rule,  the  child 
should  be  anaesthetized  with  chloro- 
form, and  if  enlarged  tonsils  co-exist, 
these  should  be  dealt  with  in  the  first 
place.  Lowenberg's  forceps,  curved 
so  as  to  allow  of  them  being  passed 
behind  the  soft  palate,  are  then  intro- 
duced with  the  right  hand,  whilst  the 
velum  is  protected  by  the  left  index- 
finger  passed  behind  it.  The  protu- 
berant masses  are  grasped  and  torn 
off,  special  attention  being  directed 
to  clearing  the  posterior  nares.  The 
orifices  of  the  Eustachian  tubes  are 
readily  detected,  and  must  not  be 
injured.  Care  must  also  be  taken  not 
to  lay  hold  of  the  uvula  by  mistake. 
The  surgeon's  finger-nail  may  be 
used  to  complete  the  removal  of  any 
tags  of  tissue  that  remain.  Of  course, 
there  is  considerable  bleeding,  but 
this  quickly  stops  of  itself,  and  as 
soon  as  the  operation  is  over,  the  head 
should  be  turned  to  one  side,  or  the 
child  held  face  downwards,  so  as  to 
allow  the  blood  to  run  out  of  the 
mouth  and  nose.    The  after-treatment 

consists  in  washing  out  the  nose  and  throat  with  either  salt  and 
water,  or  a  weak  solution  of  sanitas  ;  the  patient  is  kept  indoors 
for  a  few  days,  and  only  fluid  food  allowed.  Gottstein's  curette 
is  preferred  by  many  rhinologists,  and  we  have  often  used  it  with 
advantage. 


Fig.  280.  —  Lateral  View  of 
a  Child  with  Neglected 
Adenoids.  (From  a  Photo- 
graph lent  by  Dr.  St. 
Clair  Thomson.) 

This  is  the  same  child  whose 
face  appears  in  Fig.  279.  It 
will  be  seen  that  the  chest  is 
shallow  and  retracted,  and  the 
spine  kyphotic.  The  arms  are 
small,  but  the  legs  are  well 
developed. 


Epistaxis,  or  bleeding  from  the  nose,  may  arise  from  a  variety 
of  causes,  including  traumatism,  directed  either  to  the  mucous 
membranes  or  the  bones,  or  from  the  presence  of  ulceration  or 
tumours.  Some  of  these  local  causes  are  very  evident,  if  only 
they  are  carefully  looked  for  with  a  rhinoscope  and  frontal  mirror. 

49 


770  A   MANUAL  OF  SURGERY 

One  of  the  commonest  lesions  is  a  small  abrasion  or  ulcer  of  the 
septum,  due  to  detaching  by  the  finger  a  scab  or  dried  crust  of 
mucus  which  causes  irritation  within  the  nostril ;  each  time  the 
nose  is  '  picked  '  in  this  way  bleeding  recurs.  Another  frequent 
source  of  epistaxis  is  the  rupture  of  a  varicose  vein  in  the  mucous 
membrane  of  the  septum  ;  varix  occurs  not  unusually  in  plethoric 
individuals,  and  sneezing  or  blowing  the  nose  violently  may  lead 
to  an  attack.  Foreign  bodies  may  also  cause  haemorrhage,  as  also 
ulceration  of  an  angioma  on  the  septum.  It  frequently  occurs  in 
young  people  about  puberty  in  consequence  of  local  disturbance 
in  the  vascular  arrangement  of  the  parts  ;  again,  cerebral  conges- 
tion may  induce  it,  owing  to  the  communication  by  means  of 
emissary  veins  between  the  interior  of  the  skull  and  the  venous 
plexuses  in  the  nose ;  excessive  changes  in  the  atmospheric 
pressure,  as  in  mountaineering,  may  lead  to  epistaxis,  whilst  in 


5 


Fig.  281. — Belloc's  Sound. 

abnormal  states  of  the  blood  it  may  be  associated  with  haemor- 
rhage elsewhere,  as  in  haemophilia,  purpura,  and  scurvy.  One 
or  both  nostrils  may  be  the  seat  of  the  bleeding,  and  it  may  be  so 
excessive  as  even  to  threaten  life. 

Treatment. — It  must  not  be  forgotten  that,  in  the  majority 
of  cases,  there  is  some  local  cause  of  epistaxis  which  can  be 
found  and  treated  directly — a  fact  which  once  more  emphasizes 
the  necessity  for  gaining  a  mastery  over  the  use  of  the  rhino- 
scope.  The  bleeding  is  generally  unilateral,  and  in  nine  out  of 
ten  cases  the  source  is  within  easy  reach  of  the  anterior  nares, 
and  hence  in  many  instances  all  that  is  required  is  to  grasp  the 
nostrils  firmly,  and  thus  allow  the  blood  to  collect  within,  and 
give  it  an  opportunity  of  clotting.  At  the  same  time,  the  patient 
should  sit  up,  and  cold  be  applied  to  the  root  of  the  nose,  or  to 
the  nape  of  the  neck.  If  on  examination  the  bleeding  point  is 
detected,  whether  it  be  a  varicose  vein  or  an  ulcerated  surface, 
the  haemorrhage  can  almost  at  once  be  stayed  by  applying  a 
pointed  galvano-cautery,  or  by  sealing  the  spot  with  a  swab 
soaked  in  a  solution  of  chromic  acid.  Failing  these  measures, 
the  nostrils  may  need  to  be  plugged,  but  such  a  proceeding  ought 
to  be  seldom  resorted  to  ;  it  is  practically  a  confession  of  want  of 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX 


771 


skill  in  the  use  of  the  rhinoscope.  It  may  suffice  merely  to  stuff 
the  anterior  nares  with  long  strips  of  boric  lint,  but,  as  a  rule, 
the  posterior  nares  also  require  plugging.  For  this  purpose 
Bellocq's  sound  (Fig.  281)  is  usually  employed  in  order  to  pass  a 
thread  round  the  base  of  the  palate,  and  out  of  both  nose  and 
mouth  ;  but  where  it  is  not  obtainable,  a  suitably  curved  pair  of 
laryngeal  forceps  or  a  catheter  may  be  used  instead.  To  the 
lower  end  of  this  thread  a  pledget  of  lint  about  1^  inches  by 
1  inch  in  size  is  attached,  and  this,  guided  by  the  finger  round 
the  soft  palate,  is  drawn  tightly  forwards  into  the  posterior  nares, 
whilst  the  two  ends  of  the  thread  are  tied  together  round  the 
upper  lip  to  prevent  it  from  slipping.  The  plug  is  retained  for 
twelve  hours,  and  then  removed,  and  the  nasal  fossae  irrigated 
with  a  weak  warm  alkaline  antiseptic  lotion  in  order  to  prevent 
sepsis. 

Another  method  of  arresting  epistaxis  is  by  Cooper  Rose's 
inflating  plug  ;  it  consists  of  a  piece  of  gum  catheter,  surrounded 
by  a  thin  indiarubber  bag,  which  can  be  inflated  through  the 
hollow  stem.  It  is  oiled  and  passed  well  into  the  nose  from  the 
front ;  the  indiarubber  bag  is  then  inflated  to  the  required  extent, 
the  air  being  retained  by  a  stop-cock.  This  generally  acts  most 
efficiently,  and  can  be  introduced  and  removed  with  scarcely  any 
pain  to  the  patient. 


49—2 


CHAPTER  XXVII. 

APFECTIONS  OF  THE  MOUTH,  THROAT,  AND 
OZSOPHAGUS. 

Stomatitis,    or   inflammation    of  the    mucous    membrane   of   the 
mouth,  is  by  no  means  uncommon,  especially  in  children. 

i .  Simple  Catarrhal  Stomatitis  results  from  mechanical  irritants, 
such  as  roughened  teeth,  from  irritating  chemicals,  or  from  that 
septic  form  of  inflammation  which  is  so  liable  to  follow  operations 
involving  the  mouth.  It  may  also  arise  in  the  course  of  fevers, 
and  in  conditions  of  debility  such  as  follow  measles  and  other 
exanthemata  in  children  ;  or  be  associated  with  disturbances  in 
the  alimentary  canal,  as  by  improper  feeding,  dyspepsia,  etc. 
The  mucous  membrane  becomes  hyperaemic  and  swollen,  usually 
in  small  localized  patches,  which  may  gradually  spread  and 
become  confluent,  involving  nearly  the  whole  of  the  oral  cavity. 
The  exudation  of  mucus  is  increased,  and  becomes  viscid  and 
turbid,  whilst  the  epithelium,  at  first  white  and  sodden,  is  after 
a  while  rubbed  off,  leaving  superficial  erosions  or  distinct  ulcers, 
which  are  very  painful.  The  treatment  consists  in  the  removal 
of  all  sources  of  irritation,  and  the  administration  of  drugs  to 
correct  intestinal  derangements.  Chlorate  of  potash,  possibly  com- 
bined with  dilute  hydrochloric  acid,  is  very  useful,  both  locally 
and  internally.  In  the  more  severe  cases  antiseptic  mouth- 
washes should  be  employed,  such  as  the  liquor  soda?  chlorinatae 
(i  ounce  to  i  pint  of  water),  sanitas  (i  in  10),  boro-glyceride 
(i  in  20),  etc. 

2.  Aphthous  Stomatitis  occurs  in  badly-fed  children,  in  the 
form  of  small  whitish  spots  on  a  hyperaemic  base,  which  run 
together,  and  produce  ulceration.  Attention  must  be  directed  to 
the  general  condition,  and  a  little  borax  and  honey  or  a  solution 
of  boro-glyceride  (1  in  20)  applied  locally. 

3.  Thrush,  is  a  very  singular  condition,  but  due  to  the  presence 
of  a  parasitic  fungus,  the  Oidium  albicans.  It  occurs  in  patches 
somewhat  resembling  curdled  milk  in  appearance,  and  requires  the 
same  treatment.     In  both  these  types  there  is  often  considerable 


AFFECTIONS  OF  THE  MOUTH,   THROAT,  AND  OESOPHAGUS    773 


enlargement  of  the  lymphatic  glands,  which,  however,  frequently 
subside  without  suppuration  on  removal  of  the  cause. 

4.  Gangrenous  Stomatitis  is  much  the  same  in  origin  as  the 
preceding,  but  more  acute  in  its  course.  It  occurs  in  debilitated 
children  or  elderly  people,  the  subjects  of  albuminuria  or  diabetes, 
and  is  usually  due  to  foul  and  dirty  teeth.  The  gums  and  adjacent 
tissues  become  gangrenous,  and  severe  toxic  symptoms  result. 
Active  treatment  by  scraping  and  the  use  of  antiseptics,  such  as 
peroxide  of  hydrogen,  is  urgently  necessary. 

In  children  this  condition  is  known  as  Canerum  oris  (p.  83). 

5.  Mercurial  Stomatitis  may  arise  during  the  administration  of 
a  course  of  mercury,  or  occasionally  from  a  single  dose  in  persons 
who  are  sensitive  to  its  action.  It  is  increased  in  severity  if  the 
mouth  and  teeth  are  dirty,  or  if  the  patient  smokes  to  excess.  The 
gums  are  swollen  and  tender,  bleed  on  pressure,  and  are  very  pain- 
ful, especially  when  biting,  or  drinking  hot  fluids.  The  teeth  may 
become  loose  and  fall  out,  whilst  the  alveolar  borders  may  be  laid 
bare  and  necrose.  The  tongue  is  sometimes  swollen  and  inflamed  ; 
salivation  is  a  marked  symptom,  and  the  breath  becomes  very 
offensive.  Treatment. — Either  leave  off  the  mercury,  or  at  any  rate 
reduce  the  dose  considerably,  and  administer  saline  purgatives. 
Chlorate  of  potash,  combined  with  alum,  dilute  hydrochloric  acid, 
or  tincture  of  myrrh,  may  be  useful  locally. 

6.  For  Syphilitic  Stomatitis,  see  Chapter  VI.,  p.  127. 

The  buccal  mucous  membrane  is  also  involved  in  the  course  of 
other  diseases,  e.g.,  diphtheria,  scarlet  fever,  and  erysipelas,  but 
special  descriptions  are  not  needed  here. 

Affections    of   the    Tongue. 

Congenital  Abnormalities. — (a)  The  tongue  has  been  entirely 
absent.  (I))  One  half  of  the  tongue  is  defective  in  size 
(hemiatrophy),  (c)  Tongue-tie  is  said  to  be  present  when  the  fraenum 
is  shorter  than  usual,  causing  the  tip  to  be  depressed  and  fixed  in 
the  floor  of  the  mouth  so  that  it  cannot  be  protruded.  Sucking 
becomes  difficult  in  such  a  condition,  and  when  it  is  allowed  to 
persist,  there  is  often  a  lisp  in  the  speech.  Treatment  is  only 
needed  in  the  severer  forms,  and  consists  in  raising  the  tongue 
with  the  index  and  middle  fingers  placed  one  on  either  side,  and 
snipping  the  fraenum,  thus  put  on  the  stretch,  across  its  centre  with 
a  pair  of  blunt-pointed  scissors,  (d)  The  tongue  may  be  adherent 
to  the  floor  of  the  mouth,  being  bound  down  by  folds  of  mucous 
membrane  (Ankyloglossia).  This  may  also  exist  as  an  acquired 
condition  due  to  cicatricial  contraction  after  ulceration.  In  con- 
genital cases  the  adhesions  are  but  slight,  and  the  organ  can  be 
readily  freed  ;  in  the  acquired  condition  this  cannot  always  be 
accomplished,  (e)  The  fraenum  and  tongue  are  occasionally  too 
long,  allowing  of  increased  mobility,  and  even  fatal  results  have 


774  A  MANUAL  OF  SURGERY 


occurred  from  the  organ  rolling  backwards  and  impeding  respira- 
tion. (/)  The  tongue  may  be  cleft,  presenting  a  bifid  appearance  ; 
this  may  be  complete  or  partial,  and  is  usually  associated  with  a 
congenital  fissure  through  the  lower  lip  and  mandible,  (g)  Macvo- 
glossia  (or  large  tongue),  although  sometimes  acquired,  is  usually 
a  congenital  deformity.  The  organ  is  enlarged  in  all  directions,  and 
protrudes  from  the  mouth,  so  that  the  teeth  indent  it,  and  cause 
ulceration  and  considerable  interference  with  the  venous  return. 
It  thus  becomes  purplish  and  dry  from  exposure,  the  mucous 
membrane  looking  almost  like  skin,  although  saliva  dribbles 
freely  from  beneath  it.  In  old-standing  cases  the  teeth  are  dis- 
placed outwards  and  the  jaws  deformed,  so  that,  even  if  the  tongue 
is  reduced  to  its  normal  size  by  treatment,  it  may  be  impossible  to 
close  the  mouth.  Pathologically,  it  is  due  to  diffuse  overgrowth 
of  the  connective  tissue,  secondary  to  lymphatic  obstruction  and 
dilatation.  Recurrent  attacks  of  lymphangitis  add  to  the  trouble, 
the  tongue  gradually  increasing  in  size,  and  the  disease  has  been 
known  to  terminate  in  the  development  of  a  lymphosarcoma. 
The  treatment  consists  in  excision  of  a  V-shaped  portion,  suturing 
the  raw  surfaces  subsequently  with  catgut. 

Wounds  of  the  tongue  are  usually  caused  by  the  teeth, 
especially  during  an  epileptic  seizure,  or  in  children  as  a  result 
of  falls  with  the  tongue  out.  There  is  often  brisk  haemorrhage 
for  a  few  moments,  which  soon  ceases,  though  blood  may  be 
extravasated  into  its  substance,  and  cause  considerable  swelling. 
In  simple  cases  the  wound  should  be  examined  and  purified, 
and  the  mouth  constantly  cleansed  with  mild  antiseptic  lotions;  a 
few  points  of  suture  may  also  be  inserted  if  necessary,  but  the 
wound  must  not  be  entirely  closed,  or  tension  from  sepsis  will 
result.  When  smart  arterial  bleeding  is  present,  the  mouth 
must  be  opened,  the  tongue  pulled  forwards,  and  the  wounded 
vessel  sought  for  and  tied.  Failing  this,  the  lingual  artery  may 
be  tied  in  the  neck,  or  even  the  external  carotid. 

Acute  Superficial  Glossitis  occurs  as  part  of  a  general  stoma- 
titis, and  needs  no  special  notice. 

Acute  Parenchymatous  Glossitis,  or  acute  inflammation  of  the 
tongue,  may  arise  from  penetrating,  and  of  necessity  septic 
wounds,  or  from  the  bites  or  stings  of  insects,  or  may  be  asso- 
ciated with  acute  stomatitis  in  the  course  of  fevers,  but  is  most 
commonly  due  to  the  injudicious  administration  of  mercury.  The 
condition  may  be  limited  to  one  half  of  the  organ,  but  when  arising 
from  general  causes  is  bilateral.  The  tongue  becomes  painful, 
swells  up  rapidly  so  as  to  fill  the  mouth,  and  even  protrudes 
beyond  the  teeth,  the  pressure  of  which  leads  to  superficial 
ulceration.  The  salivary  glands  are  enlarged  and  painful,  and 
salivation  is  a  marked  feature  in  the  case.  Speech,  swallowing, 
and  even  respiration  are  much  interfered  with,  and  there  may  be 
considerable  febrile  disturbance.     The  case,  if  treated  with  care, 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  OESOPHAGUS    775 


usually  ends  in  resolution  ;  but  diffuse  or  localized  suppuration 
may  ensue,  as  well  as  the  most  urgent  dyspnoea,  arising  either 
from  cedema  glottidis  or  from  the  pressure  of  the  enlarged  organ. 
Treatment  consists  in  stopping  the  mercury,  or  removing  any 
evident  cause,  and  in  the  administration  of  saline  purgatives  with 
chlorate  of  potash.  Leeches  may  be  applied  beneath  the  angles 
of  the  jaw,  but  in  bad  cases  a  free  incision  into  the  dorsum  should 
be  made  on  either  side  of  the  median  line  to  give  exit  to  the  effused 
fluids  and  blood.  The  most  rapid  relief  to  the  symptoms  is 
thereby  obtained,  although  the  organ  may  remain  enlarged  for 
some  time.  If  asphyxia  is  threatening,  high  tracheotomy  or 
laryngotomy  is  required. 

Abscess  of  the  tongue  may  result  from  the  acute  process 
described  above,  but  it  is  more  usually  of  a  chronic  nature,  and 
situated  at  the  anterior  part  of  the  organ.  It  is  usually  due  to 
the  admission  of  micro-organisms  through  some  superficial  lesion 
which  has  quickly  healed.  It  presents  as  a  tense  swelling, 
fluctuation  in  which  may  be  masked  by  the  amount  of  inflam- 
matory thickening  which  surrounds  it.  A  free  incision  both 
settles  the  diagnosis  and  cures  the  case. 

Chronic  Superficial  Glossitis  is  an  interesting  and  important 
disease,  which  may  be  associated  with  a  similar  condition  of  the 
mucous  membrane  lining  the  interior  of  the  cheeks  and  lips.  It 
is  most  commonly  due  to  syphilis,  occurring  as  a  tertiary  pheno- 
menon, but  may  arise  from  excessive  smoking,  ragged  and  rough 
teeth,  or  spirit-drinking,  chronic  dyspepsia,  perhaps  of  a  gouty 
nature,  being  also  present  in  many  cases.  It  is  very  liable  to  be 
followed  by  epithelioma,  Barker  stating  that  out  of  no  cases  he 
carefully  investigated  cancer  occurred  in  43. 

For  purposes  of  description  it  is  useful  to  divide  the  disease 
into  the  following  five  stages,  although  it  must  be  clearly  under- 
stood that  they  are  artificial,  and  several  of  them  may  be  present 
in  different  parts  of  the  same  tongue,  (i.)  The  papillae  become 
enlarged  and  swollen,  leading  to  the  appearance  of  red  hyperaemic 
patches,  which  cannot  be  recognised  for  certain  unless  the  tongue 
is  thoroughly  dried  with  a  handkerchief,  towel,  or  piece  of  clean 
blotting-paper,  which  must  not  be  carelessly  dabbed  over  the 
organ,  but  should  be  firmly  pressed  down  upon  it  so  as  to  absorb 
all  the  moisture,  (ii.)  Overgrowth  of  epithelium  follows,  and  as 
it  increases  in  thickness,  it  becomes  opaque  and  horny,  so  that 
the  red  patches  are  replaced  by  white  ones,  leading  to  the  appear- 
ance which  has  been  designated  Leucoplakia.  Sometimes  the 
papillae  become  much  enlarged,  and  stand  out  definitely  and 
separately  from  the  organ  ;  or  the  whole  surface  may  be  covered 
with  dense  white  patches.  To  this  condition  the  term  Ichthyosis 
has  been  applied,  (iii.)  Later  on,  the  excess  of  epithelium  is  shed, 
leaving  red  smooth  patches  in  which  the  papillae  are  atrophied,  or 
have  entirely  disappeared.     If  this  occurs  over  the  greater  part  of 


776  A   MANUAL  OF  SURGERY 

the  organ,  the  glazed  red  tongue  so  characteristic  of  tertiary  syphilis 
is  produced.  If,  however,  this  process  only  occurs  in  smaller 
areas  intermixed  with  portions  covered  with  white  epithelium,  a 
patchy  appearance  of  the  tongue  results,  wrongly  termed  Psoriasis 
lingua',  (iv.)  At  varying  periods  of  the  disease,  sometimes  earlier, 
sometimes  later,  the  organ  becomes  ulcerated,  cracked,  or  fissured 
in  a  somewhat  characteristic  manner.  A  median  fissure  is  usually 
seen  running  down  the  middle,  and  from  this  furrows  extend 
transversely,  dividing  the  surface  into  rectangular  compartments. 
These  fissures  are  not  always  due  to  the  cicatrization  of  cracks, 
as  when  opened  out  healthy  papillae  are  seen  at  the  base,  and  no 
sign  of  superficial  scarring.  They  are,  then,  evidently  the  result  of 
the  contraction  of  deep  sclerosed  tissue  in  the  substance  of  the 
organ.  Superficial  ulceration  often  occurs,  apart  from  these 
fissures,  being  probably  due  to  some  local  irritation,  or  to 
smoking  ;  the  atrophic  condition  of  the  mucous  membrane 
explains  the  great  liability  to  this  occurrence,  (v.)  Still  later, 
epithelioma  may  develop,  and  usually  in  connection  with  one  of 
the  cracks,  or  of  the  cicatrices  arising  therefrom.  It  is  often 
somewhat  slow  in  its  progress,  owing  to  the  amount  of  sclerosis 
induced  by  the  preceding  inflammation. 

All  these  stages  of  the  disease  are  accompanied  with  much 
discomfort,  the  tongue  being  sometimes  so  tender  that  the  patient 
cannot  drink  hot  fluids,  or  take  condiments  or  stimulants  with- 
out pain.  The  speech,  too,  is  interfered  with,  becoming  thick 
and  indistinct.  The  course  of  the  case  varies  considerably, 
and  if  cancer  does  not  follow,  the  affection  usually  settles 
down  after  a  time,  and  causes  but  little  discomfort,  so  long  as 
the  patient  conforms  to  the  restrictions  as  to  diet,  etc.,  which 
are  essential. 

The  treatment  of  the  case  is  usually  a  matter  of  some  difficulty. 
All  sources  of  irritation  are  excluded  from  the  mouth  as  a  first 
precaution.  Thus,  smoking  or  chewing  tobacco  must  be  rigidly 
prohibited.  Spirit-drinking  and  all  acid  wines  which  cause  pain 
should  be  forbidden,  dilute  whisky  and  water  being  perhaps  the 
best  stimulant.  The  teeth  must  be  well-brushed  night  and  morn- 
ing, and  all  stumps  and  rough  excrescences  removed.  Condi- 
ments, such  as  mustard,  spices,  curry,  and  cheese,  are  excluded 
from  the  dietary,  and  only  simple  unirritating  ingesta  allowed. 
The  mouth  is  washed  out  frequently  with  an  alkaline  lotion,  e.g., 
bicarbonate  of  soda  (20  grains  to  1  ounce),  or  borax  (10  grains  to 
1  ounce),  especially  after  meals,  so  as  to  exclude  all  risk  of  acid 
fermentation  in  the  debris  of  food.  A  solution  of  perchloride  of 
mercury  (2  grains  to  1  ounce)  may  be  painted  on  twice  daily  when 
the  organ  is  cracked  or  ulcerated,  and  in  the  latter  case  powdered 
calomel  dusted  on  once  a  day  may  be  beneficial,  or  the  sores  may 
be  touched  with  solid  nitrate  of  silver. 

General  antisyphilitic  remedies  are  employed  where  necessary  ; 


AFFECTIONS  OF  THE  MOUTH,   THROAT,  AND  CESOPHAGUS    777 


the  digestion  is  attended  to,  and  if  the  new  formation  of  epithelium 
is  excessive,  arsenic  may  be  administered. 

On  the  appearance  of  definite  epithelioma  suitable  operative 
measures  must  be  instituted. 

Ulceration  of  the  tongue  arises  from  a  variety  of  causes,  and 
occurs  in  many  different  forms.  Thus,  writable  ulcers  are  due  to 
rough  and  carious  teeth.  Dyspeptic  ulcers  are  associated  with 
gastric  disturbances  ;  they  are  usually  located  on  the  middle  of 
the  dorsum,  and  are.  often  very  painful.  It  is  sufficient  to  touch 
them  with  lunar  caustic  after  dealing  with  the  cause.  Tuberculous 
ulcers  are  not  common,  and  are  always  secondary  to  pulmonary 
phthisis,  the  organ  being  infected  by  the  sputum.  They  com- 
mence in  the  form  of  a  submucous  abscess,  which  bursts  and 
leaves  a  small  painful  sore,  rarely  situated  on  the  posterior  part 
of  the  organ,  but  chiefly  at  the  sides  or  on  the  dorsum  near  the 
tip.  Secondary  abscesses  form  around  and  coalesce  with  the 
original  ulcer.  Treatment  is  chiefly  needed  on  account  of  the  pain 
and  discomfort  caused  by  them  ;  it  consists  in  cocainizing  and 
scraping  the  sores,  touching  the  base  with  pure  carbolic  acid,  and 
dressing  with  iodoform.  Applications  of  cocaine  may  also  be 
made  before  meals,  as  a  palliative  measure  where  radical  treat- 
ment is  not  undertaken  on  account  of  the  extent  of  the  pulmonary 
mischief.  Lupus  also  attacks  the  tongue,  but  is  very  uncommon, 
and  almost  invariably  secondary  to  a  similar  affection  of  the  skin 
of  the  face.  In  a  case  under  our  care  it  appeared  in  the  form  of 
an  irregular  granulating  surface  surrounded  by  nodulated  cicatricial 
tissue  of  an  exceedingly  dense  character.  The  progress  was  very 
slow,  owing  to  the  amount  of  sclerosis  present.  Treatment  con- 
sists in  scraping  and  cauterization.  Syphilitic  and  cancerous  ulcera- 
tions are  described  below. 

Syphilitic  Disease  of  the  tongue  occurs  in  a  variety  of  different 
forms.  A  primary  sore  presents  a  characteristic  indolent  and 
inactive  surface  with  subjacent  infiltration,  and  much  chronic 
enlargement  of  the  submental  lymphatic  glands,  which,  how- 
ever, do  not  tend  to  suppurate.  In  the  secondary  stage  mucous 
tubercles,  fissures,  and  ulcers  form,  and  usually  on  the  sides  or 
near  the  tip.  Occasionally  one  meets  with  a  broad  wart-like 
condyloma  on  the  dorsum,  which  may  be  associated  with  longi- 
tudinal fissures  ;  it  is  sometimes  termed  '  Hutchinson's  wart.' 
In  the  tertiary  period  chronic  superficial  glossitis  may  develop,  as 
also  diffuse  infiltration  of  the  organ,  or  gummata. 

Gumma  of  the  tongue  is  not  uncommon,  occurring  usually  in 
patients  under  forty  years  of  age,  as  a  late  tertiary  phenomenon. 
It  starts  as  a  localized  submucous  or  intramuscular  infiltration 
near  the  median  line,  and  generally  towards  the  middle  or  pos- 
terior part.  The  swelling  is  at  first  hard  and  firm,  but  later  on 
becomes  soft  and  fluctuating,  and  in  time  the  overlying  mucous 
membrane,  which  was  unaffected,  yields,  and  gives  exit  to  the 


778  A  MANUAL  OF  SURGERY 


characteristic  contents.  The  ulcer  thus  produced  is  oval  or 
round  in  shape,  and  deeply  excavated,  the  base  being  constituted 
by  a  slough,  looking  like  '  wet  wash-leather.'  There  is  but  little 
induration  either  of  the  base  or  edges,  and  one  of  the  most 
characteristic  features  is  the  fact  that  neither  the  floor  of  the 
mouth  nor  the  base  of  the  tongue  is  involved,  so  that  the  organ  can 
be  freely  protruded,  whilst  deglutition  and  articulation  are  scarcely 
interfered  with.  The  patient  complains  of  little  pain,  and  the 
submaxillary  glands  are  only  affected  either  as  part  of  a  general 
enlargement  throughout  the  body,  or  from  the  local  irritation. 
The  progress  is  slow,  and  the  effect  of  antisyphilitic  treatment 
very  decided,  the  gumma  absorbing,  or  the  ulcer,  if  present, 
healing  readily,  but  leaving  a  localized  area  of  sclerosis  or  a  deep 
cicatrix,  from  which  malignant  disease  may  subsequently  originate. 
The  treatment  consists  in  the  administration  of  iodide  of  potassium 
with  or  without  mercury,  whilst  the  mouth  is  kept  clean  with  a 
simple  mouth-wash. 

Innocent  Tumours  are  not  frequent  in  the  tongue,  papilloma, 
cysts,  lipoma,  and  nasvi  being  the  chief  varieties,  and  requiring  no 
special  treatment. 

Dermoid  Cysts  also  form  within  or  under  the  tongue,  originating 
usually  in  connection  with  the  thyro-glossal  duct  (p.  823). 

Cancer  of  the  Tongue  occurs  in  the  form  of  squamous  epithe- 
lioma, and  is  both  a  frequent  and  a  very  fatal  variety  of  this 
disease.  It  is  usually  met  wTith  in  men,  and  may  arise  as  a  result 
of  the  irritation  caused  by  excessive  smoking,  especially  of  cigars, 
cigarettes,  or  foul  pipes. 

Its  mode  of  onset  varies  somewhat  according  to  the  situation  ; 
(a)  It  arises  most  commonly  as  an  ulcer  at  the  margin  of  the 
organ,  towards  the  junction  of  the  middle  and  posterior  thirds, 
and  is  then  probably  due  to  the  irritation  caused  by  ragged  and 
irregular  bicuspid  or  molar  teeth  ;  (b)  it  may  start  in  a  crack, 
fissure,  or  cicatrix  on  the  dorsum,  as  a  result  of  chronic  superficial 
glossitis,  or  of  a  preceding  gumma;  (r)  it  may  commence  as  a 
wart-like  growth,  the  base  of  which  becomes  infiltrated,  the 
tumour  invading  the  muscular  substance,  and  spreading  to  the 
root  of  the  tongue  ;  (d)  it  may  originate  as  a  submucous  infiltra- 
tion, starting  as  an  ingrowth  from  the  mucous  membrane,  with- 
out much  external  manifestation  of  its  presence ;  (e)  it  may  first 
be  noticed  as  an  irregular  ulcer  in  the  floor  of  the  mouth  ;  or  (/) 
it  may  spread  into  the  tongue  from  surrounding  parts,  such  as  the 
tonsil  or  larynx. 

In  whatever  way  it  starts,  the  same  features  are  soon  mani- 
fested, viz.,  a  new  growth  is  noticed,  hard  in  consistence,  in- 
definite in  its  extent,  which  may  or  may  not  be  painful  from  the 
first,  and  which  ulcerates  superficially,  exposing  a  more  or  less 
crateriform  cavity,   with  a  grey,  sloughy,   foul   surface,   readily 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  CESOPHAGUS     779 

bleeding  when  touched,  and  discharging  a  foul  secretion,  which 
causes  extreme  fcetor  of  the  breath.  The  ulcer  is  surrounded  by 
an  indurated  mass,  which  gradually  shelves  off  into  the  neigh- 
bouring healthy  structures,  or  may  be  abruptly  limited.  Profuse 
salivation  is  produced  by  the  irritation  of  the  branches  of  the 
third  division  of  the  trigeminal,  and  all  the  movements  of  the 
tongue  are  painful  and  limited  on  account  of  the  infiltration  of 
the  base,  so  that  both  swallowing  and  speech  are  difficult,  the 
patient  allowing  the  saliva  to  dribble  out  of  his  mouth.  The  pain 
is  often  very  excessive,  and  usually  extends  along  many  of  the 
branches  of  the  fifth  nerve,  especially  to  the  ear,  so  that  sleep 
become  impossible,  and  the  patient's  condition  steadily  and 
rapidly  deteriorates.  The  glands  under  the  chin  and  at  the 
angle  of  the  jaw  early  become  involved  in  the  disease,  which 
ultimately  attacks  the  glandulae  concatenatae.  These  secondary 
growths  are  very  frequently  cystic  in  character,  from  the  degenera- 
tion of  the  masses  of  epithelium  formed  within  them  ;  after  a  time 
they  approach  the  surface  and  burst,  leaving  ragged  malignant 
ulcers  in  the  neck.  The  lower  jaw,  moreover,  is  often  invaded  in 
the  later  stages  of  the  disease. 

The  occurrence  of  the  typical  cachexia  is  determined  not  only 
by  the  pain  and  consequent  sleeplessness,  but  also  by  the  inability 
to  take  sufficient  nourishment,  the  absorption  of  products  of 
putrefaction  swallowed  with  the  saliva,  the  excessive  salivation, 
the  occasional  haemorrhages,  and  the  extent  of  the  secondary 
growths.  The  patient  rarely  lasts,  apart  from  treatment,  for  more 
than  twelve  months  after  the  disease  has  been  first  noticed. 

Diagnosis. — When  a  case  is  met  with  where  the  ulcer  is  situated 
at  the  side  or  base  of  the  tongue  in  a  patient  over  forty-five  years 
of  age,  with  the  typical  enlargement  of  the  glands,  profuse  saliva- 
tion, and  impaired  movements,  there  can  be  little  doubt  as  to  the 
diagnosis.  But  when  it  is  seen  in  the  early  stage,  as  an  infiltration 
of  a  syphilitic  fissure  or  cicatrix,  or  as  a  small  wart,  it  may  be 
exceedingly  difficult  to  determine  whether  or  not  malignant  disease 
is  present.  The  early  enlargement  of  the  glands,  the  amount  and 
character  of  pain,  the  fixity  of  the  organ,  and  the  infiltration  of  the 
base  of  the  ulcer,  are  important  guiding  marks ;  but  in  doubtful 
cases  a  small  portion  of  the  growth  should  be  excised  under 
cocaine,  and  subjected  to  careful  microscopic  examination,  and 
thus  its  nature  ascertained.  Moreover,  the  administration  of 
steadily  increasing  doses  cf  iodide  of  potassium  will  generally 
bring  about  rapid  improvement  in  a  syphilitic  case,  but  will  do 
no  good  to  an  epithelioma,  except  perhaps  temporarily  when  the 
two  diseases  co-exist. 

Treatment.  —The  only  hope  of  curing  the  patient  lies  in  thorough 
and  early  removal  of  the  growth,  which  it  must  be  remembered, 
has  probably  extended  much  further  than  one  expects.     Hence, 


7S0  A  MANUAL  OF  SURGERY 

no  halt-measures  should  be  adopted,  but  complete  operations, 
including  also  the  lymphatic  area,  are  desirable. 

Ligature  of  the  lingual  artery  and  division  of  the  gustatory 
nerve  have  been  performed  in  cases  where  the  disease  had  pro- 
gressed too  far  to  attempt  radical  treatment,  with  the  double  object 
of  starving  the  growth  and  relieving  the  pain  ;  such,  however,  are 
of  little  value.  Dusting  the  surface  of  the  tumour  with  pyoktanin 
will  perhaps  give  the  most  relief  to  the  unfortunate  patient. 

Many  operations  for  removal  of  the  tongue  have  been  suggested 
and  practised  from  time  to  time,  the  majority  of  which  have,  how- 
ever, fallen  into  disuse,  and  will  not  even  be  noticed  here.  We 
shall  merely  indicate  the  chief  plans  of  treatment  adopted  at  the 
present  day.  For  practical  purposes,  the  cases  may  be  divided 
into  two  groups — those  in  which  the  disease  is  limited  to  one 
portion  of  the  tongue,  and  the  muscular  tissue  is  not  extensively 
invaded  ;  and  those  in  which  glands  or  other  structures  are  also 
obviously  involved,  or  the  tongue  itself  is  widely  infiltrated.  In 
the  first  class  of  cases  an  intrabuccal  operation  will  often  suffice, 
combined  with  separate  removal  of  the  glands  ;  in  the  second, 
more  extensive  extrabuccal  procedures  are  required. 

The  Intrabuccal  Method  now  adopted  for  partial  removal  of  the 
organ  is  that  known  as  Whitehead's  Operation.  The  lingual  artery 
should  always  be  previously  secured  in  the  neck  (p.  285),  thus 
giving  the  surgeon  an  opportunity  of  removing  the  submaxillary 
gland,  with  its  associated  lymphatics,  which  are  so  often  affected. 
The  mouth  is  then  well  opened  with  an  efficient  gag,  and  the 
chloroform  administered  by  means  of  Junker's  apparatus.  A 
good  assistant  is  necessary  in  order  to  prevent  blood  entering 
the  larynx,  small  pieces  of  sponge  held  in  smooth-nosed,  long- 
handled  forceps  being  used  to  clear  the  pharynx.  A  coarse  silk 
thread  is  passed  through  each  half  of  the  tongue  to  draw  it 
forwards  and  steady  it,  and  if  portions  of  both  sides  are  to  be 
removed,  a  silver  wire  or  silk  thread  should  in  addition  be  passed 
through  the  base  not  far  from  the  epiglottis  so  as  to  command 
the  stump.  The  essential  feature  of  the  operation  is  to  carefully 
snip  through  the  organ  little  by  little  by  means  of  long-handled, 
straight,  blunt-pointed  scissors,  picking  up  all  the  vessels  as  they 
are  divided,  and  by  this  means  the  loss  of  blood  is  reduced  to  a 
minimum.  The  modus  operandi  for  partial  removal  of  one-half  is 
as  follows :  The  tongue,  being  drawn  out  of  the  mouth  by  the 
two  anterior  loops  of  silk,  is  carefully  divided  down  the  middle  line 
into  two  segments,  which  are  readily  separated  from  one  another 
by  the  finger,  the  scissors  merely  dividing  the  mucous  membrane. 
The  base  of  the  organ  is  freed  by  cutting  through  the  line  of 
attachment  of  the  mucous  membrane  to  the  alveolus,  and  then 
along  the  middle  line  of  the  floor  of  the  mouth  to  the  tip  of  the 
tongue,  so  that  the  sublingual  salivary  gland  can  be  also  taken 
away — a  most  necessary  step.     The  mucous  lining  of  the  dorsum 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  CESOPHAGUS    781 


is  now  divided  transversely  behind  the  growth,  and  the  muscular 
structure  of  the  organ  slowly  snipped  through  with  scissors,  and 
during  the  process,  by  the  aid  of  the  finger  or  a  director,  the 
vessels  and  nerves  can  be  seen  and  recognised  before  division. 
Removal  of  the  diseased  half  with  the  sublingual  gland  is  thus 
easily  accomplished  by  making  the  incisions  meet,  and  dividing  the 
intervening  tissues. 

If  the  tip  is  alone  involved,  it  can  be  removed  by  a  V-shaped 
incision,  made  after  steadying  the  tongue  with  a  deep  suture.  The 
small  ranine  artery  will  spurt  on  each  side,  but  is  easily  secured, 
and  the  gap  closed  by  catgut  sutures. 

If  the  whole  tongue  is  to  be  excised,  or  even  when  one  side  alone 
needs  removal  as  far  back  as  the  epiglottis  or  hyoid  bone,  special 
precautions  have  to  be  taken  in  order  to  diminish  the  risk  of 
asphyxia  from  falling  back  of  the  stump  of  the  organ  after  the 
operation.  Thus,  a  thick  silver  wire  can  be  passed  deeply  through 
the  epiglottis,  by  means  of  which  it  is  drawn  forwards,  and  the  wire 
is  then  fixed  to  the  upper  lip  by  a  strip  of  gauze  and  collodion. 
The  objection  to  this  plan  is  the  patent  condition  of  the  glottis, 
into  which  septic  exudations  from  the  mouth  are  likely  to  run, 
probably  inducing  septic  pneumonia.  A  much  better  method  is 
that  which  has  been  introduced  and  largely  adopted  of  late,  viz., 
the  performance  of  a  preliminary  tracheotomy  in  order  to  allow  the 
pharynx  to  be  plugged.  A  Hahn's  trachea-tube  (i.e.,  a  large  one 
surrounded  with  compressed  sponge  infiltrated  with  iodoform, 
which  will  expand  and  absolutely  shut  off  the  lower  respiratory 
tract  from  the  mouth)  is  inserted,  or  a  Trendelenburg's  air- 
tampon  ;  or  an  ordinary  tube  may  be  employed  if  the  pharynx  is 
well  packed  with  a  sponge  so  as  to  prevent  blood  trickling  down- 
wards ;  the  anaesthetic  can  then  be  administered  through  the  tube. 
The  advantages  of  this  method  of  treatment  are  threefold  :  (a)  The 
patient  can  be  kept  in  a  condition  of  complete  anaesthesia  without 
hindrance  to  the  surgeon,  so  that  the  operation  is  more  quickly 
finished,  the  shock  is  less,  and  the  removal  of  the  disease  can  be 
more  thoroughly  accomplished  ;  (b)  the  patient  runs  no  danger  of 
asphyxia  during  the  operation  by  blood  trickling  into  the  lungs, 
or  by  fragments  of  tissue  or  sponge  getting  loose  in  the  mouth 
and  being  inhaled,  whilst  later  on  falling  back  of  the  root  of  the 
tongue  does  no  harm  ;  and  (c)  the  chances  of  septic  pneumonia 
are  reduced  to  a  minimum.  Of  course,  opening  the  trachea  is 
not  entirely  devoid  of  danger,  and  therefore  this  plan  should  not 
be  adopted  except  where  extensive  dissections  are  called  for,  and 
then  may  be  undertaken  with  advantage  a  few  days  previously. 
At  the  time  of  operation  the  pharynx  is  firmly  packed  with  a 
sponge. 

Where  the  jaw,  floor  of  the  mouth,  or  glands  in  the  neck  are 
much  implicated,  or  the  tongue  substance  itself  extensively 
infiltrated,  an  Extrabuccal  Operation  is  necessary ;    and   of  the 


782  A   MANUAL  OF  SURGERY 


many  plans  that  have  been  recommended,  we  consider  Kochers 
Operation,  or  some  modification  of  it,  by  far  the  best.  The 
incision  (Fig.  271  C),  commencing  close  to  the  lobule  of  the  ear, 
runs  down  along  the  anterior  border  of  the  sterno-mastoid  to  the 
great  cornu  of  the  hyoid  bone,  and  thence  forwards  nearly  to  the 
middle  line,  and  upwards  to  the  symphysis.  This  flap  of  skin 
and  subcutaneous  tissue  is  dissected  up,  and  stitched  to  the  cheek 
out  of  harm's  way.  If  part  of  the  jaw  also  needs  removal,  the 
incision  may  have  to  extend  through  the  lower  lip,  and  the  flap  is 
then  turned  outwards  and  backwards  so  as  to  expose  the  bone. 
All  the  lymphatic  glands  in  the  region — the  submental,  sub- 
maxillary, and  those  lying  over  the  carotid — are  now  removed, 
as  well  as  the  submaxillary  salivary  gland,  the  lingual  and  facial 
arteries  being  tied  close  to  the  carotid.  Any  diseased  portion  of 
the  jaw  is  isolated  by  saw-cuts  in  front  and  behind,  and  may 
be  removed  at  once  if  desirable,  or  left  in  situ  and  taken  away 
with  the  disease  ;  but,  as  already  mentioned,  it  is  always  well,  if 
possible,  to  leave  a  bridge  of  bone  to  maintain  the  continuity  of 
the  mandible.  Where  only  half  the  tongue  is  to  be  removed,  it 
is  now  split  down  the  middle  line  with  scissors,  and  the  mucous 
membrane  in  the  floor  and  side  of  the  mouth  divided  so  as  to 
leave  that  side  of  the  tongue  attached  merely  by  the  muscular 
structures,  which  are  snipped  through  with  scissors,  any  bleeding 
points  being  secured  as  divided.  If  the  whole  organ  is  to  be 
removed,  it  is  unnecssary  to  divide  it  in  the  middle  line.  If  the 
jaw  is  healthy,  the  reflection  of  mucous  membrane  is  incised  close 
to  the  alveolus,  so  that,  by  detaching  the  mylo-hyoid  from  the 
bone,  a  communication  is  made  between  the  outside  wound  and 
the  mouth,  and  the  tongue  is  then  drawn  through  this  lateral 
opening,  and  removed  close  to  the  epiglottis  behind,  and  close  to 
the  hyoid  bone  below,  the  whole  floor  of  the  mouth  being  effectu- 
ally dealt  with  in  this  way. 

The  raw  surface  is  painted  with  Whitehead's  varnish  (which 
consists  of  Friar's  balsam,  but  with  the  rectified  spirit  replaced 
by  a  saturated  solution  of  iodoform  in  ether),  and,  where  trache- 
otomy has  been  performed,  the  mouth  is  plugged  with  aseptic 
gauze. 

The  external  incision  is  closed  by  a  continuous  suture,  a  large 
drain-tube  being  inserted  at  the  lowest  point  for  a  few  days.  No 
attempt  is  made  to  keep  the  base  of  the  tongue  forwards,  and,  in 
fact,  it  is  better  that  it  should  fall  back  so  as  to  close,  the  opening 
of  the  glottis,  and  so  prevent  septic  saliva  from  entering  the  air- 
passages  ;  it  will  be  subsequently  drawn  forwards  again  by  the 
process  of  cicatrization  of  the  wound  in  the  floor  of  the  mouth. 
The  plug  of  gauze  may  be  removed  in  twenty-four  hours,  and 
replaced  or  not  at  the  discretion  of  the  surgeon.  The  mouth 
must  be  freely  and  frequently  washed  out  with  some  unirritating 
antiseptic  lotion,  e.g.,  sanitas  (1  in   10),  boroglyceride  (1  in  20), 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  CESOPHAGUS   783 


boric  acid  (to  grains  to  1  ounce),  or  a  weak  solution  of  Condy's 
fluid.  If  all  goes  well,  a  smaller  size  of  Hahn's  tracheotomy-tube 
is  inserted  on  the  second  day,  an  ordinary  tube  on  the  fifth  or 
sixth,  and  even  this  is  removed  in  seven  to  ten  days.  The  patient 
is  fed  per  rectum  for  twenty-four  hours,  but  afterwards  a  tube 
attached  to  the  spout  of  a  feeder  is  introduced  into  the  pharynx 
or  oesophagus.  In  the  simpler  cases  he  is  able  to  swallow  freely 
and  without  difficulty  in  the  course  of  a  day  or  two,  and  even  in 
the  worst  cases  he  can  feed  himself  with  a  long  tube  passed  into 
the  pharynx  in  five  or  six  days.  Where  no  tracheotomy  has 
been  performed,  the  greatest  care  and  watchfulness  will  be  re- 
quired to  prevent  the  stump  of  the  tongue  falling  back  and  produc- 
ing asphyxia  ;  the  mouth  and  pharynx  must  be  constantly  cleansed, 
to  diminish  as  far  as  possible  the  risk  of  septic  pneumonia. 

This  operation  is  certainly  the  most  successful  of  any  for  exten- 
sive disease,  and  the  immediate  results  are  satisfactory ;  but 
necessarily  where  the  disease  is  so  widely  diffused  as  to  need 
such  a  severe  procedure,  a  considerable  percentage  of  the  cases 
will  suffer  from  recurrence. 

The  great  danger  of  the  operation — septic  pneumonia — is  best 
combated  by  carefully  cleansing  the  mouth  and  teeth  previously 
with  antiseptics,  by  a  preliminary  tracheotomy,  and  efficient 
plugging  of  the  pharynx.  Secondary  haemorrhage  is  occasionally 
met  with,  but  probably  only  when  the  patient  is  very  exhausted 
at  the  time  of  the  operation,  and  where  the  mouth  is  not  well 
irrigated  subsequently  ;  the  bleeding  vessel  should  be  again  tied 
on  the  face  of  the  stump,  or  in  the  neck  if  such  has  not  already 
been  undertaken  ;  failing  this,  one  must  depend  on  the  application 
of  perchloride  of  iron  or  the  actual  cautery.  Antistreptococcic 
serum  may  also  be  utilized  as  a  preliminary  measure  in  order  to 
prevent  the  occurrence  of  septic  troubles  ;  three  or  four  injections 
of  10  c.c.  each  are  made  on  the  day  preceding  the  operation,  and 
perhaps  one  or  two  afterwards.  The  results  obtained  in  this  way 
have  been  satisfactory. 

Kocher's  lines  of  incision  may  be  modified  according  to  circum- 
stances, provided  that  the  essential  principles  are  kept  in  view, 
viz.,  the  complete  removal  of  the  primary  disease  and  of  the 
infected  glands,  and  the  provision  of  effective  drainage. 

The  removal  of  a  part,  or  even  the  whole,  of  the  tongue  is  not 
such  a  mutilation  physiologically  as  one  might  expect  at  first. 
Deglutition  is  interfered  with  for  a  time,  but  the  power  is  soon 
regained,  and  even  articulation  may  be  in  great  measure  restored. 

Affections  of  the  Floor  of  the  Mouth. 

Sublingual  Abscess,  when  acute,  is  due  to  infection  of  the  sub- 
mucous tissue,  as  by  puncture  with  a  fishbone,  or  starts  in  a  fol- 
licle of  the  sublingual  or  in  a  submucous  gland.    The  inflammation 


784  A  MANUAL  OF  SURGERY 


which  follows  results  in  the  formation  of  a  puffy  swelling  beneath 
the  tongue,  which,  if  not  opened  early,  may  lead  to  an  extension 
downwards  of  the  mischief  into  the  submental  region.  The  tongue 
becomes  swollen  and  turgid  from  pressure  upon  the  veins,  whilst 
oedematous  laryngitis  may  also  be  induced.  Considerable  con- 
stitutional disturbance  generally  accompanies  this  process.  A 
median  incision  through  the  mucous  membrane,  and  the  insertion 
and  opening  of  a  pair  of  dressing  forceps,  is  the  safest  and  best 
method  of  treatment,  the  cavity  being  subsequently  washed  out 
and  drained.  The  more  diffuse  form  of  sublingual  abscess  is 
usually  associated  with  submaxillary  cellulitis  (p.  93). 

The  sublingual  region  is  also  a  favourite  site  for  Actinomycosis 
(p.  148),  which  manifests  itself  as  a  diffuse  brawny  induration  of 
the  tissues,  progressing  slowly,  and  not  very  tender.  As  it  comes 
to  the  surface,  the  skin  becomes  red  and  dusky,  and  sooner  or 
later  a  series  of  little  pustules  appear  one  after  another  with  a 
typical  yellowish  apex.  These  burst  and  discharge  a  glutinous 
fluid  containing  the  fungus,  and  if  kept  aseptic  and  allowed  to 
heal,  are  followed  by  depressed  and  puckered  cicatrices.  The 
administration  of  gradually  increasing  doses  of  iodide  of  potassium 
usually  suffices  to  bring  about  a  cure. 

Cystic  Swellings  are  not  uncommon  about  the  floor  of  the 
mouth,  and  amongst  them  the  following  may  be  described  : 

(a)  Mucous  Cysts  result  from  the  distension  of  mucous  glands  ; 
they  form  small  translucent  swellings,  elastic  and  fluctuating. 
All  that  is  needed  is  to  open  them,  and  remove  the  anterior  wall. 

(h)  Ranula  is  a  very  similar  condition,  but  larger  and  unilateral, 
containing  a  glairy  mucoid  fluid,  and  due  to  obstruction  and  dis- 
tension of  one  of  the  sublingual  ducts  (or  ducts  of  Rivini).  A 
similar  condition  has  been  caused  in  rare  cases  by  a  blocking  of 
Wharton's  duct,  but  this  has  generally  been  found  to  run  along 
the  outer  surface  of  the  cyst.  The  tumour  may  be  as  large  as  a 
walnut  or  pigeon's  egg.  The  treatment  consists  in  removing  a 
good-sized  piece  of  the  wall  so  that  the  cavity  may  be  obliterated 
by  a  process  of  granulation,  or  if  that  should  fail,  the  whole  cavity 
must  be  dissected  out. 

(c)  Dermoid  Cysts  are  frequently  met  with  in  the  floor  of  the 
mouth,  occupying  the  middle  line,  and  also  projecting  into  the 
neck  beneath  the  chin.  They  are  due  to  non-obliteration  of 
the  upper  end  of  the  thyro-glossal  canal  (p.  823).  The  contents 
are  of  the  usual  sebaceous  type.  Such  tumours  should  never  be 
dealt  with  from  the  mouth,  as  they  extend  deeply,  and  need  to  be 
carefully  dissected  out.  A  free  opening  must  be  made  in  the 
middle  line  under  the  chin,  and,  if  feasible,  the  whole  cyst 
removed  unopened.  If  it  gives  way,  the  entire  wall  must  be 
dealt  with,  or  recurrence  will  certainly  ensue. 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  OESOPHAGUS  785 


Affections  of  the  Salivary  Glands. 

Inflammation  of  the  Parotid  Gland  is  met  with  in  several  different 
forms. 

1.  Epidemic  Parotitis  (Mumps)  is  an  acute  specific  disease, 
usually  seen  in  children,  highly  infectious  in  character,  and 
generally  epidemic.  The  period  of  incubation  is  about  three 
weeks,  and  the  attack  itself  consists  in  a  slight  febrile  dis- 
turbance, associated  with  swelling  of  one  or  both  parotid  glands  ; 
one  gland  is  attacked  first,  becoming  enlarged  and  tender,  whilst 
the  other  side  is  similarly  affected  in  a  day  or  two.  Mastication 
becomes  difficult,  owing  to  the  tension  of  the  parts.  The  swelling, 
which  lasts  for  about  a  week  and  then  gradually  subsides,  extends 
below  and  in  front  of  the  ear,  and  the  socia  parotidis  can  be 
distinctly  felt  lying  over  the  masseter ;  the  submaxillary,  sub- 
lingual, and  neighbouring  lymphatic  glands  are  sometimes,  but 
not  frequently,  enlarged.  Suppuration  is  rare,  but  in  adults 
metastatic  inflammation  of  the  testes,  mammae,  or  ovaries  is  not 
uncommon.  This  complication  is  generally  unilateral,  and  thus, 
although  atrophy  of  the  testis  commonly  follows  orchitis,  sterility 
is  not  produced.  Treatment. — Keep  the  patient  warm  and  quiet, 
and  administer  salines.  In  the  later  stages  friction  with  stimu- 
lating liniments  will  hasten  resolution.  After  the  acute  attack, 
the  gland  may  remain  enlarged  for  some  time. 

2.  A  Simple  Parotitis  occasionally  results  from  exposure  to  co'.d 
or  from  injury,  whilst  the  presence  of  a  calculus  in  the  duct  leads 
to  a  chronic  sclerosing  inflammation.  The  symptoms  consist  of 
pain  and  swelling,  together  with  a  certain  amount  of  constitutional 
disturbance.  An  extremely  interesting  phenomenon  is  the  paro- 
titis which  follows  injuries  or  diseases  of  the  abdominal  or  pelvic 
viscera.  This  condition  is  not  very  unusual,  as  is  evident  by  the 
fact  that  Stephen  Paget  has  been  able  to  collect  101  such  cases. 
It  was  formerly  attributed  to  pyaemia,  but  is  now  considered  to 
be  due  to  infection  of  a  mild  type  from  the  mouth,  owing  to  a 
septic  state  of  the  teeth  induced  by  prolonged  rectal  feeding.  In 
confirmation  of  this  view  is  the  fact  that  it  has  been  seen  in  not  a 
few  cases  of  gastric  ulcer,  where  the  patient  had  to  be  fed  per 
rectum  for  some  time.  Treatment  in  these  simple  cases  consists  in 
the  application  of  fomentations,  perhaps  medicated  with  bella- 
donna. 

3.  Suppurative  Parotitis  is  a  much  more  serious  condition.  It 
may  extend  from  the  mouth  along  Stenson's  duct,  or  supervene  in 
the  course  of  pyaemia,  or  as  a  sequela  of  some  of  the  exanthemata, 
e.g.,  scarlet  or  typhoid  fevers.  If  the  inflammation  spreads  up 
from  the  mouth,  suppuration  occurs  primarily  within  the  tubules  ; 
under  other  circumstances,  pus  forms  in  the  interstitial  tissues. 
The  gland  becomes  much  enlarged,  with  congestion  and  oedema 
of  the   overlying  skin,  and,  owing   to   the  tension  of   the  fascia, 

5° 


786  A   MANUAL  OF  SURGERY 


exceedingly  painful.  For  the  same  reason,  pus  cannot  readily 
find  its  way  to  the  surface,  and  hence  is  likely  to  burrow  in  various 
directions,  e.g.,  amongst  the  muscles  of  the  neck,  or  even  upwards 
and  inwards  towards  the  base  of  the  skull,  or  to  the  cavity  of  the 
mouth,  finding  its  way  over  the  border  of  the  superior  constrictor 
(the  so-called  '  sinus  of  Morgagni ').  The  constitutional  symptoms 
from  toxic  absorption  are  usually  very  severe.  Owing  to  the 
fact  that  large  veins  and  arteries  pass  through  the  parotid  gland, 
pyaemic  symptoms  are  not  unlikely  to  supervene,  and  the  prog- 
nosis is  therefore  somewhat  serious. 

Diagnosis. — Inflammation  of  the  lymphatic  glands  lying  on  the 
outer  surface  of  the  parotid  closely  simulates  the  above  affections, 
but  is  distinguished  from  them  by  the  fact  that  they  are  more 
superficial,  and  that  the  socia  parotidis  is  not  enlarged. 

Treatment. — In  the  early  stages  fomentations  are  employed,  but 
as  soon  as  there  is  any  indication  that  suppuration  has  occurred, 
a  free  incision  must  be  made,  and  the  pus  let  out.  Every  precau- 
tion should  be  taken  to  prevent  mischief  to  the  facial  nerve,  and 
Hilton's  method  of  operating  maybe  advantageously  employed ; 
but  in  the  more  severe  cases  where  the  patient's  life  is  threatened 
and  the  pus  is  burrowing  in  all  directions,  the  knife  must  be  freely 
used  regardless  of  anatomical  considerations. 

Inflammation  of  the  submaxillary  and  sublingual  glands  may 
arise  in  an  exactly  similar  way,  but  no  special  description  is  called 
for.  Occasionally,  however,  the  process  extends  beyond  the  sub- 
maxillary gland  to  the  neighbouring  tissues,  giving  rise  to  what 
has  already  been  described  as  submaxillary  cellulitis,  or  Ludwig's 
angina  (p.  93). 

Obstruction  to  the  Flow  of  Saliva  results  from  various  causes, 
such  as  cicatricial  contraction  in  the  neighbourhood  of  the  entrance 
of  the  ducts  into  the  mouth,  or  from  the  presence  of  a  salivary 
calculus,  consisting  of  phosphate  and  carbonate  of  lime,  and  usually 
fusiform  in  shape. 

The  chief  Symptom  of  such  obstruction  is  a  painful  enlargement 
of  the  gland  during  and  after  meals,  which  slowly  passes  away  as 
the  saliva  finds  its  way  past  the  block ;  if  it  persists  for  long,  the 
gland  becomes  chronically  enlarged,  and  its  interstitial  tissue 
increased  in  bulk,  whilst  a  certain  amount  of  peri-adenitis  also 
follows.  When  a  calculus  is  present,  there  is  usually  a  consider- 
able discharge  of  offensive  muco-pus  into  the  mouth.  Where  the 
obstruction  is  complete,  a  cyst  may  form,  and  if  this  is  opened,  or 
finds  its  way  to  the  exterior  and  bursts,  a  salivary  fistula  results. 
The  formation  of  salivary  calculi  is  not  very  common  in  con- 
nection with  the  parotid  gland,  owing  to  the  fact  that  the  saliva 
excreted  is  limpid  in  character,  whereas  that  arising  from  the 
submaxillary  and  sublingual  glands  is  thick  and  mucoid. 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS    787 


Treatment. — In  cases  of  simple  obstruction,  an  attempt  must 
be  made  to  restore  the  natural  exit,  or  to  make  an  artificial  one. 
If  a  calculus  is  present,  it  can  usually  be  seen  or  felt  at  intervals 
projecting  from  the  entrance  of  the  duct ;  in  such  a  case  the  duct 
must  be  incised,  and  the  stone  removed.  Where,  however,  it  is 
located  in  the  substance  of  the  submaxillary,  total  removal  of  the 
gland  may  be  necessary. 

Tumours  of  the  Parotid  Gland  are  of  considerable  interest,  and 
may  be  simple  or  malignant. 

(a)  The  Simple  parotid  tumour  consists  of  a  growth  starting 
in  the  capsule  or  interstitial  tissue  of  the  superficial  part  of  the 
gland  ;  it  contains  nodules  of  cartilage  mixed  with  fibrous  and 
mucous  tissue,  whilst  some- 
times glandular  elements 
similar  to  those  met  with 
in  the  parotid  are  scattered 
through  the  mass.  It  has 
been  already  mentioned  that 
the  cartilaginous  elements 
are  probably  due  to  the 
persistence  of  remnants  of 
the  embryonic  Meckel's  car- 
tilage. The  tumour  feels 
hard,  firm,  and  nodular,  but 
where  there  is  much  myxo- 
matous tissue,  areas  of 
softening  may  be  inter- 
spersed amongst  the  harder 
portions.  The  mass  is 
situated  between  the  jaw 
and  the  sterno-mastoid,  ac- 
cessory processes  also  ex- 
tending over  the  masseter 
in  the  region  of  the  socia, 
and  later  on  burrowing 
deeply  between  the  mastoid 
bone  and  the  styloid  pro- 
cess, and  beneath  the  ramus  of  the  jaw  (Fig.  282).  In  the  early 
stages  the  tumour  is  freely  moveable  on  the  deeper  parts,  as  is 
also  the  skin  over  it,  but  subsequently  the  mass  becomes  fixed 
and  adherent.  The  growth  is  usually  slow,  and  at  first  quite 
painless,  and  there  is  no  tendency  to  invade  lymphatic  glands  or 
produce  cachexia.  Mastication  is  impaired  in  the  later  stages, 
but  otherwise  the  subjective  symptoms  are  of  but  slight  impor- 
tance, owing  to  the  fact  that  the  growth  is  superficial  to  the  gland, 
and  to   the    more   important    vessels   and  nerves.     The    simple 

50—2 


Fig. 


282. — Parotid  Tumour. 
(Fergusson.) 


788  A   MANUAL  OF  SURGERY 


tumour,  if  allowed  to  persist,  is  not  an   uncommon  precursor  of 
malignant  disease. 

(b)  Malignant  tumours  of  the  parotid  occur  in  the  form  of  endo- 
thelioma, sarcoma,  or  carcinoma,  and  are  not  unfrequently  grafted 
on  to  a  simple  tumour,  the  change  of  type  being  maiked  by 
increased  rapidity  of  growth  and  greater  pain.  The  mass  be- 
comes more  fixed,  and  signs  of  pressure  upon  the  vessels  and 
nerves  develop ;  the  facial  nerve  is  very  likely  to  be  implicated, 
leading  to  paralysis  of  the  face.  Moreover,  the  skin  becomes 
hyperaemic  and  often  adherent  to  the  tumour,  and  finally  ulcera- 
tion and  even  fungation  may  obtain.  Secondary  deposits  occur 
in  the  neighbouring  lymphatic  glands  or  in  the  viscera,  and  the 
patient  soon  passes  into  a  state  of  malignant  cachexia.  Carcino- 
matous tumours  are  less  common  than  the  sarcomata,  but  run  a 
similar  course.  The  growth  is  an  adenoid  cancer,  not  unfre- 
quently of  the  soft  or  encephaloid  type,  and  neighbouring  lym- 
phatic glands  are  early  invaded. 

The  Diagnosis  of  simple  parotid  tumours  from  malignant 
growths  is  a  matter  of  the  greatest  importance  from  a  prognostic 
point  of  view,  since  simple  tumours  are  distinctly  encapsuled, 
and  their  removal,  except  in  extreme  cases,  is  not  a  matter  of 
special  difficulty  ;  malignant  disease  is  much  more  diffuse,  render- 
ing complete  extirpation  of  the  mass  almost  impracticable.  The 
distinction  between  the  two  forms  is  made  by  a  consideration 
of  the  signs  and  symptoms  considered  above,  attention  being 
directed  to  the  rate  of  growth,  the  condition  of  the  skin  and 
surrounding  parts,  the  mobility  or  not  of  the  neoplasm,  and  the 
general  aspect  of  the  patient,  whilst  associated  paralysis  of  the 
facial  nerve  is  almost  always  characteristic  of  malignancy.  The 
lymphatic  glands  lying  on  the  surface  of  the  parotid,  when 
invaded  by  tubercle  or  by  epithelioma  secondary  to  some  intra- 
buccal  growth,  may  closely  simulate  a  true  parotid  tumour,  but 
are  recognised  by  their  more  superficial  position. 

The  Treatment  is  often  a  matter  of  some  difficulty,  owing  to 
the  important  character  of  the  surrounding  tissues.  Removal 
should  only  be  attempted  if  the  skin  is  not  extensively  involved, 
if  the  growth  is  moveable  on  the  deeper  parts,  and  if  there  is  no 
evidence  of  secondary  deposits.  Even  simple  tumours  become 
irremoveable  after  a  time  on  account  of  their  deep  connections  and 
change  of  type,  whilst  it  is  seldom  justifiable  to  touch  malignant 
growths  on  account  of  their  early  and  wide  dissemination.  Simple 
parotid  tumours  are  dealt  with  either  by  making  a  vertical 
incision  over  the  most  prominent  part  of  the  mass,  or  by  turning 
forwards  a  flap,  exposing  thereby  the  capsule,  which  is  incised 
transversely ;  for  although  the  facial  nerve  is  generally  beneath 
the  growth,  it  occasionally  runs  superficial  to  it,  or  in  its  sub- 
stance. After  this  has  been  accomplished,  the  tumour  is  often 
enucleated  without  much  difficulty,  but  the  surgeon  must  make 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  OESOPHAGUS     789 


certain  that  no  deeper  processes  are  left,  or  recurrence  will 
inevitably  follow.  The  haemorrhage  from  the  transverse  facial 
and  other  arteries  is  free,  but  easily  restrained.  There  is  no 
need  to  remove  redundant  skin  in  these  cases,  as  it  quickly 
contracts. 

In  dealing  with  early  malignant  disease  excision  of  the  whole 
parotid  gland  may  be  occasionally  undertaken.  It  is  accomplished 
through  a  vertical  incision,  or,  if  the  skin  is  involved,  by  two 
crescentic  ones.  The  gland  is  then  gradually  freed  from  its 
connections,  care  being  taken,  if  possible,  to  keep  outside  its 
capsule.  It  is  best  to  deal  with  the  lower  part  first,  securing 
with  double  ligatures  the  external  carotid  artery  and  temporo- 
facial  vein.  The  mass  is  then 
drawn  upwards  and  forwards,  and 
its  deep  connections  severed.  The 
facial  nerve  is,  of  course,  divided, 
and  the  patient  must  be  warned 
before  the  operation  of  the  neces- 
sarily resulting  facial  palsy.  Re- 
currence is  almost  certain  to  follow. 
Removal  of  the  angle  of  the  jaw  as 
a  preliminary  step  has  been  recom- 
mended, since  considerable  space 
is  gained  thereby,  and  a  better 
access  to  the  field  of  operation. 

Tumours  of  the  Submaxillary 
Gland  are  very  similar  in  nature 
to  those  of  the  parotid.  Simple 
tumours  are  represented  by  chon- 
dromata,  which  in  this  position  are 
almost  always  pure  and  without 
admixture  of  myxoma  (Fig.  283). 

Sarcoma  and  carcinoma  are  also  met  with  ;  if  seen  in  the  early 
stages  they  are  easily  removed. 

Salivary  Fistula  occurs  almost  solely  in  connection  with  the 
parotid  gland.  It  arises  from  penetrating  wounds  of  the  cheek 
dividing  Stenson's  duct,  or  more  frequently  it  follows  operations 
in  its  neighbourhood.  It  is  a  very  troublesome  condition,  both 
for  the  surgeon  who  is  called  upon  to  treat  it,  and  for  the  patient 
who  suffers  from  the  inconvenience  of  saliva  flowing  down  the 
cheek,  the  amount  being,  of  course,  increased  at  meal-times. 
Stenson's  duct  extends  forwards  from  the  socia  parotidis  across 
the  masseter  muscle  for  a  distance  of  about  2  inches,  and  then 
turns  abruptly  inwards  to  pierce  the  buccinator,  and  enter  the 
mouth  opposite  the  second  upper  molar  tooth.  The  buccal 
and  masseteric  portions  are  almost  at  right  angles,  the  latter 
being  represented  by  a  line  drawn  from  the  lobule  of  the  ear 
to   a  point   midway   between   the  ala  nasi  and  the  angle  of  the 


Fig.  283. — Submaxillary 

(TlLLMAN.NS.) 


Tumour. 


790  A  MANUAL  OF  SURGERY 


mouth.     The  diameter  of  the  duct  is  about  one-eighth  of  an  inch, 
its  narrowest  portion  being  at  the  orifice. 

Treatment. — If  the  buccal  portion  is  involved,  a  cure  is  often 
attained  by  slitting  up  the  duct  within  the  mouth  ;  but  when  the 
masseteric  portion  is  wounded,  and  especially  if  near  the  socia 
parotidis,  treatment  becomes  more  difficult.  We  have  several 
times  found  the  following  plan  successful :  A  fine  probe  is  passed 
along  the  duct  from  the  mouth  as  far  as  the  lesion  ;  it  is  then 
grasped  by  forceps  inserted  through  the  external  aperture,  and 
drawn  out  on  to  the  cheek,  a  proceeding  sometimes  facilitated  by 
slightly  enlarging  the  wound.  A  double  thread  of  silk  is  now 
tied  to  the  end  of  the  probe,  and  drawn  through  the  thickness  of 
the  cheek,  along  the  buccal  portion  of  the  duct,  and  out  of  the 
external  wound.  A  fine  drainage-tube  is  then  carried  along  the 
same  track,  and  left  so  as  to  project  both  externally  and  internally, 
A  silk  thread  is  attached  to  each  end  of  the  tube,  and  these  are 
knotted  together  round  the  angle  of  the  mouth.  By  this  means 
a  passage  is  re-established  into  the  mouth,  and  as  soon  as  it 
becomes  easier  for  the  saliva  to  travel  along  this  than  along  the 
external  wound,  the  fistula  will  close.  At  the  end  of  a  few  days 
the  outer  half  of  the  tube  is  removed,  and  only  a  silk  thread 
allowed  to  occupy  the  outer  portion  of  the  fistula,  which  gradually 
contracts  so  that  more  and  more  of  the  saliva  finds  its  way  into 
the  mouth.  The  silk  thread  and  tube  are  then  finally  removed, 
and  if  the  opening  in  the  mouth  is  kept  patent,  the  external  wound 
soon  heals.  In  those  cases  where  the  buccal  portion  of  the  duct 
is  completely  obliterated  or  obstructed  so  that  a  probe  cannot  be 
passed,  a  trocar  and  cannula  are  inserted  through  the  external 
wound  and  cheek  into  the  mouth  ;  a  silk  thread  is  insinuated 
through  the  cannula,  and  a  tube  drawn  into  position,  as  in  the 
former  case.  The  subsequent  treatment  is  the  same  as  that 
indicated  above. 

Affections  of  the  Palate. 

Cleft  Palate. — By  cleft  palate  is  meant  a  congenital  defect  of 
the  roof  of  the  mouth,  whereby  the  structures  entering  into  its 
formation  do  not  unite  in  the  middle  line,  thus  allowing  an 
abnormal  communication  to  exist  between  the  nose  and  mouth. 
The  term  does  not  include  losses  of  substance,  resulting  from 
injury,  syphilis,  or  lupus.  The  cleft  usually  starts  posteriorly, 
and  extends  forwards  for  a  variable  distance,  although  it  has 
been  known  to  be  limited  to  the  anterior  portion  of  the  palate 
and  bony  alveolus,  but  only  in  exceedingly  rare  instances.  The 
mildest  cases  consist  merely  of  a  bifid  uvula,  perhaps  not  involving 
the  palate  at  all ;  the  next  degree  of  severity  affects  the  velum 
alone ;  more  or  less  of  the  hard  palate  may  also  be  implicated, 
the  cleft  reaching  as  far  forwards  as  the  site  of  the  anterior  palatine 
canal  (Fig.  284,  B) ;  whilst  the  severest  type  of  the  deformity 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  OESOPHAGUS     791 


extends  in  addition  through  the  alveolus  and  upper  lip  on  one  or 
both  sides,  the  os  incisivum  being  in  the  latter  case  displaced 
forwards,  perhaps  on  the  tip  of  the  nose  (Fig.  284,  C). 

On  looking  carefully  at  a  cleft  palate  the  defect  usually  appears 


Fig.  284. — Various  Forms  of  Cleft  Palate;  A,  involving  merely  the 
Velum  ;  B,  traversing  the  Hard  Palate  as  far  forwards  as  the 
Anterior  Palatine  Canal;  and  C,  being  Complicated  with  a  Double 
Hare-lip. 

to  be  mesial,  but  occasionally  it  seems  as  if  a  unilateral  or 
bilateral  fissure  existed.  To  understand  such  an  occurrence  it 
must  be  remembered  that  three  bony  processes  unite  in  the 
middle  line  of  the  roof  of  the  mouth,  viz.,  the  two  palatal  pro- 


A  B  C 

Fig.  285. — Diagram  to  Show  the  Modifications  of  Cleft  Palath. 

a,  Ethmo-vomerine  septum  ;  h,  pa'atal  segments;  c,  tongue  ;  d,  cavity 
of  the  nose  ;  e,  buccal  cavity. 

cesses  growing  in  horizontally  from  the  maxillae,  one  on  each  side, 
and  the  ethmo-vomerine  septum  projecting  vertically  downwards 
from  the  under  surface  of  the  fronto- nasal  process  and  base  of  the 
skull.  All  these  should  amicably  join  together  about  the  ninth 
or  tenth  week  of  intra-uterine  life.  If,  however,  the  palatal  pro- 
cesses  fail    to   reach   the   middle   line,   a   median   defect   appears 


792  A   MANUAL  OF  SURGERY 


(Fig.  285,  A),  unless  the  ethmo-vomerine  septum  be  so  hyper- 
trophied  as  to  project  between  them,  when  the  appearance  of  a 
double  cleft  is  produced  (Fig.  285,  B).  When  one  division  of 
the  palate  unites  with  the  mesial  septum,  the  other  failing  to 
reach  it,  an  apparently  unilateral  cleft  results  ;  most  commonly 
the  defect  is  on  the  left  side,  the  vomer  being  attached  to  the 
right  free  edge,  a  left-sided  alveolar  hare-lip  also  complicating 
the  case  (Fig.  285,  C).  The  reason  why  the  anterior  portion  of 
the  palate  is  so  rarely  affected  without  the  posterior  part  being 
also  involved  is  that  the  union  of  the  various  segments  progresses 
from  before  backwards. 

The  width  of  the  cleft  and  the  slope  of  the  segments  varies 
greatly  in  different  cases.  The  wider  the  cleft,  the  more  un- 
favourable it  is  for  treatment  by  operative  means  ;  and  this  is  one 
of  the  arguments  used  in  favour  of  the  removal  of  the  intermaxilla 
in  cases  of  double  hare-lip,  so  as  to  allow  of  the  approximation  of 
the  two  maxillae.  Remove  it,  they  fall  naturally  together ;  leave 
it,  and  they  are  wedged  permanently  apart.  As  tc  the  slope  of 
the  segments,  the  more  vertical  they  are,  the  more  favourable  for 
operation,  since  the  flaps  of  muco-periosteum  easily  meet  in  the 
middle  line.  When  the  palate  is  more  horizontal,  and  like  a 
Norman  rather  than  a  Gothic  arch,  the  flaps  are  shorter,  and 
greater  lateral  displacement  is  necessary  to  bring  their  edges  into 
apposition  ;  this  involves  much  more  traction  on  the  stitches,  and 
hence  less  satisfactory  results. 

The  effect  of  such  a  deformity  upon  the  infant,  from  a  physio- 
logical point  of  view,  is  very  serious.  The  process  of  nutrition  is 
considerably  impaired,  owing  to  the  fact  that  the  power  of  suction 
is  lost,  and  fluids  taken  into  the  mouth  are  apt  to  escape  through 
the  nostrils  instead  of  being  swallowed.  Consequently  these 
children  must  be  carefully  spoon-fed  with  the  head  thrown  well 
back,  otherwise  they  become  emaciated  and  succumb  to  inanition 
or  intercurrent  maladies.  If  they  grow  up,  articulation  becomes  so 
indistinct  that  it  is  often  impossible  to  understand  what  they  say, 
the  voice  having  a  peculiar  and  characteristic  intonation.  All  the 
letters  known  as  explosives,  whether  dentals,  labials,  or  gutturals, 
requiring  a  certain  amount  of  air-pressure  within  the  mouth  for 
their  due  pronunciation,  are  difficult  to  produce,  particularly  b,  d, 
p,  t,  g,  f,  etc.  Moreover,  the  exposure  of  the  nasal  mucous  mem- 
brane to  the  air  is  so  much  greater  than  usual  that  it  is  liable  to 
catarrhal  inflammation,  resulting  in  the  formation  of  scabs  which 
undergo  putrefactive  changes  and  lead  to  a  sort  of  ozaena.  Both 
taste  and  smell  are  much  diminished,  partly  from  the  unhealthy 
state  of  the  mucous  membrane,  and  also  from  the  absence  of  an 
opposing  surface  against  which  the  food  can  be  triturated  by  the 
tongue.  The  moral  effect  of  this  deformity,  particularly  when 
associated  with  hare-lip,  is  such  as  to  cause  such  patients  to  shun 
publicity  from  a  nervous  feeling  of  self-consciousness. 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS  79;, 


As  to  the  best  period  at  which  to  interfere  by  operation,  con- 
siderable divergence  of  opinion  exists.  Some  surgeons  advocate 
its  performance  at  as  early  a  date  as  possible,  and,  in  fact,  it  has 
been  undertaken  when  the  child  wyas  but  a  few  days  old.  The 
success  attending  such  practice  has  not  been  gratifying,  since 
infants  have  no  moral  control,  and  are  much  more  likely  to  suck 
at  the  stitches  and  interfere  with  them  by  the  tongue,  whilst  the 
buccal  cavity  is  small,  and  the  tissues  so  delicate  and  friable, 
that  the  difficulty  of  the  operation  is  much  increased.  On  the 
other  hand,  it  should  not  be  deferred  too  long  ;  bad  habits  of 
articulation  will  be  contracted,  and  subsequent  physiological 
success,  as  gauged  by  the  quality  of  the  speech,  is  much  less 
likely  to  follow.  After  an  extended  experience,  it  may  be  stated 
that  the  operation  is  best  undertaken  between  the  second  and  the 
third  years,  when  a  child  can  be  easily  kept  under  control.  It  is 
most  important  that  the  general  health  be  good,  and  the  mouth 
and  throat  free  from  local  disease  or  inflammation.  To  guard 
against  accidents  it  is  well  to  make  a  routine  practice  of  keeping 
a  child  under  observation  indoors  for  a  few  days  before  operating, 
whilst  for  choice  the  spring  or  summer  should  be  selected.  If 
the  tonsils  are  enlarged,  as  is  not  uncommonly  the  case,  it  is  by 
no  means  necessary  to  remove  them  if  no  active  inflammation  is 
present  ;  pharyngeal  adenoids,  moreover,  may  sometimes  be  left 
with  advantage,  as  they  subsequently  assist  in  shutting  off  the 
nasal  cavity  during  speech. 

Operation. — The  child  should  be  placed  on  a  suitable  table 
with  a  moveable  headpiece,  if  possible,  as  it  is  often  necessary  to 
alter  the  position  of  the  head  during  the  proceedings.  The  arms 
are  fixed  to  the  sides  by  attaching  them  to  a  strap  or  bandage 
passed  round  the  thighs  below  the  trochanters,  but  the  patient 
should  not  be  tied  down  to  the  table,  so  that,  although  he  cannot 
raise  the  hands  to  the  mouth  during  the  partial  anaesthesia  which 
is  often  present,  yet  he  can  be  turned  easily  to  either  side  so  as 
to  allow  blood  to  run  from  the  mouth.  Anaesthesia  is  induced  in 
the  ordinary  way  by  chloroform  dropped  upon  the  corner  of  a 
towel.  The  greatest  care  must  be  taken  not  to  drop  chloroform 
into  the  mouth,  and  for  the  same  reason  Junker's  apparatus  is 
undesirable,  on  account  of  the  chloroform  vapour  irritating  the 
edges  of  the  cleft.  The  mouth  is  efficiently  gagged  open,  and 
preferably  by  means  of  a  unilateral  instrument,  which  can  easily 
be  slipped  in  or  out  of  position. 

In  a  case  involving  both  the  soft  and  hard  palate  there  is  no 
reason  why  the  whole  cleft  should  not  be  dealt  with  at  one  sitting. 
When  the  inter-maxillary  bone  has  been  previously  removed,  and 
a  considerable  gap  left  anteriorly,  it  is  often  only  possible  to 
close  the  posterior  two-thirds  of  the  cleft,  either  dealing  with  the 
anterior  portion  at  a  later  date,  or  trusting  to  the  application 
of  a  suitable  obturator,  to  which  artificial  incisors  can   also   be 


794 


A   MANUAL  OF  SURGERY 


attached.  The  proceeding  usually  employed  is  practically  identical 
with  that  introduced  by  Langenbeck,  and  known  as  uranoplasty. 
For  convenience  it  may  be  described  in  four  stages : 

Stage  I.  :  Incision  and  Detachment  of  Muco -periosteal  Flaps. — The 
knife  should  be  inserted  close  to  the  last  molar  tooth  and  about 
half  an  inch  from  the  alveolar  margin,  and  carried  forwards 
parallel  to  the  teeth  to  a  spot  just  anterior  to  the  apex  of  the 
cleft  ;  or,  if  the  alveolus  is  involved,  the  incision  should  stop 
behind  the  lateral  incisor  to  preserve  the  vascular  supply  of  the 
front  of  the  flap  (Fig.  286).  The  muco-periosteum  is  divided 
down   to   the   bone,  and   by  the   use  of  a  suitable   raspatory  the 


Fig.  286. — Diagram  to  Indicate  Extent  of  Incisions  in  Uranoplasty. 

The  thick  black  lines  show  the  primary  incision ;  the  thick  dotted  lines  the 
extension  backwards  of  the  same  to  relieve  any  lateral  tension ;  the  thin 
dotted  lines  indicate  approximately  the  position  of  the  free  border  of  the 
bony  palate.  The  right-hand  figure  shows  the  position  of  the  sutures,  and 
the  condition  of  the  parts  at  the  close  of  the  operation 

soft  structures  of  the  palate  are  stripped  up  towards  the  middle 
line,  until  the  point  of  the  instrument  is  seen  protruding  into 
the  cleft.  Great  care  is  needed  in  dealing  with  the  hinder  part 
to  ensure  its  total  detachment  from  the  hamular  process  and 
back  of  the  bony  palate,  and  yet  not  to  damage  it  at  this,  its 
weakest  spot.  This  must  be  thoroughly  carried  out  on  either 
side,  the  extent  of  the  incisions  being  shown  by  the  continuous 
black  lines  in  Fig.  286.  Copious  bleeding  always  accompanies 
this  stage  of  the  operation,  and  the  head  should  be  turned  on  one 
side  and  lowered,  and  the  pharynx  constantly  sponged  so  as  to 
prevent  the  blood  entering  the  air-passages. 

Stage  II.  :  Paring  the  Edges  of  the  Cleft. — This  is  accomplished 
by  grasping  the  base  of  the  uvula  with  a  suitable  pair  of  angular 
catch-forceps.     Thus  steadied  and   held,  a    thin    paring    can    be 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  OESOPHAGUS  795 

removed,  in  one  piece,  if  possible,  on  the  side  seized,  and  the  same 
process  repeated  on  the  other.  The  paring  of  the  edges  is  pur- 
posely deferred  until  after  the  muco-periosteal  flaps  have  been 
detached,  because  the  freshened  edges  do  not  thus  get  bruised 
by  the  frequent  use  of  the  sponge ;  moreover,  the  bevel  at  which 
the  edges  should  be  pared  can  be  more  accurately  estimated  when 
the  flaps  have  been  loosened. 

Stage  III.  :  Passage  and  Tightening  of  Sutures. — The  simplest  plan 
to  adopt  is  that  known  as  the  'loop  method'  of  Sir  \V.  Fergusson, 
and  it  is  carried  out  as  follows  :  A  long-handled  palate  needle 
with  a  suitable  curve,  and  threaded  with  about  18  inches  of  fine 
white  silk,  is  passed  through  the  muco-periosteal  flap  from  below 
upwards,  and  at  a  spot  about  2  or  3  mm.  from  the  margin 
(Fig.  287  A) ;  as  a  rule,  it  is  not  necessary  to  hold  the  flap  to  effect 
this.  The  loop  of  silk  projecting  from  the  cleft  (Fig.  287  B)  is  now 
grasped  with  smooth-nosed  forceps  and  drawn  out  of  the  mouth, 


Fig.  287.  Fig.  288.  Fig.   289. 

Diagrams  to  Illustrate  the  Loop-method  of  Passing  Stitches  in  the 
Operation  for  Cleft  Palate. 

The  needles  and  silk  thread  are,  for  purposes  of  illustration,  represented 
much  thicker  than  would  be  really  employed. 

whilst  the  needle  is  withdrawn.  A  similar  loop  is  inserted  through 
the  opposite  side  of  the  cleft  at  an  exactly  corresponding  point,  so 
that  there  are  now  two  loops  emerging  from  behind  through  the 
cleft  (Fig.  287  C,  D).  One  of  these  is  loosely  threaded  through 
the  other  (Fig.  288  E),  and  the  latter  gently  withdrawn,  carrying 
with  it  the  loop-end  of  the  former  (Fig.  288  F),  and  thus  a  double 
thread  is  carried  through  both  sides  of  the  palate,  a  loop  projecting 
from  one  side,  and  the  free  ends  from  the  other.  This  process  is 
commenced  anteriorly  and  carried  backwards  until  the  base  of 
the  uvula  is  reached,  the  stitches  being  inserted  about  half  a 
centimetre  apart,  so  that  nine  or  ten  threads  may  be  needed  to 
secure  the  whole  palate.  They  are  left  loose,  the  ends  being  held 
by  the  anaesthetist  or  assistant  against  the  cheeks  until  all  have 
been  inserted.  A  6-inch  length  of  fine  well-annealed  silver  wire  is 
successively  hooked  over  each  loop  (Fig.  289  G),  drawn  into  posi- 


7y6  A   MANUAL  OF  SURGERY 

tion  by  the  silk  thread  (Fig.  289  H),  and  tightened  to  a  suitable 
degree  by  a  wire-twister,  so  that  the  pared  edges  of  the  cleft  are 
exactly  apposed.  This  is  best  undertaken  from  before  backwards. 
Finally,  the  uvula  is  stitched  with  silk  inserted  by  means  of  a 
double-curved  needle  (Fig.  289  I);  silver  wire  would  irritate  the 
back  of  the  tongue  too  much  and  cause  vomiting. 

Some  surgeons  prefer  to  introduce  the  wire  by  means  of  a 
specially  constructed  hollow  needle  with  a  double  curve,  through 
which  the  wire  is  protruded  by  unwinding  a  drum  in  the  handle. 
This  is  passed  through  both  flaps,  commencing  at  the  uvula,  and 
working  forwards,  tying  each  stitch  as  it  is  inserted. 

Stage  IV. — It  is  now  only  necessary  to  take  steps  for  the  relief  of 
all  lateral  tension,  a  most  important  and  essential  proceeding.  The 
best  way  to  accomplish  this  is  to  prolong  backwards  through  the 
soft  palate  the  lateral  incisions  already  made  so  as  to  thoroughly 
divide  the  levator  palati  (see  the  thick  dotted  lines  in  Fig.  286). 
Occasionally  the  anterior  and  posterior  pillars  of  the  fauces,  con- 
taining respectively  the  palato-glossi  and  palato-pharyngei  muscles, 
will  also  need  to  be  snipped  across. 

The  child  should  now  be  put  to  bed  with  the  head  low,  so  that 
any  accumulation  of  blood  or  mucus  may  gravitate  easily  into  the 
pharynx.  The  mouth  can  be  washed  out  with  a  weak  solution 
of  sanitas,  although  some  surgeons  prefer  not  to  disturb  the  parts 
for  three  or  four  days.  No  nourishment  should  be  given  for  the 
first  four  or  five  hours,  and  but  very  sparingly  for  the  first  twenty- 
four.  Milk  and  water,  given  by  a  spoon  or  from  a  feeder,  will  form 
the  staple  article  of  diet.  By  about  the  fifth  day  soft  food,  such 
as  soaked  bread  and  custard  pudding,  may  be  safely  given.  The 
patients  are  generally  allowed  up  on  the  sixth  day.  The  silver 
stitches  may  be  left  in  for  ten  days  or  a  fortnight  without  doing 
any  harm. 

In  dealing  with  clefts  of  the  soft  palate  alone,  a  modification  of 
the  above  operation  may  be  performed,  called  staphylovraphy . 
The  edges  are  first  pared,  lateral  incisions  are  then  made  to  divide 
the  levatores  palati,  and  the  stitches  finally  passed  and  tied. 

Results. — It  is  possible  that  in  most  cases  articulation  will  be, 
if  anything,  impaired  as  the  immediate  result  of  the  operation, 
since  the  mechanism  which  the  patient  ordinarily  employs  is 
thrown  out  of  gear  ;  subsequent  education  at  the  hands  of  a  voice- 
trainer  is  absolutely  essential  in  order  to  correct  this.  Even  then 
the  unpleasant  articulation  occasionally  persists,  owing  to  the 
patient  being  unable  to  draw  up  the  velum  so  as  to  close  the 
posterior  nares ;  this  is  due  to  a  reduction  of  the  depth  of  the  soft 
palate  owing  to  the  traction  required  to  close  the  cleft.  In  spite 
of  this,  however,  the  operation  is  most  beneficial  in  that  it  shuts 
off  the  nose  from  the  mouth,  prevents  the  dropping  of  mucus, 
improves  the  sense  of  taste,  and  adds  greatly  to  the  general 
comfort  of  the  patient. 


AFFECTIONS  OF  THE  MOUTH,   THROAT,  AND  CESOPHAGUS  797 

Mechanical  Treatment  of  clefts  in  the  palate  by  means  of  obturators  or 
artificial  vela  is  still  advocated  by  some  surgeons  and  dentists  in  preference  to 
any  operative  interference.  An  obturator  consists  of  an  adjustable  plate  or  plug 
fitted  to  and  closing  an  aperture  in  the  hard  palate.  It  may  be  used  with 
advantage  in  perforations  due  to  traumatism  or  syphilis,  and  in  apertures  left 
after  operations  in  which  portions  of  the  palate  are  removed,  such  as  excision 
of  the  superior  maxilla.  In  cases  of  double  hare-lip  and  cleft  palate,  where 
the  os  incisivum  has  been  extirpated,  an  aperture  is  often  left  anteriorly  which 
cannot  be  satisfactorily  closed  except  by  an  obturator,  which  also  serves  to 
carry  the  necessary  artificial  incisors,  and  may  have  cheek  plates  attached  to 
push  forwards  the  upper  lip.  For  whatever  purpose  an  obturator  is  needed, 
it  should  never  take  the  form  of  a  closely-fitting  plug,  which,  by  its  constant 
pressure  and  irritation,  causes  the  aperture  to  become  enlarged,  but  always  that 
of  a  plate,  either  of  thin  vulcanite  or  gold,  which  can  be  fixed  to  the  teeth,  and 
maintained  in  position  by  suction.  It  is  sometimes  found,  however,  that  the 
addition  of  an  intranasal  projection  to  the  upper  surface  of  the  plate  improves 
the  articulation  by  diminishing  the  size  of  the  nasal  cavity.  An  artificial  velum 
consists  of  a  plate  obturator,  to  which  is  attached  posteriorly  a  moveable 
segment  to  take  the  place  of  the  normal  velum.  Such  consists  either  of  a 
hinged  metal  plate,  resting  on  the  nasal  side  of  the  segments  of  the  soft 
palate,  and  moved  by  them,  or  of  a  thin  indiarubber  bag  filled  with  air,  sewn 
to  the  back  of  the  obturator.  They  are  complicated  and  difficult  to  keep  in 
order,  and,  to  our  minds,  the  results  of  operative  interference -are  superior. 

Ulceration  of  the  Palate  occurs  in  a  variety  of  forms,  e.g., 
(a)  simple,  as  an  accompaniment  of  general  stomatitis:  (b)  syphilitic, 
which  may  involve  either  the  hard  or  soft  palate  ;  if  superficial,  it 
is  usually  a  late  secondary  phenomenon  ;  if  deep,  it  involves  the 
bones,  and  often  leads  to  necrosis,  and  is  then  due  to  tertiary 
mischief:  (c)  lupoid,  a  somewhat  uncommon  condition,  which  may 
result  in  great  destruction  of  tissue';  it  is  usually  seen  in  children, 
and  often  associated  with  a  similar  disease  of  the  nose,  from 
which,  indeed,  it  may  have  spread  :  (d)  tuberculous,  due  to  the 
breaking  down  of  a  tuberculous  abscess  under  the  periosteum,  and 
then  complicated  with  caries  of  the  bony  palate  :  (e)  malignant, 
usually  resulting  from  the  growth  of  epithelioma,  either  starting 
primarily  in  the  palatal  mucous  membrane,  or  extending  to  it 
from  the  tongue,  tonsil,  or  upper  jaw. 

Acquired  Perforations  of  the  Palate,  though  occasionally  caused 
by  traumatism  or  lupus,  are  in  almost  all  cases  due  to  tertiary 
syphilis.  The  ethmo-vomerine  septum  is  often  involved  in  the 
destructive  process,  giving  rise  to  a  most  offensive  discharge  from 
the  nose.  If  the  soft  palate  is  alone  affected,  the  velum  may 
become  fixed  by  cicatricial  adhesions  to  the  back  of  the  pharynx, 
and  pharyngeal  stenosis  or  considerable  loss  of  substance  of  the 
velum  results.  A  nasal  intonation  of  the  voice  is  always  caused 
by  any  condition  which  interferes  with  the  closure  of  the  naso- 
pharynx by  the  velum  during  articulation.  The  treatment  of  these 
conditions  should  follow  the  usual  antisyphilitic  course.  Perfora- 
tions are  best  remedied  by  the  use  of  plate  obturators.  We  have 
seen  out-patients  make  efficient  obturators  out  of  a  piece  of  sheet 
indiarubber  maintained  in  situ  by  suction,  or  of  two  pieces  stitched 
together  in  the  middle,  one  piece  passing  above  and  the  other 


798  A   MANUAL  OF  SURGERY 


below  the  opening.  Occasionally  when  the  aperture  is  small, 
the  local  disease  soundly  cured,  and  the  general  health  good,  an 
attempt  may  be  made  to  close  it  by  stripping  up  muco-periosteal 
flaps,  paring  the  edges  and  suturing  them  together.  The  results 
are,  however,  seldom  satisfactory. 

Any  of  the  ordinary  forms  of  inflammation  of  bone  may  be 
met  with  in  the  hard  palate.  Necrosis  is  usually  due  to  tertiary 
syphilis,  or  may  accompany  acute  subperiosteal  suppuration, 
extending  from  an  alveolar  abscess.  In  either  case  the  surgeon 
must  wait  till  the  sequestrum  is  loose,  and  then  it  may  be  re- 
moved.    Caries  is  generally  due  to  syphilis  or  tubercle. 

The  following  tumours  occur  on  the  hard  palate.  Simple  epulis 
(p.  737)  may  extend  from  the  alveolus,  or  an  identical  condition 
may  start  in  the  middle  line.  An  adenoma  of  the  palatal  glands 
is  occasionally  met  with.  It  presents  as  a  smooth  or  papillated 
tumour,  somewhat  resembling  epithelioma,  but  distinguished  from 
it  by  its  slower  rate  of  growth,  and  the  absence  of  ulceration, 
pain,  or  of  glandular  enlargement.  An  operation  limited  to  the 
soft  parts  is  probably  all  that  is  necessary.  Sarcoma  may  be 
primary,  and  is  then  often  myxo-sarcomatous  in  type,  or  secondary. 
In  the  former  case  it  simulates  rather  closely  a  diffuse  alveolar 
abscess,  but  is  recognised  by  its  slower  growth,  less  pain,  absence 
of  inflammation,  and,  if  need  be,  by  the  results  of  an  exploratory 
puncture.  Epithelioma  also  occurs,  but  is  uncommon.  Treatment 
for  the  two  latter  conditions,  if  limited  to  the  palate,  would  consist 
in  partial  removal  of  the  affected  superior  maxilla. 

Elongation  of  the  Uvula  is  frequently  the  result  of  a  chronic 
relaxed  throat.  At  first  it  merely  lasts  for  a  time,  and  by  the 
use  of  astringents  disappears  ;  but  later  on  the  elongation  becomes 
chronic,  and  causes  great  irritation  of  the  back  of  the  tongue  and 
fauces,  resulting  in  a  troublesome  throat-cough  and  even  vomit- 
ing. Under  such  circumstances  it  should  be  removed.  After  well 
cocainizing  the  part,  it  is  grasped  by  a  pair  of  hook-forceps,  which 
seize  not  only  the  mucous  membrane,  but  also  the  muscular 
structures  beneath,  and  a  sufficient  amount  is  then  removed  by 
snipping  it  across  near  the  base  with  a  pair  of  blunt-pointed 
scissors,  leaving  about  a  third  of  an  inch  of  the  organ  behind. 

Affections  of  the  Tonsils. 

Acute  Tonsillitis  results  either  from  cold,  or  from  the  inhalation 
of  impure  air,  especially  when  contaminated  with  sewer  gas.  It 
is  often  seen  amongst  the  residents  in  hospitals  (hospital  throat), 
and  may  precede  an  attack  of  acute  rheumatism.  Three  varieties 
are  described : 

(a)  Acute  superficial  tonsillitis,  which  consists  of  a  slight  super- 
ficial inflammation,  the  result  of  cold,  etc.,  in  which  the  tonsil 
participates  with  the   pharynx  and  velum.     There  is  but   little 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  OESOPHAGUS  79; 

swelling  of  the  part,  which,  however,  becomes  red  and  painful, 
rendering  swallowing  difficult.  Ordinary  anti-catarrhal  remedies 
are  necessary,  and  a  chlorate  of  potash  gargle. 

(b)  Acute  follicular  tonsillitis  is  characterized  by  a  general  en- 
largement of  the  organ,  which  is  dusky  red  in  colour  and  painful, 
causing  obstruction  to  both  breathing  and  swallowing,  the  tonsils, 
perhaps,  almost  meeting  in  the  middle  line.  There  is  a  good  deal 
of  yellow  patchy  exudation  from  the  follicles,  which  may  coagulate 
on  the  surface  and  form  a  false  membrane,  distinguished  from 
that  of  diphtheria  by  its  want  of  adhesion  to  the  subjacent 
tissue,  being  readily  detached  by  a  camel's-hair  pencil.  The 
temperature  is  high,  the  glands  below  the  angle  of  the  jaw 
enlarged  and  tender,  the  tongue  covered  with  a  thick  whitish  fur, 
and  the  bowels  confined.  Such  a  condition  may  herald  in  an 
attack  of  so-called  blood-poisoning,  or  septicaemia. 

(c)  Acute  parenchymatous  tonsillitis,  or  quinsy,  is  a  more  diffuse 
inflammation,  which  is  not  limited  to  the  organ,  but  also  involves 
the  soft  palate  and  fauces.  The  swelling  is  more  extensive, 
the  pain  is  greater,  and  suppuration  frequently  results.  Other 
symptoms  are  much  the  same  as  in  the  above. 

The  Diagnosis  must  be  made  from  scarlet  fever  by  the  absence 
of  the  characteristic  rash  and  red  tongue  of  the  latter  condition, 
and  by  the  redness  being  more  dusky  and  less  diffuse  in  tonsillitis. 
From  erysipelas  of  the  fauces,  it  is  known  by  the  redness  being 
more  concentrated,  the  oedema  less  marked  and  more  limited,  by 
the  glands  at  the  angle  of  the  jaw  being  less  enlarged,  and  by  the 
absence  of  any  external  manifestation  of  the  disease. 

Treatment  must  always  be  commenced  by  a  good  calomel  purge, 
which  mav  be  followed  by  the  administration  either  of  salicylate 
of  soda  (20  grains,  thrice  daily),  or  of  chlorate  of  potash  and 
sulphate  of  magnesia,  to  which  a  few  drops  of  tincture  of  aconite 
may  be  added  if  the  constitutional  symptoms  are  severe.  The 
patient  will  experience  much  relief  by  inhaling  the  steam  from  hot 
water  (150°  F.),  in  which  a  little  creasote  or  carbolic  acid  is  dis- 
solved, or  the  tonsils  may  be  scarified.  Suppuration  is  dealt  with 
by  a  free  incision,  the  knife  entering  the  most  prominent  part  of  the 
swelling,  and  cutting  backwards  towards  the  middle  line  ;  the  close 
proximity  of  the  carotid  should  not,  however,  be  forgotten.  Hot 
flannels  or  fomentations  may  be  applied  to  the  neck  and  throat, 
and  plenty  of  fluid  nourishment  administered.  This  is  followed 
as  soon  as  possible  by  iron,  bark,  and  other  tonics. 

Chronic  Tonsillitis  appears  in  two  distinct  forms  : 

(a)  Chronic  inflammatory  tonsillitis  occurs  in  children  whose 
tonsils,  after  one  acute  attack,  remain  enlarged,  painful,  con- 
gested, and  very  liable  to  recurrence,  which  often  runs  on  to 
suppuration  and  ulceration.  After  a  time  the  tonsils  shrink  back 
and  atrophy,  becoming  hard  and  fibroid. 

(b)  Chronic  hypertrophic   tonsillitis  is   met   with    in    tuberculous 


Soo  A   MANUAL  OF  SURGERY 

children,  resulting  from  an  overgrowth  of  the  lymphoid  tissue, 
and  is  usually  associated  with  the  presence  of  adenoids  in  the 
naso-pharynx.  The  tonsils  are  enlarged,  pale  in  colour,  and  firm 
in  consistence  ;  the  orifices  of  the  crypts  are  very  patent,  and  in 
them  are  often  seen  plugs  of  mucous  secretion,  which  may 
become  infiltrated  with  lime  salts,  forming  concretions,  which 
however,  are  never  of  any  great  size.  The  patients  are  very 
liaMe  to  recurrent  attacks  of  inflammation,  with  or  without 
suppuration,  and  even  cysts  may  form  from  the  blocking  of  the 
follicular  ducts.  When  much  enlarged,  the  tonsils  may  meet  in 
the  middle  line  beneath  the  uvula,  causing  obstruction  both  to 
swallowing  and  respiration.  The  patient  usually  breathes  with 
the  mouth  open,  owing  to  the  concurrent  naso-pharyngeal  obstruc- 
tion, and  from  the  same  cause  speaks  thickly,  as  if  he  had  some 
loose  body  in  the  mouth,  and  necessarily  snores  during  sleep. 
Hearing  is  often  interfered  with  from  the  mucous  lining  of  the 
Eustachian  tube  becoming  thickened  and  inflamed. 

The  Treatment  of  these  cases  consists  in  first  attending  to  con- 
stitutional weakness  by  removal  of  the  patient  to  fresh  or  seaside 
air,  and  by  the  administration  of  iron  and  cod-liver  oil ;  at  the 
same  time  the  throat  should  be  painted  twice  a  day  with  glycerine 
of  tannic  acid,  or  with  equal  parts  of  glycerine  and  tinct.  ferri  per- 
chloridi,  or  touched  with  the  galvano-cautery,  Failing  this,  ton- 
sillotomy should  be  performed  ;  in  children  the  organ  may  be  cut 
away  as  far  back  as  possible,  but  in  patients  over  the  age  of  twenty 
only  a  thin  slice  should  be  removed,  and  never  the  whole  organ, 
since  there  is  much  more  risk  of  grave  haemorrhage  ;  the  galvano- 
cautery  is  much  better  treatment  in  adults.  It  has  also  been 
suggested  that  the  voice  is  weakened  by  tonsillotomy,  but  this  is 
somewhat  doubtful. 

Tonsillotomy  may  be  undertaken  in  two  ways  : 

(a)  By  the  guillotine.  The  fauces  having  been  carefully  and 
repeatedly  brushed  with  a  5  per  cent,  solution  of  cocaine,  the 
mouth  is  opened  and  one  of  the  many  forms  of  tonsil  guillotine 
introduced ;  Mackenzie's  spade  guillotine  is  as  good  as  any. 
The  ring  of  the  instrument  is  passed  over  the  projecting  organ, 
external  pressure  behind  the  angle  of  the  jaw  assisting  in  this 
manoeuvre.  By  the  pressure  of  the  thumb  the  projecting  mass  is 
cut  off  by  the  sharp  blade.  In  dealing  with  the  right  side,  unless 
the  surgeon  is  ambidextrous,  he  had  better  stand  behind  the 
patient's  head,  looking  over  into  the  mouth. 

(b)  By  the  bistoury.  The  tonsil  is  seized  at  its  lowest  point  and 
drawn  well  inwards  by  means  of  hooked  forceps,  and  the  pro- 
jecting mass  removed  by  a  straight  blunt-pointed  bistoury,  the 
base  of  the  blade  being  guarded,  if  preferred,  by  a  piece  of  plaster 
wrapped  round  it.  The  incision  should  be  made  from  below 
upwards,  and  the  edge  of  the  knife  kept  rather  in  than  out,  so  as 
to  avoid  all  risk  of  wounding  the  internal  carotid,  which  is  in  close 


AFFECTIONS  OF  THE  MOUTH,   THROAT,  AND  OESOPHAGUS  Soi 


contiguity  to  the  outer  surface  of  the  gland.  The  surgeon  must 
stand  behind  the  patient's  head  in  dealing  with  the  right  side,  and 
in  front  when  operating  upon  the  left.  Care  must  be  taken  to 
include  the  lowest  portion  of  the  tonsil,  which  often  hangs  down 
into  the  pharynx,  and  is  liable  to  be  left  behind.  In  children  the 
hypertrophic  type  of  enlarged  tonsil  may  be  enucleated  without 
much  difficulty  by  dividing  the  mucous  membrane  in  front  of  it, 
and  shelling  it  out  of  its  bed,  the  posterior  reflexion  of  mucous 
membrane  being  subsequently  snipped  through  with  bistoury  or 
scissors. 

The  haemorrhage,  though  brisk  for  the  moment,  soon  ceases  if 
care  is  taken  not  to  cut  too  deeply,  or  encroach  upon  the  sur- 
rounding mucous  membrane.  Should  the  bleeding  continue,  it 
can  generally  be  arrested  by  douching  the  face  with  iced  water, 
or  by  the  local  application  of  wool  pledgets  soaked  in  iced  boric 
acid  lotion,  or  in  tinct.  ferri  perchloridi ;  possibly  a  gargle  con- 
taining hazeline  may  be  efficacious  in  bad  cases,  or  the  galvano- 
cautery  may  be  applied.  This  is  more  likely  to  occur  in  adults 
than  in  children. 

Syphilitic  Disease  of  the  Tonsil  is  met  with  in  various  stages. 
The  primary  chancre  is  seen  occasionally,  arising  in  one  case  we 
know  of  through  infection  from  a  stick  of  caustic  which  had 
been  previously  used  to  cauterize  a  syphilitic  ulcer  and  insuf- 
ficiently cleaned  before  being  applied  to  the  tonsil,  the  surface  of 
which  was  abraded.  The  glandular  enlargement  in  the  neck  is 
very  marked  in  such  cases,  and  the  course  of  the  disease  usually 
severe.  Secondary  ulcers  of  the  '  snail-track  '  type  (plaques  muqucuses) 
are  common  in  this  region,  being  usually  symmetrical.  In  the 
tertiary  period  a  diffuse  gummatous  infiltration  occurs,  involving  also 
the  palate  and  fauces  (p.  803),  and  leading  to  pharyngeal  stenosis. 

Tumours  of  the  Tonsil  are  almost  always  malignant  in  type,  but 
are  not  very  common.  Epithelioma  occurs  as  a  firm  indurated 
infiltration  rapidly  spreading  to  adjacent  parts,  and  involving  the 
lymphatic  glands.  It  generally  starts  either  in  the  root  of  the 
tongue  or  in  the  pillars  of  the  fauces,  and  presents  a  ragged 
ulcerated  surface  with  a  hard  margin  and  sloughing  base.  It  runs 
a  rapidly  fatal  course  if  left  to  itself.  Lymphosarcoma  of  the  tonsil 
arises  in  the  organ  itself,  usually  after  middle  life  ;  it  presents  a 
smooth,  dusky  red  appearance,  the  mucous  membrane  being 
stretched  over  it,  and  feels  soft  and  almost  fluctuating.  In  the 
early  stages  it  may  be  freely  moveable,  but  ere  long  it  infiltrates 
surrounding  structures,  and  affects  the  neighbouring  lymphatic 
glands.  Round-celled  sarcoma  also  attacks  the  tonsil  as  a  primary 
growth,  and  is  less  limited  and  defined  than  the  former.  In  all 
these  varieties  the  growth  extends  into  the  pharynx,  impeding 
deglutition  and  respiration,  and  ulceration  with  or  without  serious 

51 


8o2  A    MANUAL  OF  SURGERY 

haemorrhage    may   ensue ;   indeed,    the    latter    complication    is    a 
frequent  cause  of  the  fatal  result. 

Extirpation  of  Malignant  Tumours  of  the  tonsil  is  often  imprac- 
ticable from  the  extent  of  the  disease,  and  the  early  implication 
of  the  surrounding  structures,  although  it  has  now  been  shown 
that  they  are  more  amenable  to  treatment  than  was  formerly 
thought  to  be  the  case.  The  disease  may  be  dealt  with  in  two 
ways  :  (a)  From  the  mouth  in  the  case  of  the  loosely  encapsuled 
and  freely  moveable  lympho-sarcomata.  The  capsule  is  divided 
preferably  by  a  galvano-cautery,  and  the  growth  shelled  out  some- 
times with  the  utmost  ease,  and  with  very  little  haemorrhage. 
Recurrence  in  the  lymphatic  glands  is,  however,  almost  certain 
to  follow,  (b)  From  the  neck.  The  best  plan  is  to  make  an  incision 
along  the  anterior  border  of  the  sterno-mastoid,  and  carefully 
dissect  down  to  the  pharyngeal  wall,  removing  all  lymphatic 
glands,  which  are  enlarged  or  suspicious,  and  securing  the  external 
carotid  or  its  anterior  branches.  The  mass  is  then  isolated  from 
the  surrounding  structures  and  removed.  A  good  many  cases 
have  now  been  reported  which  were  treated  in  this  manner  with 
complete  success,  even  when  the  tongue,  palate,  or  pharynx  were 
invaded.  It  is  occasionally  necessary  to  make  an  incision  from 
the  angle  of  the  mouth  backwards  through  the  cheek  ;  the  tonsil 
is  thus  well  exposed,  and  can  be  dealt  with  satisfactorily.  The 
patient  should  always  be  immunized  to  streptococcal  infection 
before  the  operation. 

Affections  of  the  Pharynx. 

Acute  Pharyngitis  is  usually  associated  with  a  similar  inflam- 
matory condition  of  the  velum  palati,  nasal  mucous  membrane, 
and  tonsils,  and  results  from  exposure  to  cold,  from  absorption  of 
sewer  gas,  and  from  general  diseases  of  the  exanthematous  type, 
e.g,  scarlet  fever.  It  is  characterized  by  redness,  pain,  and 
swelling  of  the  mucous  membrane,  which  becomes  covered  with 
mucus  or  muco-pus.  An  irritable  cough,  with  perhaps  sneezing, 
interference  with  nasal  respiration,  and  great  pain  on  swallowing, 
are  produced  by  this  condition,  and  if  it  spreads  to  the  Eustachian 
tube  temporary  deafness  is  induced.  Ulceration  of  the  velum 
and  fauces  occasionally  follows. 

The  Treatment  consists  in  attending  to  the  general  condition, 
especially  if  of  exanthematous  origin,  and  when  due  to  catarrh,  in 
administering  antiphlogistic  remedies  (e.g.,  purgatives,  sudorifics, 
and  diuretics)  and  soothing  local  applications  (e.g.,  ice  to  suck, 
chlorate  of  potash  gargle,  etc.).  Great  relief  is  often  given  by 
inhaling  steam  from  water  at  1500  F.  to  which  a  little  Friar's 
balsam  has  been  added. 

Erysipelas  of  the  Fauces  and  Palate  has  been  already  alluded  to 

(p.  96). 

Chronic  Pharyngitis  is  commonly  met  with  in  clergymen   and 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  OESOPHAGUS  803 


public  speakers  who  are  called  upon  to  exert  their  voices  for  any 
length  of  time,  in  costers  and  street-hawkers  who  shout  their 
wares,  and  in  drinkers  and  smokers.  It  may  commence  as  a 
chronic  inflammation,  or  may  follow  an  acute  attack.  The  mucous 
membrane  is  more  or  less  red  and  infiltrated,  with  vessels  coursing 
over  it,  and  there  is  often  a  good  deal  of  muco-purulent  discharge. 
If  the  buccal  side  of  the  velum  palati  is  affected,  there  is  usually 
much  less  secretion  than  from  the  pharyngeal  aspect,  where  a 
considerable  amount  of  dark  green  viscid  material  may  collect 
and  cling  to  the  pharyngeal  wall,  constituting  scabs,  which  may 
decompose  and  cause  the  breath  to  be  somewhat  offensive.  Two 
main  varieties  are  described  : 

1.  Chronic  Follicular  Pharyngitis,  in  which  the  lymphoid  follicles 
scattered  throughout  the  mucous  membrane  become  enlarged. 
This  is  specially  evident  upon  the  soft  palate,  but  is  often  greater 
in  amount  upon  the  upper  wall  and  sides  of  the  pharynx,  where 
there  is  a  mass  of  lymphoid  tissue,  sometimes  known  as  the 
pharyngeal  or  Luschhas  tonsil  (vide  Adenoids,  p.  767).  The  uvula 
may  be  also  elongated  and  hypertrophic  in  this  condition. 

2.  Chronic  Atrophic  Pharyngitis  is  usually  associated  with  the 
atrophic  form  of  rhinitis  sicca  (p.  759),  and  possibly  with  chronic 
laryngitis.  The  mucous  membrane  is  smooth,  dry,  and  glazed, 
and  the  exudation  forms  adherent  scabs.  The  throat  feels  dry 
and  irritable,  and  the  voice  is  often  husky. 

The  Treatment  of  chronic  pharyngitis  varies  with  the  condition 
and  character  of  the  affection.  If  of  a  simple  type  ('  relaxed 
throat '),  all  sources  of  irritation — such  as  smoking,  spirits,  and 
condiments — must  be  avoided,  the  bowels  and  digestion  attended 
to,  and  astringent  sprays,  gargles  or  applications  made  use  of,  care 
being  taken  when  necessary  to  apply  these  to  the  naso-pharynx 
by  passing  the  brush  up  behind  the  soft  palate.  The  most  useful 
reagents  to  employ  are  the  glycerine  of  tannic  acid,  equal  parts 
of  glycerine  and  tinct.  ferri  perchloridi,  whilst  chloride  of  am- 
monium inhalations  are  sometimes  valuable,  as  also  sprays  of 
menthol  dissolved  in  paroleine.  When  the  inflammation  is  of  the 
follicular  type,  it  may  be  further  necessary  to  destroy  the  follicles 
with  the  galvano-cautery  after  cocainizing  the  surface  ;  enlarged 
and  varicose  vessels  may  be  divided  in  the  same  way.  In  the 
dry  form  of  pharyngitis,  inhalations  of  chloride  of  ammonium  are 
recommended,  or  chloride  of  ammonium  lozenges  ;  the  nasal  con- 
dition, however,  is  that  which  most  needs  treatment. 

Syphilitic  Affections  of  the  Pharynx  may  be  met  with  in  the 
secondary  or  tertiary  stages.  In  the  former  they  are  of  a  super- 
ficial character,  such  as  mucous  tubercles,  snail-track  ulcers,  etc. ; 
in  the  latter  they  appear  in  the  shape  of  a  dip/use  gummatous 
infiltration,  which  is  often  of  considerable  consequence,  both  at 
the  time  an  J   subsequently.      It  manifests  itself  as  a  widespread 

51— 2 


8o4  A   MANUAL  OF  SURGERY 


nodular  thickening  of  the  mucous  membrane,  especially  in  the 
neighbourhood  of  the  fauces  and  soft  palate,  which  rapidly  runs 
on  to  ulceration,  and  may  impede  both  respiration  and  deglutition. 
The  administration  of  mercury  and  iodide  of  potassium  usually 
causes  a  rapid  improvement,  but  the  subsequent  cicatrization 
may  bind  down  the  velum,  and  lead  to  pharyngeal  stenosis  of 
such  a  character  as  to  constitute  a  fibro-cicatricial  septum,  with 
an  opening  through  it  perhaps  only  large  enough  to  allow  a  small 
bougie  to  pass.  For  such  a  condition  much  may  be  done  ;  the 
opening  may  be  more  or  less  dilated  by  careful  division  of  some 
of  the  bands  and  the  passage  of  bougies ;  and  the  soft  palate  can 
be  set  free  from  the  dorsum  of  the  tongue.  Of  course  there  is  a 
great  tendency  for  the  opening  to  contract  again,  and  treatment 
by  bougies  must  be  persisted  in. 

A  localized  gumma  may  form  in  the  submucous  tissue,  not  un- 
frequently  involving  the  posterior  pharyngeal  wall,  and  running 
its  ordinary  course  with  or  without  ulceration. 

Tumours  of  the  pharynx  are  rarely  primary.  They  may  extend 
into  it,  however,  from  surrounding  parts,  e.g.,  naso-pharyngeal 
polypi  arising  from  the  base  of  the  skull,  or  retro-pharyngeal 
growths  from  the  spine. 

Epithelioma  either  involves  the  pharynx  primarily,  or  spreads  to 
it  from  adjacent  parts,  such  as  the  tongue  or  tonsil.  The  usual 
type  of  tumour  develops  with  some  amount  of  ulceration  ;  lym- 
phatic glands  become  secondarily  affected,  and  the  tumour  gradu- 
ally invades  surrounding  tissues,  although  it  is  interesting  to  note 
that  for  some  time  it  is  limited  to  the  mucous  membrane,  extending 
superficially  over  it,  but  not  involving  the  underlying  pharyngeal 
muscles.  Death  results  from  haemorrhage  due  to  ulceration  into 
large  vessels,  from  interference  with  swallowing  or  breathing,  from 
pressure  on  important  nerves,  or  from  general  dissemination. 

Treatment. — It  is  only  within  the  last  decade  that  any  attempt 
has  been  made  to  deal  with  these  cases ;  even  now  the  mortality 
is  very  high,  and  statistics  go  to  prove  that  if  the  operation 
involves  removal  of  portions  of  the  upper  or  lower  jaw,  a  fatal 
issue  is  likely  to  follow.  The  same  precautions  as  to  cleansing 
the  teeth,  immunization  to  streptococcal  infection,  etc.,  must  be 
taken,  as  in  dealing  with  naso-pharyngeal  or  buccal  growths.  As 
a  general  rule,  an  incision  along  the  anterior  border  of  the  sterno- 
mastoid  is  the  best  to  employ,  although  occasionally  a  second 
may  be  required,  splitting  the  cheek  towards  the  angle  of  the  jaw. 
The  external  carotid  is  tied,  all  glands  are  removed,  and  then  the 
growth  is  extirpated,  partly  from  without,  partly  from  within. 
It  is  always  advisable  to  perform  a  preliminary  tracheotomy,  and 
feeding  must  be  undertaken  for  some  days  by  means  of  a  stomach  - 
tube.  Transhyoid  pharyngotomy  is  a  useful  means  of  approach 
in  some  of  these  cases  (p.  844). 


AFFECTIONS  OF  THE  MOUTH,   THROAT,  AND  OESOPHAGUS  805 


Retro -pharyngeal  Abscess  is  acute  or  chronic  in  its  course.  The 
acute  form  results  from  infection  through  the  mucous  membrane, 
as  by  fishbones,  etc. ;  or  arises  from  an  inflammation  of  the 
lymphatic  glands  which  are  found  in  this  situation  in  children, 
but  atrophy  in  adults,  and  derive  their  lymph  from  the  interior  of 
the  nose  and  naso-pharynx.  The  chronic  variety  generally  follows 
tuberculous  caries  of  the  spine,  or  disease  of  the  bones  at  the  base 
of  the  skull.  Whether  acute  or  chronic,  the  abscess  forms  a  tense 
elastic  swelling,  situated  behind  the  posterior  pharyngeal  wall  ;  in 
the  former  case  it  is  associated  with  high  fever,  and  locally  much 
redness  and  inflammatory  oedema,  which  may  even  extend  to  the 
glottis,  and  cause  dyspnoea ;  in  the  latter,  where  the  affection  is 
chronic,  there  is  less  local  inflammatory  reaction,  but  signs  of 
cervical  spinal  disease  are  present.  The  abscess  may  burst  into 
the  pharynx,  or  may  burrow  outwards  on  either  side,  being  guided 
by  the  pre- vertebral  fascia,  and  point  either  in  front  of  or  behind 
the  sterno-mastoid. 

Treatment  should  never  be  delayed,  from  fear  of  the  superven- 
tion of  oedema  of  the  glottis.  The  abscess  should  be  opened  from 
the  neck  in  all  cases,  as  then  an  aseptic  course  can  be  maintained, 
and  there  is  no  fear  that  the  pus  will  enter  the  air-passages.  If 
pointing  in  front  of  the  sterno-mastoid,  the  abscess  is  opened  in 
that  situation  ;  but  otherwise  an  incision  should  be  made  along 
the  posterior  border  of  the  muscle,  which  must  be  drawn  forwards, 
and  the  transverse  processes  of  the  cervical  vertebrae  defined. 
Possibly  the  abscess  will  be  opened  by  the  necessary  manipulation 
of  the  wound ;  if  not,  the  index-finger  of  the  left  hand  should  be 
placed  against  the  abscess  wall  in  the  mouth  to  guard  it  from 
injury,  and  a  pair  of  sinus  forceps  thrust  into  it  in  front  of  the 
vertebrae  by  the  right  hand.  A  drain-tube  is  then  inserted,  and 
the  case  runs  an  ordinary  aseptic  course. 

Affections  of  the  (Esophagus. 

Malformations  of  the  oesophagus  are  congenital  or  acquired. 

A  Congenital  communication  may  exist  between  the  oesophagus 
and  trachea,  either  in  the  form  of  a  small  fistula,  or  the  upper 
end  of  the  oesophagus  ends  blindly,  whilst  the  lower  end  opens 
into  the  trachea  near  its  bifurcation.  Life  is  impossible  under 
such  conditions,  and  the  children  die  shortly  after  birth.  Con- 
genital stricture  may  also  be  met  with  near  the  cardiac  orifice, 
resulting  in  general  distension  and  dilatation  of  the  oesophagus 
(cesophagoccele).  The  Acquired  malformations  consist  in  the 
development  of  the  so-called  Diverticula.  Two  forms  have  been 
described  by  Zenker  :  (a)  Pressure  Diverticula,  which  are  the  more 
common,  and  seem  to  be  associated  with  some  congenital  weak- 
ness of  the  wall,  probably  connected  with  the  branchial  clefts. 
They  vary  much  in  size,  perhaps  becoming  as  large  as  a  child's 
head,  and  rarely  come  under  observation  before  the  age  of  thirty. 


So6  A   MANUAL  OF  SURGERY 


They  usually  spring  from  the  posterior  wall,  close  to  the  junction 
of  the  pharynx  and  oesophagus,  constituting  sometimes  what  is 
known  as  a  '  pharyngocoele ' ;  the  cavity  extends  downwards 
between  the  oesophagus  and  vertebral  column.  The  symptoms  are 
due  to  distension  of  the  cavity  with  food  which  stagnates  and 
putrifies,  forming  a  swelling  in  the  neck  which  can  be  emptied  by 
pressure  ;  the  difficulty  of  obtaining  sufficient  food  gradually  leads 
to  emaciation.  When  a  bougie  is  used,  it  generally  passes  into 
the  diverticulum,  and  hence  its  onward  course  is  arrested  ;  by 
careful  manipulation  it  may  be  kept  on  the  sound  wall,  and  so 
slipped  past  the  orifice  into  the  stomach.  Treatment,  where 
possible,  consists  in  exposing  the  diverticulum  in  the  neck, 
removing  it,  and  stitching  up  the  opening  in  the  pharyngeal  or 
oesophageal  wall,  (b)  Traction  Diverticula  are  much  rarer  ;  they 
usually  occur  on  the  anterior  wall,  near  the  bifurcation  of  the 
trachea,  and  are  due  to  cicatricial  traction  from  without,  as  by  an 
inflamed  bronchial  gland.  They  are  always  of  small  size,  often 
multiple,  and  cause  no  symptoms,  unless  a  foreign  body  lodges  in 
them,  when  ulceration  and  perforation  may  lead  to  suppurative 
mediastinitis  and  death.     They  cannot  be  recognised  ante  mortem. 

Foreign  Bodies  not  unfrequently  lodge  in  the  oesophagus,  especi- 
ally in  children  and  lunatics.  Portions  of  food,  coins,  fishbones, 
pins,  plates  of  false  teeth,  etc.,  are  the  substances  usually  met 
with.  The  patient  complains  that  something  has  lodged  in  the 
gullet,  causing  a  feeling  of  pain  and  distension,  whilst  swallowing 
is  painful  or  impossible,  and  respiration  may  be  more  or  less 
hampered.  Large  bodies  are  often  impacted  at  the  entrance  to 
the  gullet,  and  then  cause  sudden  death  from  dyspnoea ;  if  the 
obstruction  is  not  so  great  and  remains  unrelieved,  oedema  of  the 
glottis  may  supervene.  Impaction  lower  down  is  likely  to  be 
followed  by  ulceration,  perforation,  and  death,  either  from  haemor- 
rhage owing  to  one  of  the  large  vessels  being  opened,  or  from 
suppurative  cellulitis.  In  some  cases,  however  (Konig  states 
about  50  per  cent.),  the  foreign  body  spontaneously  passes  either 
into  the  mouth  or  stomach. 

The  Treatment  varies  much  according  to  the  nature,  size,  and 
situation  of  the  obstructing  body.  If  small  and  incapable  of 
being  detected  by  a  sound — e.g.,  a  fishbone — it  is  best  removed  by 
an  expanding  probang  (Fig.  290),  being  caught  in  the  loops  of 
thick  horsehair  forming  part  of  the  apparatus.  If  a  coin  or  small 
hard  substance  is  impacted,  it  may  be  removed  by  oesophageal 
forceps,  or  by  a  coin-catcher.  If  it  is  impossible  to  draw  it  up,  it 
may  sometimes  be  pushed  down  into  the  stomach.  A  large  bolus 
of  food  may  be  removed  by  forceps  from  the  upper  part  of  the 
oesophagus,  and  large  foreign  bodies—  e.g.,  plates  of  teeth — may 
be  similarly  extracted,  though  great  care  must  be  taken  not  to 
tear   the   mucous  membrane.      Skiagraphy  is  now  employed   to 


AFFECTIONS  OF  THE  MOUTH,   THROAT,  AND  OESOPHAGUS  807 


assist  in  the  localization  of  metallic  substances  such  as  coins,  as 
also  to  determine  whether  or  not  they  have  been  dislodged,  whilst 
removal  may  be  much  expedited  by  the  use  of  the  cryptoscope. 

If  impacted  in  the  upper  part,  asophagotomy  may  be  performed. 
An  incision,  4  inches  long,  is  made  along  the  anterior  border 
of  the  sterno-mastoid,  preferably  on  the  left  side,  because  the 
oesophagus  naturally  curves  that  way.  The  platysma  and  deep 
fascia  are  divided,  and  the  muscle  drawn  outwards ;  the  omo-hyoid 
needs  division,  and  the  surgeon  then  carefully  works  his  way 
between  the  carotid  sheath  on  the  outer  side,  and  the  larynx  and 
trachea  on  the  inner,  avoiding  the  thyroid  vessels  and  nerves. 
The  projection  of  the  foreign  body  will  indicate  the  situation  of 
the  tube,  and  this  is  carefully  incised,  and  the  obstruction  dealt 
with.  The  oesophageal  wound  may  then  be  closed  by  sutures 
which  do  not  include  the  mucous  membrane,  whilst  the  external 
wound   is   either   stuffed   with   gauze   plugs   or   drained.      When 


Fig.  290. — Expanding  Probang  for  the  Removal  of  Foreign  Bodies 
from  the  cesophagus. 

located  in  the  upper  part  of  the  thoracic  portion  of  the  oesophagus 
the  tube  is  opened  as  low  as  possible  by  cutting  down  on  the  point 
of  a  bougie  passed  from  the  mouth,  and  then  it  is  often  possible  to 
extricate  it. 

When  the  foreign  body  is  impacted  near  the  cardiac  orifice,  and 
cannot  be  moved  either  up  or  down,  the  stomach  may  be  opened, 
the  fingers  or  even  the  hand  inserted  into  it,  the  cardiac  orifice 
dilated,  and  the  obstruction  removed. 

When  once  the  foreign  body  has  passed  into  the  stomach, 
purgatives  and  emetics  should  be  avoided,  and  if  not  of  large  size 
and  irregular  shape,  the  case  is  left  to  Nature,  the  treatment 
being  merely  expectant.  The  patient  is  kept  quiet,  and  fed  on 
pultaceous  food — such  as  brown  bread,  porridge,  etc. — and  the 
motions  are  carefully  examined.  Should,  however,  the  foreign 
body  be  large,  and  the  gastric  symptoms  persist,  it  should  be  re- 
moved by  gastrotomy. 

Inflammation  of  the  oesophagus,  with  or  without  ulceration, 
is  caused  by  swallowing  corrosives  or  irritants,  and,  in  a  more 
localized  form,  by  the  impaction  of  foreign  bodies.  The  symptoms 
are  pain  and  difficulty  in  deglutition,  and  the  treatment  consists 
in  the  restriction  of  the  diet  to  liquids,  whilst  in  bad  cases  rectal 
feeding    may  be    necessary.     Chronic    catarrh    results    from    the 


SoS 


A   MANUAL  OF  SURGERY 


continual   drinking  of   raw   spirits,   and  stenosis  from  cicatricial 
contraction  may  gradually  follow. 

Varix  of  the  veins  in  the  lower  portion  of  the  oesophagus  is 
occasionally  met  with  as  the  result  of  pressure  on  the  portal  vein, 
or  from  cirrhosis  of  the  liver.  This  is  due  to  the  fact  that  these 
branches  open  into  the  gastric  division  of  the  portal  system, 
passing  through  the  oesophageal  opening  in  the  diaphragm. 
Haematemesis  may  result,  and  has  even  proved  fatal. 

Spasm  of  the  (Esophagus,  or  hysterical  stricture,  arises  in 
neurotic  young  women,  usually  under  twenty-five  years  of  age, 
and,  although  sometimes  independent  of  organic  lesion,  is  often 
associated  with  some  slight  abrasion  or  ulceration  of  the  mucous 
membrane,  perhaps  originated  by  the  impaction  at  an  earlier  date 

of  a  fishbone.  The  symptoms 
complained  of  are  difficulty  in 
swallowing,  and  a  sensation  as 
of  a  ball  arising  in  the  throat 
(globus  hystericus),  due  to  a  spas- 
modic action  of  the  pharyngeal 
constrictor  muscles.  At  times, 
when  the  patient's  attention 
is  diverted,  deglutition  occurs 
quite  normally.  The  best 
course  of  treatment  is  anti- 
neurotic  in  character  (e.g.,  cold 
douches  to  the  spine,  massage, 
the  administration  of  purga- 
tives, valerian,  etc.),  whilst  the 
passage  of  a  full-sized  oeso- 
phageal bougie  is  useful. 

Organic  Stricture  of  the  (Eso- 
phagus occurs  in  two  forms — - 
the  fibrous  and  the  malignant : 

i.  Fibrous  Stricture  of  the 
(Esophagus  is  usually  located 
near  its  commencement,  just 
behind  the  cricoid  cartilage, 
and  is  most  frequently  caused 
by  the  swallowing  of  corrosives, 
and  the  cicatrization  of  the 
wounds  caused  thereby  ;  it  also 
results  from  syphilitic  disease.  At  the  cardiac  orifice  it  may  arise 
from  the  healing  and  contraction  of  a  gastric  ulcer.  The  main 
symptom  produced  is  a  gradually  increasing  difficulty  in  the  swal- 
lowing, firstly  of  solids,  but  finally  even  of  fluids.  If  the 
obstruction  is  placed  at  the  upper  end  of  the  tube,  food  is 
returned  immediately  ;  but    if  lower  down,  the  oesophagus   may 


Fig.  291. — Cancerous  Growth  of 
the  (Esophagus.  (Treves'  Sur- 
gery.) 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  OESOPHAGUS  809 


become  dilated,  and  in  this  pouch  or  cesophagocoele  the  food 
collects  for  a  time,  and  then  returns  unchanged.  There  is  but 
little  pain  in  this  form  of  stricture,  although  the  patient  is  usually 
able  to  indicate  the  level  of  the  obstruction.  As  the  case  pro- 
gresses, he  becomes  steadily  emaciated  from  sheer  starvation,  and 
may  even  die  from  this  cause. 

2.  Malignant  Stricture  of  the  Oesophagus  is  usually  epithelio- 
matous  in  type,  occurring  in  subjects  over  forty  years  of  age, 
and  situated  either  at  the  junction  of  the  pharynx  and  oesophagus, 
i.e.,  behind  the  cricoid  cartilage  (Fig.  291),  or  in  the  middle  of 
the  tube,  where  it  is  crossed  by  the  left  bronchus  or  at  the 
cardiac  orifice  of  the  stomach  ;  in  the  latter  site,  columnar  carci- 
noma is  the  form  usually  found.  The  growth  involves  the 
whole  circumference  of  the  tube,  and  sooner  or  later  ulcerates, 
perhaps  perforating  the  trachea,  pleural  cavity,  or  one  of  the  large 
vessels.  Secondary  deposits  occur  in  the  lymphatic  glands,  either 
of  the  neck  or  posterior  mediastinum,  visceral  complications  being 
uncommon.  The  symptoms  are  similar  in  character  to  those  of 
fibrous  stenosis  detailed  above,  but  in  addition  the  vomited 
materials  may  contain  blood,  and  there  is  a  good  deal  of  cough 
and  pain,  referred  usually  to  the  site  of  the  disease.  Should  the 
growth  be  at  the  upper  end  of  the  tube,  a  tumour  may  be 
distinctly  felt,  placed  deeply  in  the  neck  and  more  marked  on 
the  left  side  ;  in  the  earlier  stages  nothing  can  be  felt  externally, 
although  the  side-to-side  movements  of  the  larynx  may  be  im- 
peded. Perforation  of  the  trachea  leads  to  the  entrance  of  food 
into  the  air  passages,  and  rapidly  results^in  septic  pneumonia  and 
death.  When  the  upper  part  of  the  gullet  is  affected,  the  growth 
may  spread  to  the  back  of  the  larynx,  and  cause  hoarseness  and 
even  aphonia.  Occasionally  the  pneumogastric  nerves  may  be 
involved  in  the  mass,  leading  to  interference  with  the  action  of  the 
heart,  whilst  implication  of  the  recurrent  laryngeal  nerve  causes 
constant  cough  and  uni-  or  bi-lateral  paralysis  of  the  larynx. 

The  Diagnosis  of  oesophageal  stricture  must  be  made  on  general 
principles,  and  by  a  process  of  exclusion  of  the  many  other  forms 
of  dysphagia  detailed  below.  It  is  confirmed  by  examining  the  con- 
dition of  the  tube  with  an  oesophageal  bougie.  A  conical-ended 
instrument  of  medium  size  should  be  employed  for  diagnostic 
purposes,  and  by  this  means  the  situation  of  the  obstruction  can 
be  ascertained.  To  pass  an  oesophageal  bougie  :  The  surgeon  stands 
in  front  and  slightly  to  the  right  of  the  patient,  who  is  seated  with 
the  head  held  forwards — if  thrown  backwards,  the  larynx  is 
pressed  against  the  spine,  and  the  difficulty  of  introducing  the 
instrument  increased.  The  bougie  is  well  warmed  and  smeared 
with  glycerine,  and,  having  been  suitably  curved,  is  guided  by  the 
surgeon's  left  index- finger  over  the  epiglottis  into  the  oesophagus. 
This  stage  usually  causes  a  certain  amount  of  discomfort  and 
retching  on  the  part  of  the  patient.     Once  past  the  entrance  to 


A   MANUAL  OF  SURGERY 


the  larynx,  the  bougie  is  pushed  steadily  onwards ;  if  there  is  no 
stricture,  the  instrument  will  enter  the  stomach  about  16  inches 
from  the  teeth.  If  any  obstruction  is  present,  the  large  instru- 
ment is  withdrawn,  and  the  passage  of  a  smaller  one  attempted. 
The  greatest  care  must  be  taken,  especially  in  suspected  malignant 
disease,  as  it  is  by  no  means  difficult  to  perforate  the  walls  and 
open  up  the  mediastinal  tissues,  even  causing  fatal  cellulitis.  A 
cancerous  stricture  sometimes  feels  rough  and  is  painful ;  a  simple 
stricture  is  smooth,  regular,  and  almost  painless.  It  is  by  no 
means  easy  to  distinguish  the  two  forms,  and  the  history  of  the 
case  and  general  condition  of  the  patient  will  need  to  be  thoroughly 
investigated;  a  hacking  cough  with  no  special  pulmonary  symptoms 
is  always  a  bad  and  suggestive  sign. 

Treatment  of  Fibrous  Stricture  of  the  (Esophagus. — (a)  Dilatation 
of  the  stricture  by  means  of  gradually  increasing  bougies  ;  for 
this  purpose  it  is  better  to  use  conical-ended  instruments  rather 
than  the  usual  type,  which  are  of  the  same  calibre  throughout. 
An  interval  of  some  days  should  elapse  between  the  attempts 
at  dilatation,  and  during  this  period  the  patient  should  be  given 
as  much  food  as  he  can  take  in  the  shape  of  strong  broths, 
minced  meat,  raw  eggs,  etc.,  or,  if  need  be,  rectal  alimentation 
must  be  resorted  to.  (b)  If  it  is  impossible  to  dilate,  or  if  the 
stricture  recurs,  a  Symond's  Tube  may  be  inserted.  It  consists  of 
a  gum-elastic,  funnel-shaped  tube,  passed  through  the  stricture 
by  a  whalebone  introducer,  the  funnel  resting  against  the  face 
of  the  stricture.  A  thread  attached  to  the  upper  end  is  brought 
out  of  the  mouth  in  order  to  remove  and  clean  it,  a  proceeding 
needed  about  once  a  fortnight,  (c)  Internal  cesophagotomy  by  means 
of  a  concealed  knife  has  also  been  attempted,  the  stricture  being 
divided  posteriorly  ;  it  is  a  somewhat  risky  proceeding,  and  is  only 
feasible  when  the  lesion  is  situated  high  up  in  the  tube,  (d)  When 
the  contraction  is  at  the  pharyngeal  extremity,  it  may  be  possible 
to  open  the  oesophagus  below,  and  either  divide  and  dilate  the 
stenosed  portion,  or  ecsophagostomy  may  be  performed  by  sewing 
the  mucous  membrane  to  the  skin,  thus  forming  an  entrance 
to  the  alimentary  canal  in  the  neck.  Under  these  circum- 
stances, it  is  better  practice  to  completely  divide  the  oesophagus, 
closing  the  upper  end  by  sutures,  and  fixing  the  lower  end  to  the 
margin  of  the  wound,  (e)  If  the  cardiac  orifice  of  the  stomach 
is  contracted,  the  stomach  may  be  opened  as  in  gastrotomy, 
and  the  fingers  used  to  dilate  the  stricture  (retrograde  dilata- 
tion), a  proceeding  similar  to  Loreta's  operation  for  stricture  of 
the  pylorus.  (/)  Where  none  of  these  proceedings  are  possible, 
or  if  tried  have  failed,  the  stomach  may  be  opened,  and  division 
of  the  sticture  by  Abbe's  string  saw  attempted.  The  patient  is 
made  to  swallow  one  end  of  a  piece  of  string,  or  a  small  shot 
may  be  clamped  on  a  piece  of  fine  silk,  and  allowed  to  find  its 
way  into  the  stomach.     When  this  viscus  is  opened,  the  free  end 


AFFECTIONS  OF  THE  MOUTH,   THROAT,  AND  CESOPHAGUS  Sn 

is  secured,  and  by  its  means  a  coarse  silk  thread  is  carried 
through  the  obstruction  ;  by  up-and-down  sawing  movements  the 
stricture  can  be  thereby  divided,  enabling  the  surgeon  to  introduce 
bougies.  Excellent  results  have  been  reported  from  such  practice. 
(g)  Gastrostomy  is  the  final  resource  ;  occasionally,  when  the 
oesophagus  has  by  this  means  been  kept  at  rest  for  some  time, 
the  stricture  will  yield,  and  dilatation  by  bougies  becomes  prac- 
ticable. In  such  a  case  the  opening  in  the  stomach  may  be 
allowed  to  close. 

Treatment  of  Malignant  Disease  of  the  (Esophagus. — Dilatation 
by  bougies  should  not  be  employed  as  a  routine  practice,  for  fear 
of  increasing  the  ulceration,  causing  severe  haemorrhage,  or  per- 
forating the  walls  of  the  tube.  It  may,  however,  be  used  as  a 
temporary  measure  in  the  earlier  stages  to  enable  the  patient  to 
take  an  increased  amount  of  food,  and  thus  for  a  time  improve  his 
general  condition  and  render  him  more  fitted  to  undergo  further 
treatment.  Symonds'  method  of  tubage  may  be  utilized  in  malig- 
nant disease,  the  patients  often  bearing  the  inserted  tube  well,  even 
when  the  cardiac  orifice  is  involved,  the  lower  end  then  projecting 
into  the  cavity  of  the  stomach.  Unfortunately  these  tubes  occa- 
sionally slip  through  into  the  stomach,  or  the  guiding  string  is 
swallowed  ;  moreover,  under  the  best  circumstances  the  tube  needs 
changing  every  fortnight,  and  the  ulceration  may  be  increased 
thereby.  Hence  gastrostomy,  performed  as  soon  as  possible  by  one 
of  the  modern  methods,  is  a  much  more  satisfactory  plan  of  treat- 
ment. Excision  of  the  growth  in  the  neck  has  been  successfully 
accomplished  in  a  few  cases  when  the  disease  was  recognised  early, 
and  very  limited  in  extent.  Tracheotomy  is  occasionally  required 
in  the  later  stages,  from  implication  of  the  glottis  or  trachea. 

By  the  term  Dysphagia  is  meant  a  condition  in  which  swallowing  is  painful 
or  difficult.  The  Causes  are  very  numerous,  and  may  be  arranged  as 
follows  : 

i.  Pharyngeal — e.g.,  acute  or  chronic  inflammation,  whether  simple,  scarlatinal, 
diphtheritic,  etc.  ;  ulceration  of  syphilitic  or  malignant  origin  ;  stenosis,  as  a 
result  of  ulceration  ;  paralysis  (eg.,  labio-glosso-laryngeal  or  bulbar)  or  spasm  ; 
impaction  of  foreign  bodies  ;  naso-pharyngeal  polypi  projecting  behind  the 
velum  ;  retro-pharyngeal  abscess  or  tumour,  etc. 

ii.  Laryngeal — eg.,  acute  or  chronic  laryngitis;  tuberculous,  syphilitic,  or 
malignant  disease. 

iii.  (Esophageal  —e.g.,  acute  or  chronic  inflammation,  impaction  of  foreign 
bodies,  the  presence  of  diverticula,  cesophagospasm,  and  simple  or  malignant 
stricture. 

iv.  Extrinsic.  In  the  neck  :  goitie,  enlarged  glands,  aneurisms,  etc. ;  in  the 
thorax  :  mediastinal  growths  or  glands,  aneurisms  of  the  aorta  and  large  vessels, 
tumours  growing  from  the  vertebral  bodies,  pericardial  effusion,  and  displace- 
ment backwards  of  the  sternal  end  of  the  clavicle. 

To  investigate  a  ease  of  dysphagia,  note  :  (i.)  the  method  of  onset,  whether  acute 
or  chronic — if  the  former,  it  is  probably  due  to  a  foreign  body  ;  (ii.)  the  condition 
of  the  pharynx  as  seen  from  the  mouth  and  on  digital  exploration  ;  (iii.)  the 
condition  of  the  neck  as  seen  and  felt  from  without,  whether  or  not  a  tumour 
is  to  be  felt  behind  the  cricoid,  or  whether  a  goitre  or  aneurism  exists  ;  (iv. )  the 
character  of  the  voice,  as  indicative  or  not  of  larvngeal  mischief — if  the  voice 


812  A   MANUAL  OF  SURGERY 

is  husky,  a  laryngoscopic  examination  must  be  made;  (v.)  the  chest  must  be 
carefully  examined  for  aneurisms,  etc.  ;  (vi.)  the  oesophagus  may  be  auscultated 
along  the  vertebral  groove  whilst  the  patient  drinks  water  to  ascertain  the 
situation  of  the  mischief;  (vii.)  it  must  be  examined  finally  by  bougies.  If 
the  obstruction  is  in  the  oesophagus,  the  patient's  age  and  general  condition 
will  give  prima  facie  evidence  as  to  whether  or  not  it  is  due  to  malignant 
disease;  but  it  must  not  be  forgotton  that  the  stenosis  per  se  causes  some  of 
the  loss  of  flesh  and  of  weight.  The  presence  of  blood  and  offensive  mucus  on 
the  bougie  or  in  the  material  vomited,  and  the  existence  of  enlarged  glands  in 
the  neck,  will  also  assist  in  establishing  a  diagnosis. 


CHAPTER  XXVIII. 

AFFECTIONS  OF  THE  EAR. 

It  is  impossible  to  do  more  than  deal  with  some  of  the  more 
important  surgical  aspects  of  diseases  of  the  ear  in  this  place,  and 
for  a  more  detailed  consideration  of  the  subject  we  must  refer  our 
readers  to  special  text-books. 

The  External  Ear  is  the  site  of  various  affections  which  may 
come  under  the  observation  of  the  general  surgeon.  Thus,  the 
pinna  may  be  congenitally  absent,  and  even  the  external  meatus 
closed,  a  malformation  often  associated  with  macrostoma. 
Nothing  can  be  done  for  this  want  of  development,  and  the 
surgeon  must  never  be  tempted  to  try  and  dig  out  the  concealed 
membrana  tympani.  More  frequently  accessory  auricles  are  pre- 
sent, consisting  merely  of  fibro-cartilage  covered  with  fat  and  skin. 
Large  and  prominent  ears  constitute  a  very  unsightly  deformity, 
for  which  operative  interference  is  occasionally  required.  The 
size  may  be  diminished  by  removing  a  V-shaped  portion  from  the 
upper  part ;  the  prominence,  by  excising  a  portion  of  skin  and 
cartilage  through  an  incision  on  the  posterior  aspect.  The  wounds 
thus  produced  are  accurately  sutured  together,  and  considerable 
improvement  in  the  appearance  results.  Haematoma  of  the  ear 
is  usually  due  to  injury,  but  is  occasionally  idiopathic  in  origin, 
especially  amongst  the  insane.  The  auricle  becomes  swollen 
and  enlarged,  and  of  a  bluish-red  colour  in  traumatic  cases 
(Fig.  292) ;  unless  inflamed  it  should  not  be  interfered  with,  as  a 
general  rule,  although,  if  the  appearance  of  the  patient  is  important, 
it  may  be  advisable  to  remove  the  blood,  since  its  organization 
and  subsequent  contraction  may  lead  to  considerable  deformity. 
Eczema,  boils,  and  other  inflammatory  affections,  are  met  with  in 
the  external  ear  and  pinna,  but  these  call  for  no  special  mention. 

Plugs  of  wax  (cerumen),  which  become  dark  and  indurated,  not 
unfrequently  block  the  meatus,  leading  to  more  or  less  complete 
deafness  ;  this  may  come  on  suddenly  after  bathing,  owing  to  the 
plug  rapidly  swelling  up.  If  they  encroach  on  the  membrana 
tympani,  subjective  symptoms  of  giddiness,  vomiting,  and  rushing 
noises  in  the  ear  may  also  be  caused.     On  examination  with  an 


8i4 


A    MAN  (LI  I,  OF  SURGERY 


Fig.  292. — Hematoma  Auris. 


ear  speculum,  their  presence  is  readily  detected.     Treatment  con- 
sists in  washing  them  away,  after  previously  softening  with  oil  or 

glycerine.  A  large  syringe  with  a 
fine  nozzle  should  be  used,  and  a 
stream  of  warm  water  injected  along 
the  roof  of  the  meatus  ;  as  it  returns, 
the  softened  masses  of  wax  are 
washed  away.  Foreign  bodies  in  the 
meatus,  such  as  buttons  or  beads, 
are  similarly  removed,  if  possible,  by 
syringing  ;  if  this  fails,  a  fine  pair  of 
forceps  is  employed  for  the  purpose, 
but  it  must  be  remembered  that 
behind  the  foreign  body  lie  delicate 
structures,  which  can  readily  be 
harmed  by  the  exhibition  of  im- 
patience or  force.  Where  all  other 
plans  fail,  the  auricle  may  be  turned 
forwards  and  the  meatus  opened  from 
behind.  Exostoses  are  occasionally 
met  with  springing  from  the  bony 
walls  of  the  meatus;  they  give  rise 
to  deafness  by  obstructing  the  passage,  and  may  be  removed  by 
the  dental  drill. 

The  Surgical  Complications  of  Chronic  Otorrhcea  are  frequently 
serious,  and  call  for  prompt  treatment.  The  discharge  usually 
comes  from  the  middle  ear  (otitis  media)  through  a  perforation  in 
the  tympanic  membrane.  It  must  be  noted  that  the  tympanic 
cavity  is  lined  by  a  mucous  membrane  which  is  in  direct  communi- 
cation through  the  Eustachian  tube  with  that  lining  the  nasal 
fossae  ;  and  since  this  membrane  is  adherent  to  the  periosteal 
lining  of  the  cavity,  every  case  of  otitis  media  is  likely  to  be 
associated  with  an  internal  periostitis  of  the  temporal  bone.  These 
complications  may  be  classified  under  three  main  headings — the 
extracranial,  the  cranial,  and  the  intracranial. 

The  extracranial  complications  of  otorrhcea  are  comparatively 
unimportant. 

(a)  Eczema  of  the  meatus  is  frequently  seen,  and  merely  needs 
the  parts  to  be  kept  dry  and  clean,  and  possibly  a  little  boric 
acid  powder  insufflated  ;  it  readily  disappears  when  the  discharge 
ceases,  but  is  not  unfrequently  associated  with  enlargement  of  the 
cervical  glands,  which  may  suppurate,  or  in  predisposed  indi- 
viduals may  become  the  seat  of  tuberculous  disease. 

(b)  Boils  arise  from  infection  of  the  sebaceous  glands  in  the 
meatus  with  pyogenic  cocci  from  the  discharge,  and  are  exceed- 
ingly painful  owing  to  the  denseness  of  the  tissues  involved. 
They  should  be  fomented,  and  opened  when  pus  has  formed. 


AFFECTIONS  OF  THE  EAR  Si 


(c)  Inflammation  may  occasionally  spread  from  the  meatus  to 
the  tympanic  plate  of  the  temporal  bone,  leading  to  subperios- 
teal abscess  and  necrosis  ;  or  it  may  extend  into  the  temporo- 
maxillary  articulation,  giving  rise  to  suppurative  arthritis  and 
disorganization  of  that  joint  (p.  750). 

The  cranial  complications  of  otitis  media  are  often  of  a  grave 
nature,  and  may  end  in  permanent  deafness,  or  even  endanger 
the  life  of  the  individual. 

(a)  The  ossicles  frequently  necrose,  and  are  cast  off  in  the 
discharge,  and  thus  hearing  may  be  impaired,  although  not 
necessarily  destroyed  ;  ankylosis  of  the  ossicles  one  to  another 
may  also  be  determined,  leading  to  considerable  loss  of  function. 

(b)  The  inflammation  may  extend  from  the  lining  membrane  of 
the  tympanum  to  the  bony  walls  surrounding  it,  giving  rise  to 
a  limited  caries  or  necrosis  of  the  temporal  bone.  This  may  be 
associated  with  suppuration  within  the  skull,  and  any  of  the 
intracranial  complications  mentioned  below.  The  roof  of  the 
tympanic  cavity  (tegmen  tympani),  which  is  very  thin,  is  especially 
liable  to  be  affected  in  this  way.  If  diseased  bone  can  be  felt 
through  the  external  auditory  meatus  with  a  probe,  an  attempt 
should  be  made  to  remove  it ;  if  this  is  impossible,  the  part  must 
be  kept  clean  by  the  injection  of  mild  antiseptics,  retention  of 
discharges  being  prevented  by  the  regular  use  of  Politzer's  bag. 

(r)  Polypi  may  also  develop,  consisting  essentially  of  granulation 
tissue  protruding  through  the  opening  in  the  membrane  ;  they 
lead  to  considerable  obstruction,  and  may  do  harm  by  keeping 
back  the  discharge.  They  should  be  removed  by  the  curette, 
and  the  bare  bone,  usually  felt  at  their  base,  scraped ;  the  part 
is  subsequently  syringed  with  a  weak  carbolic  solution  and 
dressed  antiseptically. 

(d)  Facial  paralysis  not  uncommonly  arises  from  sclerosis 
and  thickening  of  the  bony  tissue  surrounding  the  aqueductus 
Fallopii,  causing  pressure  on  the  nerve  in  that  region.  It  must 
be  remembered  that  the  bony  canal  lies  immediately  behind  the 
tympanic  cavity,  and  to  the  inner  side  of  the  passage  from  the 
attic  to  the  mastoid  antrum  (iter  ad  antrum).  All  the  muscles  on 
that  side  of  the  face  are  involved,  and  possibly  also  the  palate  and 
uvula.  No  radical  treatment  is  practicable,  although  the  face 
should  be  regularly  faradized,  so  as  to  maintain  as  far  as  possible 
the  tone  of  the  muscles. 

(e)  Inflammation  may  also  extend  into  the  mastoid  cells,  giving 
rise  to  the  condition  known  as  mastoiditis.  The  mastoid  process 
is  a  triangular  mass  of  bone,  which  is  practically  undeveloped 
until  the  age  of  puberty.  Before  that  period  a  single  cell  rela- 
tively of  large  size  communicates  with  the  posterior  portion  of 
the  tympanic  cavity  and  represents  the  antrum  ;  but  after  puberty 
the  whole  bone  becomes  hollowed   out  into  a  series  of  spongy 


8i6  A   MANUAL  OF  SURGERY 


cells,  lined  with  mucous  membrane,  which  open  into  the  floor 
of  the  antrum.  When  the  inflammation  in  otitis  media,  which  has 
almost  always  become  septic,  extends  into  this  bony  process, 
severe  local  and  general  symptoms  are  likely  to  result.  The 
patient  complains  of  intense  pain  in  the  ear,  with  tenderness  on 
pressure,  and  perhaps  redness  and  oedema  over  the  mastoid 
process.  The  discharge  from  the  ear  often  ceases  for  a  time  at 
the  commencement  of  these  symptoms,  but  reappears  later  on. 
As  the  case  progresses,  febrile  symptoms  of  an  intermittent  type, 
and  even  rigors,  may  supervene,  whilst  the  patient  becomes 
drowsy,  or  may  be  irritable  and  restless.  An  abscess  may  form 
under  the  periosteum  covering  the  mastoid  process,  with  or 
without  caries  or  necrosis  of  the  outer  table  of  the  bone  ;  in 
children,  where  this  bony  lamella  is  thin,  it  is  not  unfrequently 
absorbed,  and  on  incising  the  abscess  protuberant  masses  of 
granulations,  springing  from  the  interior  of  the  bone,  may  be  seen. 
When  an  abscess  has  developed,  the  auricle  is  characteristically 
displaced  downwards  and  outwards.  Any  of  the  intracranial 
complications  mentioned  below  may  occur  as  sequelae.  Occa- 
sionally the  mastoid  trouble  is  of  a  more  chronic  type,  and  even 
tuberculous  in  nature,  the  cells  being  choked  up  with  lymph  and 
inflammatory  material  of  a  cheesy  nature,  whilst  the  bone  itself 
becomes  thickened  and  condensed.  The  process  feels  distinctly 
enlarged,  and  a  good  deal  of  deep-seated  pain  of  an  aching 
character  is  experienced,  and  worse  at  night. 

When  the  discharge  is  inspissated  and  mixed  with  epithelial 
cells  and  cholesterine,  so  as  to  form  flaky  masses  like  the  layers 
of  an  onion,  the  condition  is  known  as  cholesteatoma.  It  is  often 
the  cause  of  great  distension  of  the  antrum,  which  in  a  case 
operated  on  by  one  of  us  measured  quite  i|  inches  across.  The 
symptoms,  at  first  of  a  chronic  type,  are  likely  to  be  followed 
sooner  or  later  by  an  acute  attack  of  septic  inflammation. 

Treatment. —  In  the  early  acute  stage  belladonna  fomentations 
may  be  employed,  and  the  patient  kept  quietly  in  bed,  whilst  the 
diet  is  regulated  and  a  suitable  purgative  administered  ;  accu- 
mulated discharge  is  removed  from  the  tympanum  by  the  use 
of  Politzer's  bag.  Two  or  three  leeches  may  also  be  applied 
over  the  mastoid  process,  and  relief  to  the  pain  thus  obtained, 
though  it  is  often  only  of  a  temporary  character.  It  is  most 
important  not  to  rely  upon  such  palliative  measures  for  too  long, 
but  when  the  symptoms  are  well  marked,  even  in  the  early  stages, 
and  before  suppuration  has  occurred,  it  is  good  practice  to  make 
an  incision  (Wilde's  incision)  down  to  the  bone,  reaching  from  the 
base  to  the  apex  of  the  process ;  much  relief  is  always  obtained 
by  this  procedure,  and  the  inflammatory  phenomena  are  some- 
times completely  checked.  Should  this  not  succeed,  the  mastoid 
antrum  must  be  laid  open  and  its  contents  evacuated  (Schwartze's 
operation).      Many  instruments  have  been  suggested  in  order  to 


AFFECTIONS  OF  THE  EAR  Si  7 

accomplish  this ;  thus,  it  has  been  recommended  to  use  the  brad- 
awl, trephine,  gouge,  or  gimlet ;  the  gouge  is,  however,  probably 
the  best,  if  a  burr  worked  by  a  surgical  engine  is  not  obtainable. 
A  curved  incision  is  made  immediately  behind  the  ear,  which  is 
drawn  well  forwards  (Fig.  293),  and  the  gouge  applied  on  a  level 
with  the  roof  of  the  external  auditory  meatus,  and  about  -|  inch 
behind  its  centre  (Fig.  294).  A  small  dimple  in  the  bone  can 
often  be  felt  at  the  required  spot,  which  can  also  be  found  by 
taking  the  point  of  junction  of  two  lines  drawn  as  tangents  to 
the  roof  and  posterior  wall  of  the  bony  meatus  respectively 
(Fig.  295,  C).  The  direction  taken  by  the  gouge  should  be 
slightly  downwards,  forwards,  and  inwards,  and  a  useful  guide 
will  be  found  in  a  probe  passed  down  the  external  auditory 
meatus,  the  boring  being  made  exactly  parallel  to  this.     In  an 


t'-^^ja^ 


Fig.  293. — Incision  for  Mastoid        Fig.  294  .—Site  for  Drilling  Bone 
Operations.  in  order  to  open    the    Mastoid 

Antrum. 

It  is  often  well  to  apply  the  chisel  as  indicated  here  so  as  to  include  a  triangle, 
the  centre  of  which  corresponds  to  the  apex  of  the  so-called  supra-meatal 
triangle.  As  soon  as  the  outer  layers  of  the  bone  have  been  removed  by 
the  chisel,  the  gouge  is  used  to  reach  the  deeper  parts. 

adult  the  mastoid  antrum  is  reached  about  three-fifths  of  an  inch 
from  the  surface  of  the  bone.  The  surgeon  recognizes  that  he 
has  opened  the  cavity  by  the  loss  of  resistance,  and  the  escape 
of  exceedingly  offensive  pus.  The  opening  is  then  freely  enlarged 
by  the  use  of  the  gouge  and  cutting  pliers,  and  the  cavity  syringed 
out  through  the  external  meatus.  Diseased  bone  in  the  mastoid 
process  or  around  the  tympanic  cavity  may  be  scraped  away,  and 
the  wound  plugged  with  antiseptic  gauze ;  it  should  be  syringed 
through  from  the  external  meatus  daily.  In  the  more  chronic 
cases  it  may  be  advisable  to  split  off  the  whole  of  the  outer 
coating  of  bone  from  the  mastoid  process,  so  as  to  lay  open  all  the 
cells,  which  will  often  be  found  filled  with  inspissated  pus. 

In  the  more  severe  forms  it  is  recommended  to  detach  the 
auricle  posteriorly  from  the  bony  margins  of  the  meatus,  and 
then  to  gouge  away  the  whole  of  the  osseous  tissue  intervening 

52 


8i8  A   MANUAL  OF  SURGERY 


between  the  meatus  and  tympanic  cavity  in  front  and  the  mastoid 
antrum  behind.  A  metal  guide  is  passed  from  the  opening  in  the 
antrum  into  the  attic  along  the  iter,  and  all  the  bone  in  front  of 
the  guide  may  be  safely  removed.  The  facial  nerve  and  superior 
semicircular  canal  lie  behind,  and  are  protected  by  the  guide. 
The  remains  of  the  membrane  and  the  ossicles  are  then  removed, 
and  the  whole  cavity  well  curetted.  The  deep  portion  of  the 
posterior  wall  of  the  cartilaginous  meatus  is  incised  longitudinally 
and  the  margins  of  the  aperture  stitched  to  the  posterior  edge  of 
the  wound,  the  meatus  thus  leading  to  the  whole  of  the  opening 
in  the  bone,  which  can  in  this  way  be  syringed  out  and  cleaned 
more  efficiently  (Stacke's  operation).  The  results  of  this  proceeding 
have  been  very  satisfactory,  but  the  proximity  of  the  facial  nerve 
must  never  be  forgotten,  and  the  anaesthetist  should  be  instructed 
to  watch  the  face  continuously  for  any  twitching,  which  indicates 
that  the  nerve  is  being  touched,  inasmuch  as  the  surgeon  is 
working  at  the  side,  and  cannot  see. 

The  intracranial  complications  of  otorrhcea  are  subcranial 
abscess,  localized  or  diffuse  meningitis,  thrombosis  of  the  lateral 
sinus,  and  abscess  in  the  cerebrum  or  cerebellum. 

(a)  Subcranial  Abscess. — When  the  roof  of  the  tympanum  or 
any  part  of  the  lining  of  that  cavity  which  encroaches  on  the 
cranium  becomes  inflamed  or  carious,  suppuration  between  the 
skull  and  dura  mater  may  ensue.  The  membranes  are  gradually 
stripped  from  the  bone  by  the  increasing  pressure  of  the  exuda- 
tion, and  symptoms  of  cerebral  compression  and  irritation  are 
thereby  induced.  Accumulations  of  pus  occur  most  commonly 
along  the  summit  of  the  petrous  portion  of  the  temporal  bone, 
and  in  the  sulcus  in  which  the  lateral  sinus  is  lodged.  The 
patient  complains  of  pain  and  headache,  which  increase  for  a 
time  and  are  then  followed  by  drowsiness,  which  may  pass  into 
coma.  The  temperature  is  usually  raised,  but  rigors,  even  if 
present  at  first,  are  by  no  means  a  constant  feature  of  the  case. 
The  pulse  is  of  the  usual  febrile  type,  viz.,  full  and  bounding. 
There  is  no  pain  in  the  neck  along  the  course  of  the  jugular  vein, 
but  retraction  of  the  head  occurs  if  basal  meningitis  is  present, 
and  vomiting  is  a  marked  symptom.  Optic  neuritis  may  be 
observed  in  consequence  of  the  inflammation  extending  to  the 
membranes  at  the  base  of  the  brain.  There  may  be  some  tender- 
ness on  pressure  over  the  temporal  region,  and  even  possibly 
oedema.  In  some  cases  the  pus  finds  its  way  outwards  along  the 
mastoid  emissary  vein,  or  through  the  suture  between  the  occipital 
and  temporal  bones      (See  also  p.  690.) 

The  Diagnosis  from  cerebral  abscess  is  sometimes  a  matter  of 
considerable  difficulty.  The  symptoms,  however,  set  in  some- 
what more  acutely,  whilst  the  temperature  is  raised,  and  the  signs 
of  irritation  of  the  membranes,  such  as  retraction  of  the  neck,  all 


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820  A  MANUAL  OF  SURGERY 


suggest  that  the  lesion  is  extradural,  and  not  cerebral  in  origin. 
The  pulse  is  fast,  and  not  slow,  and  focal  symptoms  are  less  likely 
to  develop. 

The  Treatment  consists  in  trephining  above  and  behind  the 
meatus,  so  as  to  escape  the  lateral  sinus,  and  in  much  the  same 
situation  as  for  a  temporo-sphenoidal  abscess  (q.v.).  The  pus  is 
washed  out,  and  a  drainage-tube  inserted  for  a  few  days. 

(b)  Meningitis  may  be  localized  or  diffuse.  The  former  often 
accompanies  some  other  condition,  and  is  in  itself  of  little  moment. 
It  may  produce  fixed  headache,  but,  if  non-suppurative,  usually 
disappears  when  the  originating  disease  has  been  cured.  The 
diffuse  variety  is  generally  septic  in  nature,  and  secondary  to  some 
suppurative  affection  in  the  neighbourhood,  or  to  thrombosis  of 
the  lateral  sinus.  For  symptoms,  see  p.  691.  Occasionally  a 
simple  serous  effusion  occurs  within  the  meninges,  leading  to 
increased  pressure  and  consequent  drowsiness,  but  disappearing 
entirely  when  the  cause  has  been  removed. 

(c)  Thrombosis  of  the  Lateral  Sinus  arises  from  direct  extension 
of  the  inflammatory  process  from  the  middle  ear  through  the 
mastoid  bone,  or  it  may  be  set  up  by  a  septic  thrombosis  of  the 
mastoid  emissary  vein  spreading  to  the  sinus.  A  clot  forms 
within  it,  which,  gradually  increasing  in  size,  leads  finally  to 
occlusion  of  its  lumen.  Infection  with  pyogenic  organisms  deter- 
mines disintegration  of  the  clot,  septic  emboli  are  detached,  and 
thus  pyaemic  symptoms  originated.  In  well-marked  cases  the 
thrombus  extends  as  far  back  as  the  Torcular  Herophili,  and 
downwards  along  the  jugular  vein  into  the  neck. 

The  most  marked  Symptom  of  the  case  is  the  sudden  appear- 
ance of  a  high  temperature,  which  is  usually  remittent,  and 
associated  with  rigors,  vomiting,  and  localized  pain  in  the  head, 
perhaps  most  marked  over  the  point  of  emergence  of  the  emissary 
vein  at  the  posterior  border  of  the  mastoid  process.  The  pulse  is 
slow  and  easily  compressible,  and  in  the  later  stages  the  patient 
is  drowsy  and  dull,  probably  from  serous  exudation  within  the 
meninges.  The  discharge  from  the  ear,  which  may  have  been 
previously  offensive,  usually  ceases.  Optic  neuritis  may  or  may 
not  exist,  being  often  preceded  by  photophobia.  If  the  thrombus 
extends  into  the  neck,  a  firm,  tender,  elongated  swelling  is  felt  in 
the  region  of  the  jugular  vein,  and,  owing  to  the  interference  with 
the  venous  circulation,  the  face  often  becomes  dusky.  Stiffness  of 
the  muscles  at  the  back  of  the  neck  is  an  evidence  of  a  certain 
amount  of  associated  basal  meningitis,  as  is  also  the  optic  neuritis. 
Suppuration  may  occur  outside  the  sinus,  or  around  the  vein  in 
the  neck,  which  becomes  swollen,  red,  and  cedematous. 

In  well-marked  cases  the  Diagnosis  is  easily  made,  but  in  the 
early  stages,  and  especially  in  children,  it  is  often  a  matter  of 
some  difficulty.  The  abrupt  onset,  the  oscillating  temperature, 
the  recurrent  rigors,  the  pain  in  the  neck,  and  the  deep  tenderness 


AFFECTIONS  OF  THE  EAtf  821 

on  pressure  over  the  course  of  the  lateral  sinus  or  jugular  vein, 
are  the  most  trustworthy  signs  of  this  affection. 

Treatment,  to  be  successful,  should  be  undertaken  early.  The 
skull  is  trephined  at  a  spot  about  j  inch  above  Reid's  base  line, 
and  about  1  inch  behind  the  centre  of  the  external  auditory  meatus 
(Fig.  295,  A  or  B).  The  outer  wall  of  the  sinus  is  thereby 
exposed,  and  a  puncture  with  a  fine  needle  readily  determines 
whether  it  contains  fluid  blood  or  thrombus.  If  it  is  thrombosed, 
there  is  often  some  evidence  of  inflammation  or  pus  around  it, 
between  the  dura  mater  and  the  bone.  Having  thus  verified  the 
diagnosis,  an  incision  is  made  along  the  anterior  border  of  the 
sterno-mastoid,  through  which  the  jugular  vein  is  tied  at  a  spot 
below  the  lowest  point  of  the  thrombus,  so  as  to  prevent  the 
escape  of  any  more  emboli  into  the  general  circulation.  The 
lateral  sinus  is  now  freely  opened,  and  the  septic  thrombus  partly 
scraped,  partly  washed  away,  additional  bone  being  removed  if 
necessary.  It  is  desirable,  but  not  essential,  to  completely  remove 
the  lower  part  of  the  thrombus  ;  if  such  is  attempted,  the  jugular 
must  be  opened  above  the  ligature,  and  the  clot  syringed  away. 
Bleeding  occurs  from  the  posterior  part  of  the  upper  opening  as 
soon  as  all  the  coagulum  is  removed,  but  it  is  easily  controlled  by 
plugging  the  sinus  with  a  small  piece  of  aseptic  sponge  or  gauze. 
The  wound  in  the  neck  should  be  lightly  stuffed  and  not  closed, 
since  septic  infection  is  almost  certain  to  follow.  The  upper  wound 
is  also  packed  in  the  same  way,  and  allowed  to  granulate. 

(d)  Abscess  in  the  cerebrum  or  cerebellum,  a  complication  not 
unfrequently  met  with,  has  been  already  discussed  (p.  718). 


CHAPTER  XXIX. 

SURGERY  OF  THE  NECK. 

Affections  of  the  Neck. 

Affections  connected  with  the  Branchial  Clefts.  —  In  the  second  or  third  week 
of  intra-uterine  life  a  series  of  branchial  arches  form  in  the  human  embryo, 
as  in  other  mammalia,  constituting  the  foundation  from  which  the  future 
structures  of  the  neck  are  developed.  In  the  majority  of  mammals  five  such 
post-oral  arches  occur,  separated  from  one  another  by  the  so-called  branchial 
clefts  ;  but  in  man  the  fourth  and  fifth  are  amalgamated.  They  project  from 
the  side  of  the  primitive  spinal  column,  and  consist  of  mesoblast  lined  on 
either  side  by  epithelium,  They  unite  across  the  median  line  at  an  early  date, 
and  also  one  with  another,  thereby  leading  to  a  large  extent  to  the  obliteration 
of  the  clefts.  Occasionally,  however,  this  union  is  imperfect,  and  sundry 
malformations  result. 

It  must  be  remembered  that  the  mandible  and  the  processus  gracilis  of 
the  malleus  arise  from  the  first  arch  ;  the  Eustachian  tube,  tympanic  cavity, 
external  auditory  meatus,  and  Glaserian  fissure  from  a  normally  unobliterated 
portion  of  the  first  cleft ;  the  styloid  process,  stylo-hyoid  ligament  and  lesser 
cornu  of  the  hyoid  bene  from  the  second  arch  ;  the  body  and  great  cornu  of 
the  hyoid  bone  from  the  third  arch  ;  and  the  rest  of  the  cervical  tissues  from 
the  remaining  arch  ;  whilst  the  second,  third,  and  fourth  clefts  are,  under 
ordinary  circumstances,  totally  obliterated. 

Branchial  Fistulse  are  due  to  imperfect  closure  of  the  branchial  clefts.  They 
consist  of  narrow  sinuous  tracts  extending  inwards  from  the  skin,  and  perhaps 
communicating,  but  not  necessarily  so,  with  the  pharynx.  The  external 
opening  is  usually  situated  along  the  anterior  border  of  the  sterno-mastoid, 
and  most  commonly  near  its  lower  end,  close  to  the  episternal  notch,  the 
fistula  then  arising  from  the  lowest  cleft.  They  are  lined  with  epithelium, 
and  secrete  a  glairy  or  mucoid  fluid.  They  are  not  uncommonly  associated 
with  other  abnormalities,  such  as  macrostoma,  absence  of  the  pinna,  or 
accessory  auricles  situated  either  near  the  orifice  of  the  fistula  or  close  to  the 
ear.  In  the  majority  of  cases  they  may  be  disregarded,  but  if  troublesome 
should  be  laid  open  and  the  lining  membrane  either  dissected  away  or 
destroyed  with  the  galvano-cautery. 

Branchial  Cysts  arise  from  incomplete  closure  of  a  branchial  cleft,  the 
unobliterated  portion  being  distended  with  secretion.  They  usually  appear  in 
adolescents,  often  between  the  ages  of  ten  and  twenty,  and  are  frequently 
attributed  to  a  blow,  which,  it  may  be  presumed,  brings  into  activity  struc- 
tures which  would  otherwise  have  remained  passive.  They  grow  slowly  and 
painlessly,  forming  rounded  swellings,  often  rather  soft,  with  more  or  less 
distinct  fluctuation,  according  to  the  depth  at  which  they  are  situated  ;  their 
contents,  if  near  the  cutaneous  end  of  the  cleft,  are  sebaceous  in  character, 
similar  to,  but  more  fluid   than,  that  found  in  dermoid  cysts  (viz.,  flattened 


SURGERY  OF  THE  NECK  823 


epithelial  cells,  cholesterine  plates,  and  fatty  granules).  If  placed  nearer  to 
the  pharynx  they  are  occupied  by  a  glairy  mucoid  fluid.  They  are  usually 
lined  with  squamous  epithelium,  but  a  few  cases  have  been  recorded  in  which 
the  cells  were  columnar,  and  even  ciliated,  in  character.  The  most  common 
situation  is  in  the  third  cleft,  the  cyst  then  lying  between  the  thyroid  cartilage 
and  the  anterior  border  of  the  sterno-mastoid,  in  relation  with  the  great  wing 
of  the  hyoid  bone  ;  when  of  large  size,  they  may  extend  beneath  that  muscle, 
displacing  it  outwards.  More  rarely  a  cyst  arises  from  the  second  cleft,  being 
then  located  in  the  upper  third  of  the  neck,  and  tending  to  spread  up  towards 
the  styloid  process  ;  it  may  even  reach  from  the  mastoid  process  to  the  hyoid 
bone,  running  parallel  to  the  posterior  border  of  the  jaw,  and  fluctuation  may 
be  detected  through  the  mouth.  Treatment  consists  in  extirpation  when  the 
condition  has  attained  sufficient  size  to  be  troublesome. 

Branchial  Carcinoma.  — Considerable  doubt  has  been  expressed  as  to  whether 
it  is  possible  for  carcinoma  to  originate  in  the  obliterated  remains  of  the 
branchial  clefts,  cases  which  might  have  been  considered  of  this  nature  being 
ascribed  to  developments  of  epithelioma  in  the  deep  lymphatic  glands  which 
have  undergone  cystic  degeneration,  and  secondary  to  some  undiscovered  or 
aborted  lesion  in  the  pharynx  or  larynx.  The  balance  of  evidence  is,  how- 
ever, in  favour  of  the  fact  that  carcinoma  can  start  in  this  way,  giving  rise 
tc  what  has  been  described  as  a  malignant  cyst  of  the  neck.  It  is  characterized 
by  the  formation  of  a  tumour  placed  deeply  beneath  the  sterno-mastoid, 
indefinite  in  outline,  and  of  firm  consistence.  Considerable  pain  is  experi- 
enced, and  lymphatic  glands  become  secondarily  enlarged.  The  disease  runs 
its  ordinary  course,  but  may  destroy  life  through  haemorrhage  from  the  main 
vessels,  which  are  invaded  by  the  tumour.  The  cyst  sometimes  gives  way 
into  the  pharynx,  and  a  malignant  ulcer  of  the  pharyngeal  wall  is  thus 
induced.  Pathologically,  the  condition  is  an  interesting  one,  since  the  tumour 
does  not  always  possess  the  characters  of  an  epithelioma.  Its  embryonic  origin 
is  sometimes  indicated  by  the  fact  that  myxomatous  and  cartilaginous  tissue  is 
included  in  its  substance.*  Treatment  is  usually  impracticable  owing  to  the 
deep  connections  of  the  growth. 

Various  other  congenital  conditions  may  be  met  with  in  the  neck.  Con- 
genital induration  of  the  sterno-mastoid  in  all  probability  arises  from  injury 
during  parturition,  and  usually  occurs  in  head  presentations,  probably  from 
bruising  of  the  side  of  the  neck  against  the  under  surface  of  the  symphysis ; 
it  is  said  to  be  more  common  on  the  left  side  than  on  the  right.  In  cases 
that  have  been  examined  microscopically,  the  indurated  mass  has  been  found 
to  consist  of  fibrous  tissue.  It  disappears  spontaneously  after  a  time,  but 
may  lead  to  torticollis  at  a  later  date.  The  congenital  form  of  torticollis 
(P-  378)i  cysts  in  connection  with  the  thyro-glossal  duct,  and  cystic  hygroma, 
may  also  be  mentioned. 

Cysts  of  the  Neck. 

1.  Cysts  of  Congenital  Origin. — (a)  Dermoids  occur  here  as  in 
any  other  region  where  congenital  remains  are  found.  As  already 
mentioned,  they  may  develop  from  the  branchial  clefts,  but  may 
also  be  found  in  the  middle  line,  or  in  connection  with  the  thyro- 
glossal  duct,  (b)  The  thyro-glossal  duct  (Fig.  296)  consists  of  a 
tubular  outgrowth  from  the  embryonic  pharynx  passing  down- 
wards behind  the  body  of  the  hyoid  bone  in  front  of  the  larynx 
and  trachea  as  far  as  the  isthmus  of  the  thyroid  gland,  which 
is  subsequently  developed  from  it,  and  unites  with  the  lateral 
lobes,  which  in  turn  spring  from  the  deeper  parts  of  the  branchial 
*  For  pathological  report  of  a  case  see  Veau,  Revue  tie  Chirurgie,  March,  1900. 


824  A   MANUAL  OF  SURGERY 


arches.  The  upper  end  of  this  duct  is  situated  at  the  foramen 
caecum  of  the  tongue,  and  thence  traverses  the  substance  of  that 
organ  between  the  genio-hyo-glossi  muscles  to  reach  the  hyoid 
bone ;  the  lower  end  is  represented  by  the  pyramid  of  the  thyroid 
isthmus.  The  whole  of  this  tube  disappears  under  ordinary 
circumstances  ;  if,  however,  the  upper  part  remains  unobliterated 
a  dermoid  cyst  may  originate  from  it,  placed  either  in  the  sub- 
stance of  the  tongue  or  immediately  below  it  (see  p.  784).  If  the 
lower  portion  remains  patent,  a  cyst  develops  containing  mucoid 


Fig.  296. — Median  Section  of  Tongue,  Larynx,  and  Trachea,  showing 
Thyro-glossal  Duct  extending  from  the  Foramen  C/ecum  of  the 
Tongue  downwards  behind  the  Hyoid  Bone,  and  in  Front  of  the 
Trachea  to  the  Isthmus  of  the  Thyroid  Body.  (Semi-diagram- 
matic, from  College  of  Surgeons'  Museum.) 

A  small  dermoid  cyst  in  the  centre  of  the  tongue  is  also  represented. 

or  glairy  fluid,  which,  however,  is  not  present  at  birth.  If 
it  bursts  spontaneously,  or  is  opened,  a  so-called  median  cervical 
fistula  results,  which  requires  the  same  treatment  as  a  branchial 
fistula,  viz.,  incision,  and  complete  removal  or  destruction  of  the 
epithelial  lining.  Accessory  thyroid  growths  of  an  adenomatous 
nature  may  develop  from  any  part  of  the  duct,  but  especially  from 
the  lower  end  ;  they  are  quite  innocent  in  nature,  and  unless 
troublesome  may  be  left  alone,  (c)  Cystic  hygroma  is  sometimes 
congenital,  but  may  also  be  acquired.  It  consists  of  a  multi- 
locular  swelling,  the  spaces  composing  it  being  due  to  dilatation 
of  lymphatic  spaces,  and  filled  with  serum.     The  tumour  is  often 


SURGERY  OF  THE  NECK  825 


of  considerable  size,  with  a  sinuous,  irregular  outline,  and  may 
produce  great  deformity  and  marked  pressure  effects.  The  skin 
over  it  may  be  occupied  by  dilated  capillaries  or  lymphatics. 
Unless  extending  to  inaccessible  parts,  such  as  the  superior 
mediastinum,  it  should  be  dealt  with  by  excision. 

2.  Acquired  Cysts  of  the  Neck  are  of  the  following  types  : 
(a)  Sebaceous  cysts  develop  in  the  skin  as  elsewhere,  but  need  no 
separate  notice,  (b)  Bursal  cysts  are  stated  to  occur  in  connection 
with  the  larynx  and  hyoid  bone.  There  is  usually  a  bursa  over  a 
prominent  pomura  Adami,  and  this  may  become  enlarged  and 
distended  with  fluid.  A  bursa  also  exists  between  the  back  of 
the  hyoid  bone  and  the  thyroid  cartilage,  which  might  easily  be 
mistaken  for  one  of  thyro-glossal  origin.  In  doubtful  cases  a 
microscopical  examination  of  the  lining  wall  will  quickly  settle 
the  diagnosis,  since  if  it  is  bursal  in  origin  it  is  lined  with  endo- 
thelium, whilst  if  it  is  thyro-glossal  it  is  lined  with  epithelium. 
In  the  former  case  incision  and  drainage  usually  suffice  to  bring 
about  a  cure,  although  excision  is  preferable  ;  in  the  latter  case 
the  lining  wall  must  be  entirely  removed,  (c)  Unilocular  serous 
cysts  are  sometimes  met  with  in  the  lower  part  of  the  posterior 
triangle,  constituting  the  condition  known  as  '  hydrocele  of  the 
neck.'  They  contain  serous  fluid  with  perhaps  an  admixture  of 
blood.  Their  origin  has  not  been  defined  with  any  certainty,  but 
they  are  probably  due  to  a  dilatation  of  the  lymph  spaces,  and 
are  best  treated  by  excision,  (d)  True  hydatid  cysts  also  occur  in 
this  region  (see  p.  187).  (e)  Blood  cysts  have  been  found  in  close 
connection  with  the  large  vessels  of  the  neck.  They  are  possibly 
due  to  the  dilatation  of  a  vein,  and  may  communicate  or  not 
with  some  vascular  channel,  such  as  the  jugular,  being  then 
partly  emptied  on  pressure.  Where  no  communication  with  a 
venous  trunk  exists,  the  lining  membrane  is  intensely  vascular. 
In  the  former  case  they  may  be  treated  by  excision,  securing  the 
vessels  with  which  they  communicate  above  and  below  ;  in  the 
latter  tapping  and  injection  of  perchloride  of  iron  may  suffice, 
or  they  may  be  opened  and  stuffed.  (/)  Cysts  are  also  occa- 
sionally met  with  in  connection  with  the  salivary  glands  and  the 
thyroid  body,  (g)  Malignant  cysts  arise,  as  already  mentioned, 
from  the  remains  of  the  branchial  clefts,  or  from  a  degeneration 
of  epitheliomatous  lymphatic  glands.  They  are  often  of  large 
size,  and  their  removal  is  impracticable  owing  to  the  adhesions 
which  they  contract  to  the  deeper  structures. 

Cut  Throat. 

Injuries  of  the  neck  are  commonly  met  with  in  cases  of  attempted 
homicide  or  suicide,  and  vary  much  in  severity  according  to  the 
extent  and  position  of  the  wound.  A  right-handed  suicide  usually 
cuts  his  throat  from  left  to  right,  and  therefore  the  incision  is  bold 


826  A   MANUAL  OF  SURGERY 


and  clean  on  the  left  side,  tailing  off  towards  the  right  ;  in  a  left- 
handed  suicide  the  incision  runs  in  the  opposite  direction.  A 
homicidal  cut  throat  varies  in  its  direction  according  to  whether 
it  is  done  from  behind  or  in  front,  and  also  with  the  hand  employed. 
If  the  front  of  the  neck  is  mainly  involved,  the  air-passages  are 
laid  open  and  the  patient's  life,  though  much  endangered,  is  not 
necessarily  destroyed.  If,  however,  the  wound  chiefly  affects  the 
side,  the  great  vessels  and  nerves  may  be  divided,  and  death  from 
haemorrhage  is  very  liable  to  ensue.  The  course  and  treatment 
of  the  latter  class  of  case  require  no  particular  notice,  since  the 
general  principles  relating  to  all  wounds  must  be  adhered  to. 
Where,  however,  the  air-passages  have  been  opened,  special 
complications  arise,  requiring  suitably  modified  treatment. 

Wounds  involving  the  Air-passages,  the  result  of  cut  throat,  may 
be  situated  at  four  different  levels  :  (a)  above  the  hyoid  bone, 
encroaching  on  the  base  of  the  tongue ;  (b)  through  the  thyro- 
hyoid space,  the  most  common  situation;  (c)  in  the  larynx;  and 
(d)  opening  or  dividing  the  trachea. 

The  immediate  effects  of  such  lesions  are  due  to  shock,  haemor- 
rhage, asphyxia,  or  the  entrance  of  air  into  veins.  When  above  the 
hyoid  bone,  the  root  of  the  tongue  and  submaxillary  region  are 
involved,  and  haemorrhage  from  the  lingual  or  facial  arteries  or 
their  branches  follows ;  if  the  wound  extends  far  enough,  the 
main  vessels  are  divided,  and  death  results.  In  the  less  severe 
cases  the  patient  runs  considerable  risk  of  being  suffocated  by  the 
epiglottis  and  base  of  the  tongue  falling  back  over  the  larynx. 
Much  difficulty  will  be  subsequently  experienced  in  feeding  the 
patient,  owing  to  impairment  of  the  movements  of  the  tongue. 
When  the  thyvo-hyoid  space  is  opened,  the  origins  of  the  facial  and 
lingual  arteries  are  again  in  danger,  as  also  the  upper  part  of  the 
superior  thyroid.  The  base  of  the  epiglottis  is  divided,  and 
portions  of  mucous  membrane  around  the  entrance  of  the  larynx 
may  be  detached,  and  cause  obstruction  to  respiration.  Blood 
may  also  trickle  down  the  larynx  into  the  trachea,  and  lead  to 
asphyxia.  Wounds  of  the  larynx  are  usually  transverse,  and  not 
very  extensive,  owing  to  the  resistance  offered  to  the  knife  by  the 
cartilage.  The  thyroid  body  may  be  wounded  and  bleed  freely, 
otherwise  there  is  but  little  haemorrhage.  Blood  may  find  its 
way  into  the  trachea  or  lungs,  and  asphyxiate  the  patient.  WThen 
the  trachea  is  involved,  the  common  carotid  and  inferior  thyroid 
vessels  are  very  liable  to  be  wounded,  giving  rise  to  severe,  if  not 
fatal  haemorrhage.  Asphyxia  may  be  brought  about  by  displace- 
ment of  the  severed  portions  of  the  tube,  or  from  the  entrance  of 
blood  into  the  air-passages,  whilst  air  may  also  be  sucked  into 
opened  veins.  The  recurrent  laryngeal  nerve  may  be  divided, 
causing  paralysis  of  the  larynx. 

The  secondary  effects  following  cut  throat  are  mainly  inflam- 
matory in  origin,     (a)  Any  form  of  septic  inflammation  may  occur 


SURGERY  OF  THE  NECK  827 


in  the  wound,  possibly  giving  rise  to  cellulitis,  which  may  spread 
downwards  to  the  mediastinum.  Where  it  involves  the  tissues 
above  the  entrance  to  the  larynx,  oedema  of  the  glottis  may  be 
produced.  Secondary  haemorrhage  also  arises  from  this  cause, 
and  even  general  pyaemia,  (b)  Inflammation  of  the  air-passages, 
tracheitis,  bronchitis,  or  broncho-pheumonia,  frequently  follows, 
partly  as  a  result  of  the  entrance  of  cold  air,  partly  from  the 
admission  of  septic  material,  such  as  food,  decomposing  blood- 
clot  or  discharges.  The  patient  may  become  cyanosed  from  these 
causes,  and  in  consequence  of  this  partial  asphyxia,  the  sensibility 
of  the  mucous  membrane  of  the  glottis  is  diminished,  allowing  of 
the  passage  into  it  of  food  which  appears  at  the  mouth  of  the 
wound  ;  in  some  cases  this  may  have  arisen  from  division  of  the 
superior  laryngeal  nerve,  but  the  depth  at  which  this  structure  is 
situated  in  the  neck  makes  it  difficult  to  conceive  how  it  could  be 
divided  without  injury  to  the  main  vessels,  (c)  Surgical  emphysema, 
or  the  entrance  of  atmospheric  air  into  the  cellular  tissue,  may 
also  follow  a  wound  of  the  air-passages.  It  is  not  limited  to  the 
neck,  but  extends  to  the  trunk,  being  recognised  by  the  puffy 
distension  of  the  part,  and  by  a  soft  crackling  crepitus  elicited  on 
pressure.  It  is  of  no  great  consequence,  and  usually  disappears 
in  a  few  days,  (d)  Septic  traumatic  fever  is  almost  always  present 
in  these  cases,  the  temperature  varying  with  the  extent  of  the 
inflammation  in  the  cellular  tissue  or  in  the  lungs. 

The  Treatment  consists  in  securing  all  bleeding-points,  if  pos- 
sible, but  occasionally  they  are  placed  so  deeply  that  it  is  neces- 
sary to  tie  the  external  carotid.  General  oozing  from  the  surface 
must  be  attended  to,  for  fear  of  blood  being  sucked  into  the  air- 
passages  ;  if  it  persists  after  thoroughly  opening  the  wound  and 
exposing  it  to  the  cold  air,  it  must  be  checked  by  sponge  pressure. 
Every  attempt  should  be  made  to  render  the  wound  aseptic,  and 
if  there  is  a  reasonable  prospect  that  this  has  been  attained,  it  may 
be  closed  by  sutures  in  the  ordinary  way.  Where,  however, 
asepsis  is  doubtful,  only  the  ends  of  the  incision  should  be  drawn 
together,  the  central  portion  being  left  open. 

The  treatment  of  the  air  passages  varies  with  the  site  of  the 
lesion.  If  the  trachea  has  been  roughly  divided,  the  portions 
should  be  steadied  by  a  stitch  on  either  side,  and  a  tracheotomy- 
tube  inserted — at  any  rate,  for  a  few  days ;  in  some  cases  where 
cleanly  cut,  total  closure  without  the  use  of  a  tube  can  be  safely 
effected.  When  the  wound  involves  the  larynx,  it  is  desirable  to 
close  the  opening  at  once,  since  the  larynx  does  not  readily 
tolerate  the  presence  of  a  tube  ;  if  it  is  necessary  to  introduce  one, 
it  is  better  to  perform  a  high  tracheotomy.  When  the  wound 
involves  the  thyro-hyoid  space,  or  is  situated  above  the  hyoid  bone, 
it  is  quite  safe  in  many  cases  to  close  the  wound  layer  by  layer 
after  carefully  disinfecting  it.  The  mucous  membrane  is  first 
dealt  with  by  stitches  which  do  not  penetrate  its  whole  thickness, 


8?8  A  MANUAL  OF  SURGERY 


and  then  a  more  thorough  purification  of  the  wound  can  be  under- 
taken ;  if  the  epiglottis  is  divided,  it  must  be  accurately  sutured. 
If  there  is  any  doubt  as  to  the  advisability  of  this  proceeding,  a 
high  tracheotomy  is  first  performed,  and  then  the  wound  closed 
as  far  as  possible. 

In  every  instance  the  head  should  be  flexed  on  the  chest,  and 
in  suicidal  cases  a  careful  watch  maintained  to  prevent  the  patient 
tearing  the  wound  open.  Extreme  shock  from  loss  of  blood  is 
dealt  with  by  the  infusion  of  saline  solution,  and  the  patient's 
general  health  attended  to.  Feeding  should  always  be  under- 
taken through  a  tube  passed  into  the  oesophagus,  whether  that 
structure  is  wounded  or  not,  and  such  should  be  continued  until 
the  patient's  natural  powers  of  swallowing  are  restored. 

The  following  Sequelae  occasionally  result  from  a  cut  throat : 
(a)  An  aerial  fistula  is  a  persistent  abnormal  communication 
between  the  air-passages  and  the  external  air,  and  occurs  most 
often  in  the  thyro-hyoid  space,  the  skin  and  mucous  membrane 
being  continuous  one  with  the  other  around  the  margins  of  the 
opening.  In  some  cases  it  may  be  closed  ;  but  if  laryngeal  stenosis 
or  adhesions  are  present,  it  must  be  left  alone  for  a  time  until  these 
conditions  have  been  treated.  The  operation  consists  in  separat- 
ing the  skin  from  the  mucous  membrane,  and  in  order  to  accom- 
plish this,  the  external  wound  must  be  enlarged  vertically.  The 
edges  of  the  mucous  membrane  are  then  pared,  and  stitched 
together  horizontally.  The  external  wound  is  either  left  open  to 
allow  of  the  escape  of  air  and  discharge,  or  may  be  partially  closed, 
and  a  drainage-tube  or  gauze  stuffing  inserted,  (b)  Laryngeal  or 
tracheal  stenosis,  due  to  the  cicatrization  of  wounds  in  these  regions, 
may  be  remedied  by  wearing  an  O'Dwyer's  tube  (p.  853)  for  a 
time,  or  may  necessitate  the  constant  use  of  a  tracheotomy-tube. 
(c)  Aphonia  may  arise  from  division  of  the  recurrent  laryngeal 
nerve,  and  is  then  usually  persistent,  (d)  Oesophageal  or  pharyngeal 
fistula  may  also  in  rare  instances  complicate  the  healing  of  an 
extensive  wound  in  the  throat,  but  tend  to  close  of  themselves, 
and  require  no  special  treatment. 

Diseases  of  the  Thyroid  Body. 

Goitre. — Enlargement  of  the  thyroid  body,  or,  as  it  is  termed, 
bronchocele  or  goitre,  is  a  condition  frequently  seen  in  this 
country,  and  to  which  much  attention  has  been  directed  of  recent 
years,  owing  to  the  discovery  that  the  thyroid  body  exercises 
considerable  influence  over  the  metabolism  and  nutrition  of  the 
body.  Total  absence  or  removal  of  the  gland  or  its  complete  de- 
generation leads  to  accumulation  of  mucin  in  the  body,  producing 
myxcedema  or  tetany  ;  whilst  recently  it  has  been  suggested  that 

*  For  fuller  information  than  can  be  given  here,  see  Berry,  '  Diseases  of  the 
Thyroid  Gland  and  their  Surgical  Treatment.'     J.  and  A.  Churchill.     1901. 


SURGERY  OF  THE  NECK  829 


the  symptoms  of  Graves'  disease  are  due  to  the  excessive  absorp- 
tion of  normal  or  vitiated  thyroid  secretion. 

The  Causes  of  bronchocele  are  still  enshrouded  in  a  good 
deal  of  uncertainty.  It  occurs  endemically  in  this  and  some 
other  countries,  being  especially  frequent  in  the  hilly  parts  of 
Derbyshire  and  Gloucestershire  (and  known,  in  fact,  as  Derby- 
shire neck),  whilst  it  is  also  exceedingly  common  in  Switzerland. 
The  old  idea  that  it  occurs  more  frequently  in  places  located  on 
chalk  or  magnesian  limestone  is  not  true,  it  being  more  common, 
perhaps,  in  regions  where  the  green  sandstone  and  carboniferous 
limestone  crop  up.  Possibly  the  disease  is  due  to  the  presence 
or  absence  of  some  mineral  constituent  of  the  drinking  water, 
and  the  discovery  made  by  Baumann,  of  Friburg,  suggests  that 
an  absence  of  iodine  is  the  cause  of  the  trouble.  At  any  rate, 
iodine  is  to  be  found  in  the  normal  thyroid  secretion  in  close 
combination  with  albumen,  whilst  it  is  absent  in  cases  of  goitre, 
the  enlargement  of  the  gland  being  looked  on  in  the  light  of 
a  compensatory  hyperplasia.  Other  causes  which  have  been 
suggested  are  want  of  sunshine  and  air,  as  in  the  case  of  individuals 
who  live  in  valleys  into  which  the  air  does  not  readily  penetrate, 
or  in  the  underground  kitchens  and  cellars  of  large  towns,  defective 
sanitary  conditions  and  the  habit  of  carrying  weights  upon  the 
head  also  possibly  assisting.  In  the  form  ordinarily  met  with,  it 
is  not  hereditary  to  any  great  extent,  and  is  not  influenced  by 
intermarriage ;  but  it  may  be  congenital,  and  if  associated  with 
skeletal  changes,  defective  growth,  and  intellectual  weakness, 
constituting  the  condition  known  as  cretinism,  and  in  reality  a 
manifestation  of  myxcedema,  it  certainly  runs  in  families.  Cre- 
tinism is,  however,  more  frequently  due  to  total  absence  of  the 
gland  than  to  degeneration  of  a  goitrous  tumour.  The  ordinary 
type  of  goitre  seen  in  this  country  is  much  more  common  in  women 
than  in  men. 

Varieties  and  Clinical  Features. — Four  chief  forms  of  goitre  are 
described,  viz. :  The  parenchymatous  or  simple,  the  cystic,  the 
fibro-adenomatous,  and  the  exophthalmic  ;  but  the  thyroid  body 
may  become  enlarged  in  other  ways,  giving  rise  to  the  conditions 
known  as  malignant  goitre  and  acute  goitre,  whilst  acute  inflam- 
mation is  sometimes  seen. 

General  Features.  —  In  all  these  cases  the  thyroid  body  is  the 
site  of  a  swelling  involving  its  whole  substance,  or  one  or  other 
of  its  lobes,  or  possibly  the  isthmus  alone.  Its  consistence  varies 
with  the  nature  of  the  growth,  but  it  always  moves  with  the 
larynx  on  deglutition.  In  every  form  there  is  probably  a  certain 
amount  of  anaemia,  whilst  some  of  the  symptoms  characteristic 
of  the  exophthalmic  variety  are  often  produced  even  in  simple 
cases,  possibly  from  the  excessive  absorption  of  thyroid  secretion. 
Pressure  on  surrounding  structures  leads  to  dyspnoea  or  dysphagia, 
and  cerebral  symptoms  may  arise  from  interference  with  the  main 


830 


A   MANUAL  OF  SURGERY 


vessels,  which  are  displaced  outwards.  The  trachea  is  especially 
liable  to  changes  of  situation  and  shape  from  its  compression  ;  it 
is  usually  flattened  from  side  to  side,  and  is  sometimes  pushed  an 
inch  or  more  from  the  middle  line  (Fig.  300) ;  atrophy  of  the 
cartilaginous  rings  may  also  be  induced.  Pressure  on  the  re- 
current laryngeal  nerve  leads  to  harshness  in  speaking  or  aphonia, 
and  to  spasmodic  attacks  of  dyspncea,  which  may  even  prove  fatal. 
Simple  or  Parenchymatous  Goitre  (Fig.  297)  consists  of  a  diffuse 
overgrowth  of  the  whole  thyroid  body,  the  parts  retaining  to  a 
great  extent  their  usual  proportions.  The  enlargement  is  due 
partly  to  an  overgrowth  of  the  glandular  tissue,  but  also  to  an 
accumulation  of  colloid   material   within   the  vesicles ;  a  normal 


Fig. 


297.- 


-Large  Simple  or  Parenchymatous  Goitre  involving 
the  whole  gland. 


amount  of  fibrous  stroma  is  usually  present.  The  whole  gland  is 
generally  involved,  but  possibly  one  lobe  is  larger  than  the  other. 
It  is  soft  and  elastic  to  the  touch,  quite  painless,  and  unless  large 
gives  rise  to  but  little  inconvenience.  Some  amount  of  lobulation 
is  occasionally  present.  Not  uncommonly  it  is  associated  with 
some  cystic  development  or  new  formation  of  an  adenomatous 
type  and  malignant  disease  is  always  preceded  by  this  condition. 
When  the  interstitial  tissue  is  abnormally  abundant,  as  often 
occurs  in  the  later  stages,  the  tumour  feels  harder  than  usual,  and 
is  more  definitely  lobulated.  It  is  then  termed  a.  fibrous  goitre,  and 
if  the  sclerosis  is  very  marked,  myxoedema  may  supervene. 

The  Fibro-adenomatous  Goitre  (Fig.  298)  consists  in  the  develop- 
ment of  one  or  more  encapsuled  adenomatous  nodules  in  the  sub- 
stance of  the  thyroid  body,  which  is  itself  concurrently  enlarged. 


SURGERY  OF  THE  NECK 


831 


These  nodules  are  perhaps  most  common  in  the  isthmus,  but  may 
occupy  one  or  other  lobe,  or,  when  multiple,  be  scattered  through 
the  substance  of  the  organ.  If  situated  near  the  surface,  their 
limitation  and  free  mobility  in  the  gland  can  be  easily  detected, 
but  when  placed  deeply  their  special  features  cannot  be  recognised. 
Two  varieties  have  been  described  :  (a)  The  foetal,  in  which  the 
growth  is  solid  and  homogeneous,  consisting  under  the  microscope 
of  closely  apposed  alveoli  in  which  there  is  no  colloid  develop- 
ment, and  identical  in  structure  with  embryonic  thyroid  tissue. 
Such  growths  are  usually  seen  in  young  people  ;  they  are  seldom 
very  large,  but  frequently  rather  vascular,  (b)  The  more  ordinary 
type  of  adenoma  resembles  ordinary  adult  thyroid  tissue  more 
closely  and  shows  a  considerable  tendency  to  cyst  formation.  It 
is  impossible  to  draw  an  exact  line  of  separation   between  this 


Fig. 


298. — Fibroadenoma  of  Isthmus  of  Thyroid  Body  in  a  Woman, 
aged  Twenty-three  Years. 


latter  condition  and  the  simple  hypertrophy,  which  is  often  of  a 
diffuse  adenomatous  nature. 

Cystic  Goitre  (Cysto-adenoma)  arises  from  the  dilatation  into 
cysts  of  alveolar  spaces  in  the  normal  gland  tissue  or  in  a 
localized  adenoma,  the  inter-alveolar  walls  being  absorbed.  They 
may  be  single  or  multiple,  and  contain  either  a  thin  fluid  or  a 
thick  grumous  colloid  material,  somewhat  like  furniture  polish. 
Intracystic  growths  of  a  papillary  nature  are  not  unfrequent. 
The  lining  membrane  of  these  cysts  is  epithelial  in  nature,  the 
individual  cells  being  cuboidal  when  the  cyst  is  small,  and 
flattened  out  or  squamous  when  large.  It  is  sometimes  intensely 
vascular,  and  haemorrhage  into  the  cysts  is  by  no  means  un- 
common, causing  the  contents  to  be  brown  or  blood-stained. 


832 


A   MANUAL  OF  SURGERY 


Secondary  changes  occur  in  any  of  these  varieties,  chiefly 
affecting  the  interstitial  tissue,  which  may  develop  into  cartilage 
or  bone,  or  may  calcify,  but  only  in  very  chronic  cases.  Haemor- 
rhage into  the  alveolar  spaces  or  cysts  is  not  uncommon  ;  acute 
infective  inflammation  may  also  involve  the  mass,  and  malignant 
disease,  usually  of  a  cancerous  nature,  sometimes  supervenes. 

The  Treatment  of  the  three  preceding  forms  of  goitre  may 
be  considered  together,  as  they  are  very  different  in  nature  to 
those  which  follow.  In  the  early  stages  palliative  measures  can 
be  employed,  consisting  in  the  improvement  of  the  general  health 
and  the  correction  of  errors  in  the  personal  and  sanitary  hygiene. 
Change  of  air  to  the  seaside  is  often  advisable,  whilst  iron  and 
iodide  of  potassium  may  be  administered  internally,  and  iodine 


Fig.  299. — Diffuse  Fibro-adeno- 
mata  of  Thyroid  Body  with  a 
tendency  to  become  cystic. 


Fig.  300. — Large  Unilateral 
Goitre  displacing  the  Trachea 
to  the  Right,  and  Compressing 
it  Laterally  to  a  Serious  Ex- 
tent.    (Tillmanns.) 


paint  or  iodide  of  potassium  ointment  applied  locally.  In  India 
cures  are  often  produced  by  inunction  of  iodide  of  mercury 
ointment,  the  part  being  subsequently  exposed  to  the  rays  of  the 
mid-day  sun  ;  such  treatment  is  generally  impracticable  in  this 
country.  The  deficient  amount  of  iodine  present  in  the  gland  in 
these  cases  explains  why  this  drug  is  so  pre-eminently  useful,  and 
it  has  been  found  that  the  active  principle  of  the  gland  isolated  by 
Baumann  and  called  '  thyro-iodine  '  is  the  best  form  in  which  it 
can  be  administered.  The  exhibition  of  thyroid  extract  is  some- 
times followed  by  a  diminution  of  a  simple  goitre,  and  the  same 
explanation  of  its  value  probably  holds  good. 

In  cases  where,  in  spite  of  such  treatment,  the  growth  persists 
or  increases  in  size,  other  measures  must  necessarily  be  employed, 


SURGERY  OF  THE  NECK  833 


and  there  is  no  doubt  that  removal  of  the  tumour  or  of  a  part 
of  the  gland  is  the  best  practice  to  adopt.  Total  extirpation, 
as  already  mentioned,  results  in  myxcedema  ;  but  as  long  as  a 
sufficient  portion  of  the  secreting  substance  is  left,  whether  it  is 
derived  from  the  isthmus  or  from  one  of  the  lobes,  no  such 
accident  need  be  feared.  The  operation  necessitates  a  somewhat 
deep  dissection,  and  will  encroach  on  important  structures;  but 
with  due  care  and  the  maintenance  of  efficient  asepsis,  the  most 
satisfactory  results  are  obtained,  except  when  the  growth  is  of 
very  great  dimensions.  We  would  particularly  emphasize  the 
fact  that  goitres  should  be  treated  in  the  same  way  as  other  new 
growths,  viz.,  by  removal  when  small.  There  is  still  unfor- 
tunately a  considerable  tendency  amongst  practitioners  and 
patients  to  leave  them  untouched  until  they  are  of  large  size,  thus 
greatly  increasing  the  risk  of  the  operation.  Other  plans  of  treat- 
ment have  been  utilized  in  the  past,  e.g.,  ligature  of  the  thyroid 
vessels,  division  of  the  isthmus,  curetting  the  mass  with  a  large 
Yolkmann's  spoon,  passage  of  a  seton,  or  intraglandular  injection 
of  irritants,  such  as  tincture  of  iodine  ;  but  they  should  be  entirely 
discarded  in  favour  of  more  radical  measures. 

Partial  thyroidectomy  (or  Kocher's  operation)  is  conducted  as 
follows  :  An  incision  is  made  over  the  most  prominent  part  of  the 
tumour,  preferably  along  the  lower  third  of  the  anterior  border 
of  the  sterno-mastoid.  Kocher  recommends  a  transverse  or 
angular  incision  in  order  that  the  scar  may  be  less  visible,  and 
this  may  be  employed  in  suitable  cases.  The  platysma  and  deep 
fascia  are  divided,  the  sterno-mastoid  drawn  outwards,  and  the 
sterno-hyoid,  sterno-thyroid,  and  omo-hyoid  displaced  inwards, 
or,  if  need  be,  divided.  The  lobe  to  be  removed  is  thus  exposed 
within  its  capsule,  which  should  not  be  opened.  The  limits  of 
the  mass  are  defined  by  the  finger  or  a  blunt  dissector,  and  the 
vessels  entering  or  leaving  it  are  secured.  The  superior  thyroid 
vessels  are  doubly  ligatured  and  divided  at  the  upper  end  of 
the  growth,  the  middle  thyroid  vein  is  secured  at  the  middle 
of  its  outer  border,  whilst  the  inferior  thyroid  vessels  are 
dealt  with  below,  special  care  being  taken  of  the  inferior  or 
recurrent  laryngeal  nerve  by  tying  the  vessels  as  near  to  the 
gland  as  possible.  The  lobe  is  now  freed  from  the  underlying 
structures,  as  also  the  isthmus  from  the  trachea.  In  detaching 
the  latter,  the  surgeon  must  not  forget  that  the  cartilaginous  rings 
may  have  been  absorbed,  and  that  the  walls  of  the  trachea,  being 
then  merely  fibrous  in  nature,  are  easily  wounded.  The  isthmus 
should  be  transfixed  and  tied  in  two  halves  with  a  silk  ligature,  so 
as  to  prevent  haemorrhage.  The  growth  can  now  be  removed, 
the  bleeding  points  secured,  and  the  wound  closed,  the  muscles 
and  fascia  being  drawn  together  by  buried  catgut  stitches.  A 
drainage-tube  is  best  inserted  for  twenty-four  or  forty  eight  hours, 
as  it  is  difficult  to  employ  much  pressure  on  the  neck,  but  this 

53 


834  A  MANUAL  OF  SURGERY 


precaution  may  sometimes  be  omitted.  Healing  by  first  intention 
should  be  the  invariable  result. 

Fibro '-adenomata,  when  multiple  or  deeply  placed,  are  treated  by 
extirpation  of  the  affected  lobe  ;  but  if  the  new  growth  is  single 
and  superficial,  its  enucleation  should  be  undertaken  by  the  pro- 
ceeding known  as  Socin's  operation,  which  has  been  mainly  popu- 
larized in  this  country  by  Mr.  C.  J.  Symonds,  of  Guy's  Hospital. 
The  skin  and  muscles  are  divided  as  before,  and  the  gland 
substance  and  capsule  incised  down  to  the  growth,  which  is 
readily  shelled  out. 

A  single  cyst  is  treated  in  the  same  way  as  a  fibro-adenoma, 
viz.,  by  enucleation  ;  if  several  cysts  are  present,  removal  of  the 
affected  lobe  may  be  necessary.  The  old  line  of  practice,  which 
is  still  occasionally  utilized,  consisted  in  tapping  with  a  full- 
sized  trocar  and  cannula,  and  injecting  with  tr.  ferri  perchlor.  or 
iodine.  Good  results  sometimes  followed  these  measures,  but 
occasionally  the  sudden  relief  of  tension  within  the  cyst  gave 
rise  to  severe  haemorrhage  from  its  walls,  which  threatened  the 
patient's  life.  In  such  cases  the  cyst  was  laid  freely  open,  and 
the  cavity  plugged  with  sponges  or  gauze  soaked  in  some  strong 
haemostatic  ;  or  it  was  sometimes  feasible  to  rapidly  enucleate  the 
whole  cyst,  and  then  command  the  haemorrhage  by  ligaturing  the 
supplying  vessels. 

Myxaedema  (or  cachexia  strumipriva)  is  a  curious  condition,  which,  as 
already  mentioned,  supervenes  when  the  thyroid  body  is  totally  removed,  or 
so  absolutely  disorganized  or  infiltrated  by  a  new  growth  as  to  be  functionless. 
Although  it  is  possible  that  we  still  have  much  to  learn  of  the  duties  of  this 
organ,  yet  we  do  know  that  the  elimination,  if  not  the  development,  of  mucin 
in  the  body  is  controlled  by  it,  and  that  its  absence  leads  to  an  accumulation 
of  this  substance  in  the  blood  and  tissues.  The  condition  and  appearance  of 
the  individual  are  very  characteristic.  The  face  is  puffy,  waxy  white,  and 
expressionless,  with  perhaps  a  hectic  flush  over  the  malar  eminences  ;  the 
tongue  is  enlarged  ;  the  limbs  become  thickened  and  clumsy  by  an  increase  in 
bulk  of  the  soft  tissues ;  there  is  often  a  puffy  mass  occupying  the  supra- 
clavicular fossa,  which,  however,  does  not  pit  on  pressure.  The  mental 
faculties  are  dulled,  and  all  intellectual  processes  are  slow  ;  the  temperature 
is  subnormal,  and  the  heart's  action  weakened.  Left  to  itself,  death  will 
supervene  from  asthenia  sooner  or  later  ;  should  the  case  be  treated  by  thyroid 
gland  or  extract  (half  a  gland,  raw  or  lightly  cooked,  twice  a  week,  or  a 
5 -grain  tabloid  once  or  twice  a  day),  the  symptoms  soon  disappear,  and  the 
change  from  the  dull,  heavy  condition  of  myxoedema  to  one  of  normal  health 
of  mind  and  body  is  almost  miraculous. 

Similar  treatment  should  be  employed  for  myxoedematous  cretins,  who  often 
start  growing  rapidly  as  soon  as  treatment  commences. 

Tetany  is  another  condition  which  sometimes  obtains  after  complete  removal 
or  disorganization  of  the  thyroid  body.  It  consists  in  a  peculiar  irritability  of 
the  gray  matter  of  the  spinal  cord,  resulting  in  the  development  of  tonic  con- 
traction of  groups  of  muscles  which  may  last  for  minutes,  hours,  or  even  a  day 
or  two ;  the  irritability  of  the  facial  nerve  is  especially  noticeable.  The  condition 
may  prove  fatal  from  spasm  of  the  respiratory  muscles,  but  is  more  usually 
chronic,  lasting  perhaps  for  years,  and  running  its  course  concurrently  with 
myxcedema.  It  is  supposed  to  be  due  to  actual  poisoning  with  mucin,  and 
the  treatment  required  is  the  same  as  for  myxcedema. 


SURGERY  OF  THE  NECK  835 

Exophthalmic  Goitre,  or,  as  it  is  often  termed,  Graves'  or 
Basedow's  disease,  is  a  condition  characterized  by  a  diffuse 
enlargement  of  the  thyroid  body,  which  often  pulsates  forcibly 
owing  to  the  dilatation  of  the  vessels  (particularly  those  in  the 
capsule),  associated  with  marked  anaemia,  severe  palpitation  and 
cardiac  irritability  (tachycardia),  and  protrusion  of  the  eyeball 
(exophthalmos  or  proptosis).  The  nature  of  the  disease  has  long 
been  a  topic  of  discussion,  one  of  the  earliest  ideas  being  that 
it  results  from  some  derangement  of  the  sympathetic  nervous 
system,  or  possibly  of  the  medulla.  Lately,  however,  owing  to 
the  fact  that  in  cases  where  thyroid  extract  has  been  given  to 
excess  symptoms  somewhat  akin  to  those  seen  in  this  condition 
have  arisen,  it  has  been  suggested  that  the  disease  is  due  to  the 
excessive  absorption  of  thyroid  secretion,  although  why  it  occurs 
in  some  cases  of  enlargement,  and  not  in  others,  has  not  been 
explained.  In  all  probability  the  truth  lies  half-way  between 
the  two  theories,  the  enlarged  thyroid  and  some  of  the  symptoms 
being  alike  due  to  some  central  disturbance  in  the  upper  part 
of  the  medulla,  whilst  others  are  due  to  excessive  absorption  of 
thyroid  secretion. 

The  patients  usually  affected  are  females,  about  the  middle 
period  of  life,  whose  menstrual  functions  are  often  impaired. 
Overwork,  worry,  and  severe  mental  strain,  are  apparently  re- 
sponsible for  the  onset  of  the  symptoms  in  many  instances,  and 
a  sudden  shock  or  fright  accounts  for  others.  The  protrusion  of 
the  eyeball  is  a  marked  feature  of  the  case,  and  is  sometimes 
due  to  an  increase  of  the  orbital  fat.  Contraction  of  the  so-called 
muscle  of  Miiller  (unstriped  muscular  fibres  stretched  across  the 
spheno-maxillary  fissure)  has  also  been  suggested  as  a  more 
plausible  theory.  When  the  patient  looks  down,  the  upper 
eyelid  does  not  immediately  follow  the  eyeball,  allowing  the 
white  sclerotic  to  be  seen  between  the  lid  and  the  cornea  (von 
Graefe's  sign).  A  fine  fibrillary  tremor  of  the  limbs  is  also 
commonly  observed  in  these  cases.  The  patient  is  always  ex- 
tremely nervous,  and  the  pulse-rate  high  ;  any  exertion  or 
excitement  increases  the  irritability  of  the  heart's  action,  and 
may  induce  considerable  respiratory  distress.  Leit  to  itself, 
the  disease  in  some  cases  tends  to  improve,  but  in  others  it 
may  progress  to  a  fatal  issue  from  asthenia  or  cardiac  compli- 
cations. 

Treatment  consists  in  freeing  the  patient,  if  possible,  from  all 
sources  of  worry,  whilst  bromides,  iron,  and  perhaps  iodide  of 
potassium,  are  administered  internally,  attention  being  aiso  directed 
to  correcting  menstrual  derangements,  or  any  other  abnormalities 
of  function  or  structure  ;  thus,  the  cure  of  a  nasal  catarrh  by 
cauterizing  the  nasal  mucosa  has  several  times  led  to  a  rapid 
amelioration  of  the  symptoms.  Phosphate  of  soda  has  lately 
been  much  commended  in  this  disease,  and  Kocher  speaks  favour 

53—2 


836  A  MANUAL  OF  SURGERY 

ably  of  it  when  conjoined  with  suitable  hygienic  measures. 
Thymus  extract  has  also  proved  beneficial. 

Since  the  introduction  of  the  theory  that  the  derangement  is 
mainly  thyroidal  in  origin,  surgical  treatment  by  removal  of  a 
portion  of  the  gland  has  been  suggested,  and  the  results  gained 
so  far  have  been  encouraging,  although  the  proceeding  is  not 
devoid  of  serious  risk,  and  should  not  be  lightly  undertaken. 
Half  of  the  gland  has  usually  been  removed,  but  some  surgeons 
have  been  satisfied  with  tying  three  of  the  thyroid  arteries  in 
order  to  starve  the  growth.  The  patients  never  take  an  anaes- 
thetic well,  and  several  fatal  results  have  ensued  from  this  cause. 
They  are  also  very  liable  to  syncope  after  the  operation,  and  occa- 
sionally a  curious  train  of  symptoms  supervenes  within  a  few 
hours.  The  temperature  rises  suddenly  to  1040  or  1050,  the  pulse- 
rate  is  greatly  accelerated,  and  the  patient  becomes  delirious 
and  finally  comatose,  dying  in  that  state  in  about  forty-eight  hours. 
It  is  supposed  that  excessive  thyroid  toxaemia  is  responsible  for 
these  phenomena.  The  wound  should  be  at  once  opened  up, 
and  probably  a  considerable  quantity  of  a  thin  glairy  fluid  will  be 
found  within  it.  This  should  be  soaked  up  by  repeatedly  packing 
the  wound  with  dry  aseptic  wool. 

In  the  cases  that  recover,  a  gradual  improvement  usually  shows 
itself,  but  the  full  benefit  of  the  operation  is  rarely  gained  under 
six  or  twelve  months,  and  even  then  the  exophthalmos  often 
persists.  It  is  a  little  doubtful  whether  the  improvement  is  really 
to  be  ascribed  to  the  operation,  or  to  the  altered  environment 
necessitated  by  it.  The  symptoms  sometimes  recur  at  a  later 
date,  and  such  cases  have  been  treated  by  removing  another 
portion  of  the  gland. 

Excision  or  division  of  the  cervical  chain  of  sympathetic 
ganglia  has  also  been  employed  in  this  condition,  and  apparently 
with  good  effects ;  but  no  final  statement  as  to  its  value  can  yet 
be  hazarded. 

Malignant  Disease  of  the  Thyroid  Body  is  more  frequently 
cancerous  in  nature  than  sarcomatous,  usually  taking  the  form 
of  an  adenoid  cancer,  and  always  preceded  by  simple  enlarge- 
ment. The  tumour  grows  rapidly,  infiltrating  the  surrounding 
parts,  and  causing  enlargement  of  the  lymphatic  glands,  and 
secondary  deposits  in  the  viscera  and  elsewhere.  The  trachea  is 
severely  compressed,  and  in  some  cases  perforated  by  the  growth. 
The  secondary  deposits  frequently  affect  osseous  tissues,  con- 
stituting pulsating  tumours  exactly  simulating  thyroid  tissue  in 
nature.  Myxoedema  may  ensue  as  a  complication,  owing  to  the 
total  destruction  of  the  glandular  substance.  Treatment  by 
extirpation  can  only  be  undertaken  in  the  early  stages. 

Acute    Goitre    is   but   rarely  met  with,   consisting   of  a  rapid 


SURGERY  OF  THE  NECK  837 


enlargement  of  the  thyroid  body,  which  attains  a  considerable 
size  in  the  course  of  a  few  days  or  weeks.  It  affects  young 
subjects,  and  is  generally  fatal  from  asphyxia  due  to  pressure  on 
the  trachea  or  spasm  of  the  glottis.  Comparatively  little  can  be 
done  for  such  cases  ;  incisions  into  the  fascia,  division  of  the 
isthmus,  and  tracheotomy,  have  been  suggested.  In  the  latter 
case  it  will  be  necessary  to  have  a  specially  long  tube,  which  can 
be  passed  for  some  distance  down  the  trachea. 

Inflammation  of  the  Thyroid  Body,  or  acute  thyroiditis,  occa- 
sionally supervenes  as  a  complication  of  an  ordinary  goitre.  It 
is  almost  always  infective  in  nature,  the  cocci  reaching  it  from 
without,  as  in  a  punctured  wound,  or  from  within  the  body  on  a 
pyaemic  embolus,  suppuration  being  usually  induced  ;  it  some- 
times follows  a  blow,  and  may  then  be  simple.  The  gland 
becomes  enlarged,  hot  and  tender,  fever  and  rigors  follow,  and 
the  presence  of  pus  is  indicated  by  superficial  cedema  and  fluctua- 
tion. The  early  treatment  consists  in  the  application  of  fomenta- 
tions and  perhaps  leeches,  or  in  the  use  of  an  ice  compress.  The 
patient  is  kept  in  bed,  purged,  and  carefully  dieted.  Under  such 
a  regime,  resolution  may  occur  ;  but  if,  as  happens  more  frequently, 
pus  forms,  free  incisions  should  be  made. 

Accessory  Thyroids  sometimes  develop  above  or  below  the 
isthmus,  or  closely  attached  to  one  of  the  lateral  lobes.  They 
are  recognised  by  their  connection  with  the  thyroid  body,  moving 
up  and  down  with  it  on  deglutition,  and  if  troublesome  should  be 
removed.  They  may  also  occur  in  any  part  of  the  thyro-glossal 
duct,  and  even  in  the  base  of  the  tongue,  in  that  situation 
resembling  a  dermoid  cyst. 


CHAPTER   XXX. 
SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST. 

Foreign  Bodies  in  the  Air-passages. 

Any  part  of  the  respiratory  tract  may  be  partially  or  completely 
obstructed  by  the  presence  of   some  foreign  body,  the  effect  of 
which  may  be  of  greater  or  less  gravity  according  to  the  situation, 
character,  and  size  of  the  intruding  substance, 
i.  In  the  Nasal  Passages,  see  p.  757. 

2.  Obstruction  occurring  at  the  Rima  Glottidis,  or  pharyngeal 
entrance  to  the  larynx,  is  usually  due  to  attempts  to  bolt  large 
masses  of  food,  which,  becoming  impacted,  may  cause  immediate 
death.  A  person,  eating  a  meal  voraciously,  turns  black  in  the 
face  and  falls  off  his  chair,  dead.  A  similar  result  has  followed 
such  a  foolish  act  as  attempting  to  swallow  a  billiard  ball.  If 
the  obstruction  is  not  complete,  as  when  a  plate  of  false  teeth 
becomes  impacted,  great  dyspncea  is  caused,  and  absolute  inability 
to  swallow,  the  symptoms  rapidly  increasing  owing  to  oedema  of 
the  submucous  tissue  of  the  glottis.  Accidents  of  a  similar  nature 
may  occur  during  chloroform  narcosis,  an  epileptic  fit,  or  drunken- 
ness, some  such  substance  as  a  plate  of  teeth  being  dislodged  from 
the  mouth,  or  a  mass  of  food  being  vomited,  and  blocking  the 
entrance  to  the  larynx.  The  Treatment  must  be  very  prompt, 
since  there  is  no  time  to  lose.  The  mouth  should  be  forced  open 
by  the  handle  of  a  fork  or  anything  suitable  that  happens  to  be 
near,  and  the  finger  rapidly  swept  round  the  pharynx  so  as  to 
dislodge  the  foreign  body.  Failing  this,  laryngotomy  must  be 
performed  at  once,  and  artificial  respiration,  if  necessary,  instituted. 
In  less  urgent  cases  there  is  time  to  remove  the  substance  from 
the  mouth  with  the  assistance  of  a  frontal  mirror. 

3.  In  the  Larynx. — A  foreign  body  enters  the  larynx  by  inhala- 
tion during  a  deep  inspiratory  effort,  when  the  glottis  is  widely 
open.  Anything  large  is  likely  to  be  stopped  above  the  larynx, 
and  hence  the  type  of  foreign  bodies  we  find  in  this  region  consists 
of  small  coins,  buttons,  nutshells,  or  a  small  tooth-plate.  It  may 
cause  total  obstruction  and  immediate  death,  or  may  enter  one  of 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST    839 


the  ventricles,  and  only  produce  partial  obstruction,  as  evidenced 
by  a  sudden  sense  of  suffocation,  urgent  dyspnoea,  and  a  violent 
attack  of  coughing,  attended  perhaps  by  vomiting,  such  as  occurs 
when  anything  is  said  to  have  'gone  down  the  wrong  way.'  The 
voice  becomes  croupy  and  hoarse,  respirations  stridulous,  and  any 
movement  of  the  patient  may  for  some  time  bring  on  a  spasmodic 
fit  of  dyspnoea.  After  a  while  the  obstruction,  which  is  at  first 
partial,  may  become  complete  from  oedema  of  the  glottis,  whilst 
perichondritis  and  ulceration  or  necrosis  of  the  cartilages  may  be 
induced.  Laryngoscopic  examination  should  reveal  the  situation 
of  the  intruding  body.  The  Treatment  consists  in  attempting  to 
remove  it  through  the  mouth  with  suitably  curved  forceps  guided 
by  a  laryngoscope  (endo-laryngeal  method) ;  or,  failing  that,  a 
laryngotomy  is  performed,  and  the  body  dislodged  if  possible  from 
below.  Should  this  not  be  successful,  thyrotomy  (p.  845)  must 
be  undertaken. 

4.  In  the  Trachea. — To  lodge  in  this  situation  a  foreign  body 
must  be  small  enough  to  pass  through  the  glottis,  and  not  too 
heavy,  otherwise  it  drops  into  one  of  the  bronchi ;  it  may  become 
impacted,  if  it  has  jagged  edges,  but  is  not  uncommonly  free.  It 
may  remain  in  one  spot,  only  moving  when  the  patient  alters  his 
position  or  coughs,  and  then  the  longer  it  stays,  the  less  moveable 
it  is,  owing  to  its  becoming  embedded  in  mucus. 

The  Symptoms  may  be  described  as  those  of  obstruction,  irrita- 
tion, and  inflammation.  During  the  passage  of  the  body  through 
the  larynx,  the  patient  suffers  from  a  severe  attack  of  spasmodic 
dyspnoea  and  coughing,  which  may  last  for  some  time.  Later  on 
similar  attacks  may  be  induced  by  the  foreign  body  being  coughed 
up  against  the  lower  aspect  of  the  vocal  cords,  and  death  has 
even  resulted  from  its  impaction  in  the  larynx  brought  about  in 
this  way.  The  irritation  of  the  unusual  occupant  of  the  trachea 
produces  tracheitis,  with  frothy  expectoration  and  spasmodic 
cough ;  the  lower  it  lies,  the  less  the  irritation,  the  mucous 
membrane  being  apparently  less  sensitive  as  it  descends  from  the 
larynx.  Treatment  consists  in  performing  a  low  tracheotomy  with 
a  good-sized  opening,  and  if  possible  removing  the  intruding  body 
at  once ;  or  the  patient  may  be  inverted  and  the  back  well 
concussed  in  order  to  dislodge  it.  Failing  this,  the  wound  in 
the  trachea  must  be  left  widely  open,  by  inserting  a  wire  stitch 
through  each  side  of  the  incision  and  tying  the  ends  behind  the 
neck  ;  very  probably  the  body  will  be  expelled  through  it  during 
an  attack  of  coughing. 

5.  To  become  impacted  in  a  Bronchus,  the  foreign  body  must 
be  sufficiently  small  to  pass  through  the  rima  glottidis,  and  heavy 
and  smooth  enough  to  allow  of  its  dropping  down  the  trachea ; 
the  most  common  articles  met  with  are  buttons,  pebbles,  slate 
pencils,  an  O'Dwyer's  tube,  or  the  inner  cannula  of  a  tracheotomy- 
tube.    The  right  bronchus  usually  becomes  obstructed,  the  reason 


840  A  MANUAL  OF  SURGERY 

for  this  being  that  although  the  left  bronchus  is  more  in  a  direct 
line  with  the  trachea,  yet  the  right  is  the  larger,  the  septum 
between  them  lying  to  the  left  of  the  middle  line.  A  series  of 
symptoms  similar  to  those  described  above  manifests  itself,  viz., 
obstruction,  irritation,  and  inflammation.  The  obstruction  is 
twofold :  immediate,  as  a  result  of  the  passage  of  the  body 
through  the  glottis,  a  condition  due  more  to  spasm  than  to 
mechanical  causes ;  and  late,  as  a  sequence  of  its  lodgment 
in  the  bronchus.  Even  if  at  first  the  obstruction  is  partial,  it 
soon  becomes  complete  from  swelling  of  the  mucous  membrane; 
for  a  time  it  is  more  or  less  valvular  in  character,  allowing  exit 
to  air  during  expiration,  but  absolutely  preventing  its  entrance. 
Collapse  of  that  portion  of  the  lung  supplied  by  the  affected 
bronchus  is  thus  induced,  as  indicated  by  dulness  and  the  absence 
of  breath-sounds.  Irritation  and  inflammation  soon  follow,  re- 
sulting in  bronchitis,  the  formation  of  a  bronchiectasis,  and  peri- 
bronchial pneumonia ;  suppuration  ensues,  and  the  foreign  body 
may  be  expelled  sooner  or  later  with  a  sudden  gush  of  pus  during 
a  fit  of  coughing.  Thus,  in  a  case  treated  by  the  late  Mr.  William 
Rose  (grandfather  to  one  of  the  authors*),  a  beech-mast  was 
inhaled  in  November,  1812,  and  was  not  extruded  till  May,  1822, 
the  patient  having  in  the  meantime  developed  all  the  symptoms 
of  a  bronchiectasis.  Sometimes  the  abscess  may  extend  through 
the  lung  substance  to  the  pleura,  setting  up  a  localized  empyema, 
through  which,  when  opened,  the  article  is  expelled.  In  other 
cases  the  lung  becomes  riddled  with  abscesses,  and  the  patient 
dies  of  exhaustion. 

Treatment.  —  The  position  of  the  foreign  body  must  be,  if 
possible,  ascertained  by  careful  examination  of  the  lungs,  which 
may  reveal  a  certain  amount  of  collapse,  whilst  skiagraphy 
may  also  be  useful.  A  low  and  extensive  tracheotomy  is  then 
performed,  and  the  bronchi  examined  by  a  long  bullet  probe, 
suitably  curved.  The  foreign  body  may  thus  be  felt,  and  its 
removal  accomplished  by  a  delicate  pair  of  forceps,  a  loop  of 
wire,  or  a  coin-catcher.  Abscess  of  the  lung,  and  localized 
empyema,  are  dealt  with  by  incision,  and  it  is  possible  that  the 
foreign  body  may  be  removed  by  this  means  through  the  thoracic 
parietes. 

Injuries  of  the  Larynx. 

Several  conditions  arising  from  traumatism  of  the  upper  air- 
passages  have  been  already  described,  e.g.,  fracture  of  the  hyoid 
bone  (p.  443),  and  incised  wounds,  as  in  cut  throat  (p.  825). 

Occasionally  the  thyroid  or  other  cartilages  may  be  injured  or 
fractured  by  direct  violence,  as  in  garrotting,  causing  local  pain 
and  haemorrhage,  and  possibly  some  obstruction  to  the  respira- 

*  Lancet,  August,  1843. 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST     841 


tion.  As  a  rule,  no  treatment  is  required  beyond  keeping  the 
patient  quiet,  but  should  symptoms  of  dyspnoea  arise,  intubation 
or  tracheotomy  must  be  undertaken. 

Diseases  of  the  Larynx. 

The  study  of  laryngeal  diseases  can  only  be  briefly  referred  to  here,  since  it 
is  now  so  extensive  as  to  require  special  text-books. 

Before  the  student  can  understand  the  subject,  it  is  absolutely  essential  for 
him  to  master  the  use  of  the  laryngoscope.  This  consists  of  a  circular  mirror 
set  at  an  angle  on  the  end  of  a 

metal  stem,  which  is  inserted 

into  the  patient's  widely-opened  ,    '  ■.. 

mouth  in    such  a  way  that   it 

rests  against,  and  slightly  ele-  ..■  > 

vates,  the  soft  palate.     A  beam  •  ■ 

of    light    is    thrown    into    the  • \-  •  ; 

mouth,  either  from  an  electric  (  ..  \ 

head  -  lamp   on    the    surgeon's  \ 

forehead,  or  reflected  by  a 
frontal  mirror  from  a  suitable 

source   of    illumination.      The  " 

patient's  tongue,  held  with  a 
towel,  is  drawn  well  forwards  so 
as  to  enable  the  light  to  reach 

the  larynx,  the  image  of  which  "J 

is  seen  in  the  mirror.  Con- 
siderable practice  is  needed  in 
order  to  attain  any  facility  in 
the  use  of  this  instrument,  as 
also  to  be  able  to  recognise 
normal  from  abnormal  struc- 
tures. The  use -of  cocaine  to 
anaesthetize  the  fauces  is  in 
many  cases  indispensable.  It 
must  be  remembered  that  the 
image  is  always  inverted,  so 
that  the  anterior  portion  of  the 
larynx  appears  behind, but  there 
is  no  reversal  of  the  sides. 

Acute  and  Chronic  Laryngitis 
are  conditions  of  but  slight 
surgical  interest.  The  acute 
affection  arises  from  cold  or 
over-exertion  of  the  vocal  ap- 
paratus, and  is  characterized 
by  aphonia  (loss  of  voice)  and 
cough.   Locally,  the  vocal  cords 


({■>» 


Fig.  301. — CEdema  of  Glottis  and  Tongue 
from  Behind.     (College  of  Surgeons' 
Museum.) 
are  seen  to  be  hyperaemic  and    The  tongue  is  seen  to  be  enlarged  and  swollen, 
swollen.  The  Treatment  is  rather        and    the    aryteno-epiglottidean    folds   are 
medical  than  surgical,  although        cedematous,  so  that  the  entrance  to   the 
in  children  intubation  or  trache-        larynx  is  represented  by  a  mere  chink, 
otomy    may  be   sometimes   re- 
quired. 

Diphtheritic  Inflammation  of  the  Larynx  is  usually  met  with  as  an  extension 
of  a  similar  affection  of  the  fauces.  It  gives  rise  to  severe  dyspnoea  from 
obstruction  in  the  rima  glottidis,  and,  if  the  condition  does  not  yield  to  the 
injection  of  the  diphtheritic  antitoxin,  will  probably  require  intubation  or 
tracheotomy. 


842  A  MANUAL  OF  SURGERY 

Acute  (Edematous  Laryngitis,  or  oedema  of  the  glottis,  is  a  condition  of  con- 
siderable surgical  importance.  Causes. — (a)  It  is  either  secondary  to  some 
other  laryngeal  affection,  such  as  acute  catarrhal  laryngitis,  or  acute  peri- 
chondritis ;  or  (b)  may  extend  from  inflammatory  conditions  of  neighbouring 
tissues,  such  as  the  root  of  the  tongue,  or  the  submaxillary  region,  e.g.,  in 
cellulitis  or  Ludwig's  angina ;  or  it  may  be  secondary  to  a  retropharyngeal 
abscess.  (c)  It  is  also  not  un frequently  seen  in  children  from  drinking 
scalding  water,  as  from  the  spout  of  a  kettle,  or  sometimes  in  adults  from 
swallowing  corrosives,  (d)  It  may  result  from  the  presence  of  a  foreign  body. 
Characters.  —  The  folds  cf  mucous  membrane  extending  on  either  side  of  the 
epiglottis  both  to  the  root  of  the  tongue  and  backwards  to  the  arytenoid  car- 
tilages become  swollen  and  cedematous  from  a  serous  infusion  into  the  sub- 
mucous tissue  (Fig.  301).  The  same  condition  also  involves  the  inter-arytenoid 
fold  and  the  false  vocal  cords  (superior  thyro-arytenoid  folds),  extending  down 
as  far  as  the  true  cords.  The  process,  is  checked  at  this  level  owing  to  the 
absence  of  submucous  tissue,  the  vocal  cords  consisting  of  elastic  fibres, 
merely  covered  with  a  layer  or  two  of  squamous  epithelium.  The  epiglottis 
becomes  folded  laterally  upon  itself  as  a  leaf,  merely  leaving  a  valve-like  chink 
which  permits  of  expiration,  although  considerably  checking  inspiration.  The 
Symptoms  produced  by  this  condition  are  those  of  mechanical  dyspnoea, 
to  which,  not  unfrequently,  spasm  of  the  glottis  is  superadded,  and  this  is 
sometimes  of  sufficient  intensity  to  destroy  the  patient's  life.  There  may  be 
also  some  amount  of  febrile  disturbance.  The  diagnosis  is  made,  either  by 
passing  the  finger  into  the  pharynx,  when  the  rigid  swollen  epiglottis  can 
be  felt,  or  by  laryngoscopic  examination,  when  the  slit-like  opening  of  the 
glottis,  bounded  below  and  behind  by  thickened  cedematous  folds  of  mucous 
membrane,  can  be  seen.  Treatment  consists  in  scarification  of  the  swollen 
tissues  below  and  behind  the  epiglottis,  which  can  be  effected,  after  spraying 
the  parts  with  cocaine,  either  by  the  finger-nail  or  with  a  suitable  knife  guided 
by  a  laryngoscope.  The  usual  result  is  a  rapid  diminution  of  the  oedema, 
and  additional  relief  may  be  gained  by  inhaling  steam  arising  from  hot  water, 
to  which  some  tinct.  benzoini  co.  has  been  added.  Fomentations  or  ice  com- 
presses applied  externally  are  also  useful,  especially  the  latter.  In  more  severe 
cases,  and  especially  in  children,  intubation  may  be  necessary,  or  the  air- 
passages  may  be  opened  below  the  obstruction,  laryngotomy  sufficing  in  adults, 
but  a  high  tracheotomy  being  needed  in  children. 

Syphilitic  Disease  of  the  Larynx. — In  the  secondary  stage,  mucous  tubercles 
or  superficial  ulcers  occasionally  form  in  the  neighbourhood  of  the  vocal  cords, 
concurrently  with  the  rash  on  the  skin,  and  the  formation  of  condylomata  and 
mucous  tubercles  elsewhere.  It  is  very  likely  to  occur  in  costermongers  or 
those  who  have  to  speak  loudly,  and  may  then  lead  to  a  good  deal  of  thickening 
of  the  cords.  Apart  from  such  cases,  it  rarely  causes  much  trouble  beyond 
a  little  hoarseness.  No  special  treatment  is  required,  although  possibly  the 
parts,  if  ulcerated,  may  be  brushed  over  with  a  solution  of  perchloride  of 
mercury.  In  the  tertiary  period,  diffuse  gummatous  infiltration  or  localized 
gummata  may  develop,  giving  rise  to  destructive  ulceration,  which  especially 
affects  the  epiglottis  and  aryteno-epiglottidean  folds,  and  may  spread  back- 
wards and  involve  the  whole  glottis  (Fig.  302).  Inflammation  of  the  peri- 
chondrium is  likely  to  follow,  leading  to  necrosis  of  the  cartilages.  Hoarseness 
and  dyspnoea  are  the  chief  symptoms  of  this  affection,  whilst  considerable 
obstruction  may  be  subsequently  caused  by  cicatrization  and  laryngeal  stenosis. 
Treatment  consists  in  the  administration  of  iodide  of  potassium  and  mercury, 
whilst  ulcers  may  be  sprayed  with  perchloride  of  mercury  solution,  or  dusted 
over  with  calomel  or  iodoform.  Should  urgent  dyspnoea,  arise,  tracheotomy 
must  be  undertaken. 

Tuberculous  Laryngitis  (Fig.  303)  is  occasionally  a  primary  manifestation, 
but  is  much  more  frequently  secondary  to  phthisis,  arising  from  infection 
of  the  mucous  membrane  owing  to  the  constant  passage  over  it  of  the 
sputum.     It  usually  commences  at  the  posterior  part  of  the  larynx  in  tha 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST     843 


neighbourhood  of  the  arytenoid  cartilages,  as  a  submucous  infiltration,  which 
breaks  down,  and  leads  to  typical  tuberculous  ulcers,  similar  to  those  occurring 
in  other  viscera  (p.  359).  Considerable  destruction  of  tissue  ensues,  involving 
the  whole  circumference  of  the  larynx,  and  even  leading  to  necrosis  and 
destruction  of  the  cartilages.  Hoarseness,  cough,  and  perhaps  a  certain 
amount  of  dyspnoea,  in  a  patient  suffering  from  phthisis,  are  the  chief  symp- 
toms arising  from  this  affection,  the  prognosis  of  which  is  always  of  a  grave 
nature.  Treatment  .—In  phthisical  patients  local  treatment  is  of  but  little  avail, 
but  where  the  disease  is  primary  an  attempt  should  be  made  to  deal  with  it ; 
such,  however,  can  only  be  undertaken  by  the  skilled  laryngologist,  as  it 
consists  in  the  topical  application  of  caustics  and  antiseptics.  Thyrotomy  or 
subhyoid  pharyngotomy  has  sometimes  been  practised,  in  order  to  attain  this 
object  more  thoroughly. 

Paralysis  of  the  Larynx  is  observed  in  a  variety  of  conditions,  but  is  only  of 
surgical  interest  when  arising  from  injury  or  division  of,  or  pressure  upon,  the 
recurrent  laryngeal  nerve.  It  may  follow  the  removal  of  a  goitrous  tumour 
or  of  tuberculous  glands,  but  is  most  commonly  seen  in  connection  with 
aneurisms  of  the  innominate  or  aorta,  or  tumours  in  the  same  neighbourhood, 
e.g.,  cancer  of  the  oesophagus,  the  factual  "pressure  in  the  latter  case  being 


Fig.  302. — Gummatous  Disease  of 
the  Larynx.     (Tillmanns.) 

Small  gummata  are  seen  invading 
the  mucous  membrane  of  the 
epiglottis  and  front  of  the  larynx. 


Fig.  303. — Tuberculous  Disease 
of  the  Larynx,  with  Extensive 
Ulceration  in  Front  and  Behind. 
(Tillmanns.) 

a,  b,  c,  Remains  of  the  epiglottis. 


probably  exercised  by  secondarily  enlarged  lymphatic  glands.  Paralysis  from 
the  above  causes  is  generally  unilateral,  but  if  due  to  cancer  both  sides  may 
be  involved.  The  effect  of  complete  paralysis  of  one  recurrent  laryngeal  is  to 
produce  total  immobility  on  the  affected  side  of  the  vocal  cord,  which  lies  in 
what  is  known  as  the  '  cadaveric  position' — i.e.,  midway  between  that  in  which 
it  is  placed  during  phonation  and  during  inspiration.  Not  uncommonly  the 
paralysis  is  incomplete,  and  then  merely  affects  the  abductor  muscle  (the 
crico-arytenoideus  posticus).  The  Symptoms  arising  from  unilateral  recurrent 
paralysis  are  often  slight,  the  voice  being  usually  but  little  modified,  owing  to 
the  healthy  cord  being  capable  of  passing  across  the  middle  line.  If,  however, 
both  sides  are  completely  paralyzed,  absolute  aphonia,  without  dyspnoea, 
results ;  but  if  only  the  abductors  are  involved,  the  voice  may  be  unimpaired, 
although  severe  dyspnoea  is  often  present,  and  this  may  prove  fatal  unless 
tracheotomy  is  promptly  performed. 

Papilloma  of  the  Larynx  (Fig.  304)  occurs  in  the  form  of  wart-like  masses, 
usually  growing  from  the  true  vocal  cords,  and  giving  rise  to  considerable 
hoarseness  and  perhaps  some  dyspnoea.  They  are  recognised  on  laryngo- 
scopy examination,  and  may  be  removed  successfully  by  laryngeal  forceps, 
after  the  parts  have  been  efficiently  cocainized.  It  is  recommended  by  some 
authorities  to  destroy  the  growth  with  a  galvano-cautery. 

Epithelioma  Laryngis  occurs  in  patients  over  forty,  originating  as  a  papillary 
overgrowth,  usually  near  the  base  of  the  epiglottis,  or  from  the  true  or  false 
cords  (Fig.  305).    The  tumour  gradually  spreads,  both  superficially  and  deeply, 


844 


A   MANUAL  OF  SURGERY 


and  may  invade  the  cartilages,  giving  rise  to  necrosis.  At  a  later  stage  it 
extends  beyond  the  limits  of  the  larynx,  attacking  the  base  of  the  tongue, 
oesophagus,  and  even  the  lateral  walls  of  the  pharynx.  As  long  as  the  disease 
is  strictly  limited  to  the  larynx  (intrinsic),  the  growth  is  often  unilateral, 
causing  hoarseness  and  aphonia,  together  with  an  irritable  cough  and  the 
expectoration  of  blood-stained  muco-pus,  which  may  be  horribly  offensive  ;  it 
is  associated  with  but  little  tendency  to  affection  of  lymphatic  glands.  When, 
however,  the  growth  has  extended  to  surrounding  structures  (extrinsic), 
lymphatic  enlargement  follows,  and  the  disease  runs  its  usual  course,  destroy- 
ing life  by  dyspnoea  and  exhaustion.  Pain  is  often  a  most  distressing  symptom, 
being  referred  either  to  the  larynx  or  pharynx,  or,  according  to  Ziemssen,  not 
unfrequently  to  the  ear.  Treatment. — In  the  early  stages  it  is  possible  that 
thyrotomy  and  efficient  curetting  and  cauterization  may  suffice  to  bring  about 
a  cure.  Later  on,  removal  of  one  or  both  halves  of  the  larynx  will  be 
required,    and   the   operation    may   even    include   parts   of    the  tongue   and 


Fig.  304. — Papillomata  of  the 
Larynx,  springing  from  the 
Right  Vocal  Cord.     (Till- 

MANNS.) 


Fig.  305. — Epithelioma  of  the  Larynx, 
involving  the  Right  Vocal  Cord 
and  Base  of  the  Epiglottis.     (Till- 

MANNS.) 


pharyngeal  wall.  Where,  however,  the  disease  has  spread  extensively,  its 
total  extirpation  is  rarely  practicable,  and  all  that  can  be  done  is  to  treat 
symptoms  as  they  arise,  and  perform  tracheotomy  when  necessary. 


Operations  upon  the  Air-passages. 

1 .  Subhyoid  Pharyngotomy  was  devised  by  Malgaigne,  in  order 
to  provide  access  to  the  upper  parts  of  the  larynx  in  the  treat- 
ment of  foreign  bodies  or  tuberculous  disease.  A  transverse 
incision  is  made  through  the  thyro-hyoid  space,  the  pharynx  is 
opened,  and  the  epiglottis  detached  from  the  base  of  the  tongue 
(Fig.  306,  I.).  It  is  a  proceeding  that  is  seldom  undertaken,  and 
scarcely  necessary. 

A  much  more  satisfactory  procedure  is  Trans-hyoid  Pharyn- 
gotomy,^ in  which  the  hyoid  bone  is  divided  in  the  middle  line 
through  a  vertical  incision  extending  from  the  symphysis  menti 
to  the  thyroid  cartilage. 

The  pharynx  can  then  be  opened  either  above  or  below  the  level 
of  the  hyoid  bone,  and  the  back  of  the  tongue,  the  posterior  wall 
of  the  pharynx,  or  the  upper  part  of  the  larynx  freely  exposed.  A 
preliminary  tracheotomy  is  of  course  necessary.    We  have  utilised 

*  See  Revue  de  Chirurgie,  May,  1900. 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST    845 


this  operation  both  for  the  removal  of  an  epithelioma  of  the  epi- 
glottis and  back  of  the  tongue,  and  for  enucleating  a  sarcoma  of 
the  posterior  pharyngeal  wall,  and  were  much  pleased  with  the 
approach  given  to  these  parts. 

2.  Thyrotomy  (Fig.  306,  II.)  consists  in  a  partial  or  complete 
vertical  section  of  the  thyroid  cartilage,  and  may  be  required 
for  the  removal  of  foreign  bodies  or 
tumours,  or  for  the  radical  treatment 
of  laryngeal  tuberculosis  or  cancer. 
Tracheotomy  is  performed  as  a  pre- 
liminary measure,  and  the  trachea 
plugged  around  the  tube.     An  in- 


A.. 


J\ 


\ 


II 


111 


%Zi 


Sch 


H 


Th 


Th 


cision  is  then  made  in  the  middle  line 
of  the  neck,  extending  from  the  hyoid 
bone  to  the  cricoid  cartilage.  The 
crico-thyroid  ligament  is  clearly  de- 
fined and  severed  transversely,  and 
the  thyroid  cartilage  accurately 
divided  by  a  knife,  cutting-pliers,  or 
fine  saw.  The  lateral  halves  are 
separated,  and  the  intra-laryngeal 
portion  of  the  operation  proceeded 
with.  When  closing  the  wound,  the 
greatest  care  must  be  taken  to  bring 
the  sides  together  in  such  a  way 
that  the  vocal  cords  are  exactly 
opposite  each  other,  or  phonation 
will  be  considerably  impaired.  This 
is  best  ensured  by  making  a  hori- 
zontal cut  across  the  front  of  the 
cartilage  before  dividing  it. 

3.  Extirpation  of  the  Larynx 
(Laryngectomy)  is  always  a  serious 
operation,  which  is  never  under- 
taken except  for  malignant  disease. 
According  to  the  site  of  the  tumour 
the  removal  may  be  partial  or  com- 
plete ;  for  a  growth  strictly  limited 

to  one  side,  extirpation  of  that  half  will  suffice,  and  admirable  re- 
sults have  followed  such  treatment,  distinct  speech  remaining  ;  but 
if  the  whole  larynx  is  removed,  although  the  patient  is  subsequently 
able  to  whisper,  phonation  is  impossible  without  mechanical  assist- 
ance, whilst  if  the  disease  has  extended  beyond  the  limits  of  the 
larynx,  operative  interference  is  very  unsatisfactory. 

Operation  for  Complete  Extirpation. — A  low  tracheotomy  should 
be  performed,  as  a  preliminary  measure,  and  preferably  a  few  days 
before  ;  the  trachea  is  plugged  with  a  Halm's  tube  or  a  Trendelen- 
burg's air  tampon  at  the  commencement  of  the  operation.     An 


V 


\1 


Fig.  306. — Operations  on   the 

Air-passages.     (Tilmanns.) 

I.,  Subhyoid pharyngotomy  ;  II., 
thyrotomy:  III.,  laryngotomy ; 
IV.,cricotomy;  V.,  high  trache- 
otomy ;  VI.,  low  tracheotomy  ; 
Z,  hyoid  bone;  Sch,  thyroid 
cartilage  ;  R,  cricoid  ;  Th, 
thyroid  body. 


846  A   MANUAL  OF  SURGERY 


incision  is  made  in  the  middle  line  of  the  neck  from  the  hyoid 
bone  to  below  the  cricoid  cartilage,  at  the  upper  end  of  which  a 
transverse  cut  is  made,  extending  as  far  as  the  sterno-mastoid 
muscle  on  either  side.  The  soft  parts  are  then  stripped  from  the 
lateral  borders  of  the  thyroid  cartilage  with  raspatories,  the  sterno- 
hyoid, sterno-thyroid,  and  thyro-hyoid  muscles  being  divided  at 
their  insertions.  Both  the  superior  and  inferior  laryngeal  vessels 
are  tied  and  divided.  Having  thus  freed  the  larynx  anteriorly, 
the  subsequent  steps  of  the  operation  may  be  undertaken  either 
from  below  upwards  or  from  above  downwards  ;  the  former  pro- 
ceeding is,  to  our  minds,  the  better.  The  crico-tracheal  mem- 
brane is  divided,  and  the  larynx  drawn  forwards,  so  as  to  enable 
the  posterior  attachments,  i.e.,  the  connections  of  the  constrictor 
muscles  to  the  cricoid  and  thyroid  cartilages,  to  be  severed  by 
scissors,  the  larynx  being  thus  separated  from  the  anterior 
pharyngeal  wall,  which  must  be  left  intact,  if  possible.  The 
thyro-  hyoid  membrane  and  the  base  of  the  epiglottis  are  cut 
through,  and  the  final  steps  of  the  operation  consist  in  clearing 
the  superior  cornua  of  the  thyroid,  and  dividing  the  lateral  thyro- 
hyoid ligaments.  The  operation  is  not  particularly  difficult  or 
dangerous,  provided  that  the  surgeon  keeps  close  to  the  larynx, 
and  that  the  disease  does  not  spread  beyond  its  limits.  When 
other  structures,  such  as  the  base  of  the  tongue,  have  been 
invaded  by  the  growth,  these  steps  must  be  modified  so  as  to 
secure,  if  possible,  complete  removal  of  the  disease.  Finally,  the 
transverse  incision  is  sutured,  but  no  stitches  are  inserted  in  the 
median  wound,  which  is  plugged,  and  allowed  to  heal  by  granula- 
tion. The  upper  end  of  the  trachea  should  be  secured  to  the  skin 
at  the  lower  angle  of  the  wound,  so  as  to  prevent  its  retraction. 
The  patient  is  fed  per  rectum  for  a  few  days,  or  by  the  passage  of 
an  oesophageal  tube.  At  the  end  of  a  week  the  tracheotomy  tube 
is  removed  from  its  original  situation,  and  inserted  into  the  upper 
end  of  the  trachea,  the  lower  opening  being  allowed  to  close. 
When  the  wound  has  healed  sufficiently,  an  artificial  larynx  can 
be  inserted,  by  means  of  which  the  patient  is  able  to  speak  in  a 
somewhat  reedy  monotone,  but  it  is  seldom  satisfactory. 

Dr.  H.  Lambert  Lack  advocates  the  total  closure  of  all  com- 
munication between  the  pharynx  and  the  air-passages  after 
laryngectomy.  The  upper  end  of  the  trachea  is  securely  stitched 
all  round  in  the  lower  angle  of  the  incision  and  flush  with  the 
surface.  The  rent  in  the  mucous  membrane  of  the  pharynx  is 
then  carefully  closed ;  the  wound  is  thoroughly  disinfected,  and 
the  various  layers  of  muscles  are  sutured  together,  as  also  the 
skin.  Union  by  first  intention  can  thus  be  attained,  and  the 
results  have  been  most  gratifying.  Phonation  is  of  course  lost 
absolutely,  but  the  patient  can  whisper,  the  necessary  air-pressure 
being  obtained  in  the  dilated  pharynx  or  upper  end  of  the 
oesophagus. 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST    847 

If  the  disease  is  limited  to  one  half  of  the  larynx,  the  thyroid 
cartilage  is  cleft  in  the  middle  line,  and  the  operation  confined  to 
the  affected  side. 

4.  Laryngotomy  is  always  undertaken  for  the  relief  of  dysp- 
noea arising  from  some  sudden  obstruction  to  the  respiration, 
and  is  thus  to  be  looked  on  as  an  operation  of  urgency.  It  is 
required  in  cases  where  the  entrance  to  the  larynx  is  obstructed 
by  a  foreign  body,  for  spasm  of  the  glottis,  or  for  accumulations 
of  blood  in  the  neighbourhood  of  the  larynx  during  an  operation. 
It  is  readily  performed  by  making  a  vertical  incision  over  the 
situation  of  the  crico-thyroid  membrane,  which  is  then  divided 
transversely  along  the  upper  border  of  the  cricoid  cartilage,  the 
sterno  hyoid  muscles  being,  if  necessary,  drawn  aside,  and  a  tube 
inserted.  Possibly  the  small  crico-thyroid  artery  arising  from  the 
superior  thyroid  may  require  a  ligature.  In  cases  of  great 
urgency,  a  simple  transverse  incision  may  be  made  with  a  pen- 
knife, and  the  larynx  opened,  the  margins  of  the  wound  being 
held  aside  by  a  hairpin,  or  by  the  handle  of  a  scalpel  turned  edge- 
ways, whilst  a  toothpick  will  serve  temporarily  as  a  cannula. 
Whenever  there  is  time  to  operate  deliberately,  a  high  tracheotomy 
is  the  better  practice,  since  a  tube  inserted  through  the  crico- 
thyroid space  gives  rise  to  considerable  irritation,  and  the  voice 
may  be  subsequently  impaired  by  the  contraction  of  the  cicatrix. 
A  special  laryngotomy  tube  is  required,  the  lumen  of  which  is  oval 
and  flattened  from  above  downwards,  not  circular. 

In  children,  where  there  is  but  little  space,  the  proceeding  may 
be  modified  by  division  of  the  cricoid  cartilage,  and  even  of  the 
first  ring  of  the  trachea,  constituting  what  is  known  as  cricotomy, 
or  lavyngotvacheotomy  (Fig.  306,  IV.). 

5.  Tracheotomy. — The  trachea  usually  consists  of  from  sixteen 
to  twenty  rings,  of  which  six  or  seven  are  situated  above  the 
sternum.  The  isthmus  of  the  thyroid  body  usually  covers  the 
third  and  fourth  rings,  and  the  trachea  may  be  opened  either 
above  or  below  it,  or  even  sometimes  behind,  the  isthmus  being, 
if  necessary,  divided.  Tracheotomy  is  required  in  any  condition 
in  which  there  is  serious  obstruction  to  the  respiration,  e.g., 
various  forms  of  laryngitis,  and  especially  that  due  to  diphtheria ; 
for  stenosis,  tumours,  and  some  forms  of  paralysis  of  the  larynx  ; 
for  the  removal  of  foreign  bodies,  either  in  the  larynx,  trachea, 
or  one  of  the  bronchi;  or  for  compression  of  the  larynx  or  trachea 
by  external  tumours,  such  as  an  enlarged  thyroid  body.  It  is 
also  undertaken  as  a  preliminary  measure  in  operations  on  the 
mouth,  tongue,  pharynx,  or  larynx,  in  which  there  is  any  likeli- 
hood of  asphyxia  or  secondary  septic  pneumonia,  owing  to  the 
entrance  of  blood  or  septic  discharges  into  the  air-passages.  As 
a  general  rule,  the  high  operation  (that  is,  above  the  isthmus  of 
the  thyroid  body)  is  to  be  preferred,  but  under  special  circum- 
stances it  may  be  advisable  to  open  the  trachea   lower   down. 


84S 


A  MANUAL  OF  SURGERY 


The  risk  attaching  to  the  high  operation  is  considerably  less  than 
to  the  low,  but  the  opening  is  made  nearer  to  any  disease  which 
may  exist  in  the  larynx.  For  the  removal  of  foreign  bodies  from  the 
bronchi  or  trachea,  the  low  operation  should  always  be  employed. 
The  high  operation  (Fig.  306,  V.)  is  performed  as  follows  :  The 
patient  is  placed  on  the  back,  with  a  sandbag  or  pillow  beneath 
the  neck,  so  as  to  throw  the  head  backwards  and  put  the  struc- 
tures on  the  stretch,  and  with  the  shoulders  somewhat  raised. 
Anaesthesia  may  be  induced  by  chloroform,  but  it  is  unnecessary, 
and  indeed  unwise,  to  push  the  anaesthetic,  since  it  is  only  needed 
for  the  division  of  the  skin  ;  where  the  dyspnoea  is  considerable,  it 
is  better  to  employ  cocaine.  The  head  is  held  exactly  in  the 
middle  line,  and  the  surgeon  feels  for,  and  identifies,  the  cricoid 
cartilage.  The  incision  extends  from  this  structure  downwards 
for  about  1^  inches.  The  superficial  fascia  is  divided,  and  the 
interval   between   the  sterno-hyoid  muscles  made  out,  so  as   to 


Fig.  307. — Durham's  Tracheotomy-tube.     (Down  Brothers. 
A,  Outer-tube  with  introducer;  B,  lobster-tailed  inner-tube. 

enable  them  to  be  separated  one  from  the  other.  The  edges  of 
the  wound  are  drawn  aside  by  blunt  hooks,  which  should  both  be 
held  by  one  assistant,  so  as  to  ensure  equable  traction. 

The  isthmus  of  the  thyroid  body  may  now  be  seen,  and,  if  pro- 
jecting unduly  upwards,  should  be  pushed  down  after  the  fascia 
along  its  upper  border  has  been  transversely  incised.  The  trachea 
is  next  clearly  exposed  by  using  the  handle  of  a  scalpel  and  dis- 
secting forceps,  and  should  be  fixed  and  steadied  by  inserting  a 
sharp  hook  into  the  lower  border  of  the  cricoid  cartilage.  The 
wound  is  freed  from  blood  as  far  as  possible,  and  the  trachea 
opened  by  inserting  the  point  of  the  scalpel  and  dividing  two  of  the 
rings  from  below  upwards.  A  deep  inspiration  is  usually  taken  at 
once,  followed  by  a  severe  fit  of  coughing,  and  if  the  operation  is 
undertaken  for  diphtheria  the  surgeon  must  be  careful  not  to  let 
any  membrane  which  may  then  be  expelled  enter  his  eyes,  nose, 
or  mouth.     The  insertion  of  the  tube  is  in  many  cases  easy,  in 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST     849 


others  a  matter  of  some  difficulty  ;  a  good  deal  depends  upon  the 
age  of  the  patient,  the  urgency  of  the  symptoms,  and  the  depth 
from  the  surface  at  which  the  trachea  lies.  Anything  which 
suffices  to  separate  the  lips  of  the  tracheal  incision,  e.g., the  handle 
of  a  scalpel  introduced  and  turned,  a  couple  of  hooks,  or  dressing 
forceps,  will  form  an  efficient  guide  for  this  purpose.  The  breath- 
ing soon  becomes  quiet  and  regular,  and  the  tube  is  fixed  in 
position  by  tapes  passed  through  lateral  openings  in  the  face-plate, 
and  tied  round  the  neck.  No  dressing  is  required  for  the  wound 
except  a  few  layers  of  gauze  beneath  the  plate. 

Low  tracheotomy  (Fig.  306,  VI.)  is  performed  in  almost  precisely 
the  same  way,  except  that  the  in- 
cision extends  farther  downwards, 
even  reaching  to  the  episternal 
notch,  although  the  deeper  part  of 
the  wound  should  never  pass  be- 
yond a  finger's  breadth  above  the 
sternum,  for  fear  of  opening  that 
portion  of  the  cervical  fascia 
which  is  prolonged  downwards 
to  the  pericardium,  or  of  wound- 
ing the  left  innominate  vein.  The 
superficial  layers  of  fascia  are 
divided,  and  the  sterno-hyoid  and 
sterno-thyroid  muscles  drawn  to 
either  side  by  retractors.  The 
inferior  thyroid  veins  then  come 
into  view,  and  may  cause  trouble 
if  they  are  distended  with  blood , 
as  is  so  frequently  the  case  in 
patients  suffering  from  dyspncea. 
They  must  be  held  aside  by 
hooks,  or  divided  between  liga- 
tures, and  the  deep  layer  of  fascia 
behind  them  incised  so  as  to 
expose  the  trachea,  which  is 
cleared,  fixed,  and  opened  in  the 
same  way  as  described  above. 

Many  different  forms  of  tracheotomy -tube  have  been  used  from 
time  to  time,  but  that  most  generally  employed  consists  of  a  double 
cannula,  the  inner  portion  of  which  can  be  readily  removed  and 
cleansed  ;  it  should  always  be  longer  than  the  outer,  in  order  to 
prevent  any  plug  of  mucus  being  left  within  the  outer  tube  on 
removal  of  the  inner.  A  face-plate,  or  some  similar  contrivance, 
is  attached  to  the  outer  cannula,  in  order  to  fix  and  study  it.  One 
of  the  best  is  that  known  as  Durham's  lobster -tailed  tracheotomy -tube 
(Fig.  307,  A  and  B)  ;  the  rigid  outer  tube  of  this  instrument  is 
introduced  by  means  of  a  flexible  guide  set  on  a  handle,  and  passed 

54 


Fig.  308. — Parker's  Tracheotomy- 
tube  and  Introducer.  (Down 
Brothers.) 


850  A   MAM  UAL  OF  SURGERY 

within  it.  The  guide  is  then  withdrawn,  and  replaced  by  the  inner 
flexible  cannula  (B).  Parker's  tube  (Fig.  308)  also  has  a  handy 
introducer,  and  is  perhaps  of  a  better  shape  than  most  of  the 
others,  following  more  closely  the  direction  of  the  trachea.  The 
bivalve  tube  is  another  useful  instrument  ;  the  outer  sheath  consists 
of  two  lateral  portions,  attached  to  a  single  face-plate,  and  these 
can  be  pressed  together,  and  hence  with  care  easily  inserted 
through  the  incision  in  the  trachea.  The  surgeon  must  see  that 
both  limbs  enter  the  trachea,  as  trouble  has  arisen  from  one  limb 
passing  outside,  and  the  other  inside,  thus  hindering  the  intro- 
duction of  the  inner  tube.  In  cases  of  preliminary  tracheotomy 
(p.  781),  undertaken  to  prevent  the  entrance  of  blood  during  opera- 
tions, Halm's  tube  may  be  used  with  advantage ;  in  this  the  outer 
cannula  is  covered  with  a  layer  of  compressed  sponge  which  swells 
up  from  the  absorption  of  moisture,  and  thus  occludes  the  lumen  of 
the  trachea.  Trendelenburg's  tampon  is  recommended  by  some  for 
the  same  object  ;  the  outer  tube  is  here  ensheathed  with  a  thin 
indiarubber  casing,  which  can  be  distended  with  air  at  will. 

Difficulties  and  Dangers  of  the  Operation. — Although  the  above 
description  might  lead  the  student  to  suppose  that  tracheotomy 
is  an  easy  operation,  this  is  by  no  means  always  the  case,  partly 
owing  to  the  fact  that  it  frequently  has  to  be  undertaken  in  a 
hurry,  with  perhaps  inefficient  assistance,  and  in  a  bad  light,  and 
partly  owing  to  the  intense  vascular  engorgement  of  the  structures 
met  with.  A  cool  head  and  a  steady  hand  are  in  such  cases 
of  infinitely  more  value  to  the  operator  than  the  most  perfect 
anatomical  knowledge.  The  following  are  the  chief  conditions 
which  may  lead  to  mistakes  and  accidents  : 

(1)  The  administration  of  any  general  anaesthetic  is  often 
inadvisable  in  semi-asphyxiated  patients,  since  complete  cessa- 
tion of  respiration  may  be  caused  thereby,  possibly  from  spasm 
of  the  glottis.  In  such  the  cutaneous  incision  may  be  made 
under  the  influence  of  some  local  anaesthetic,  whilst  for  the 
deeper  parts  of  the  operation  nothing  is  required. 

(2)  It  is  not  always  easy  to  find  the  trachea,  especially  in  the  necks 
of  fat  children,  or  where  it  is  hidden  by  an  unduly  large  thyroid 
isthmus,  or  possibly  by  the  projection  of  the  thymus  gland  into 
the  neck.  It  is  here  most  essential  to  remember  the  old  adage, 
In  medio  tutissimus  ibis,  although  occasionally  the  trachea  may  be 
displaced  from  the  middle  line  by  some  external  growth,  and  can 
then  only  be  found  by  careful  exploration  with  the  finger. 

(3)  Hemorrhage  is  generally  troublesome.  It  is  usually  venous 
in  character,  arising  either  from  the  anterior  jugular  vein  or  from 
the  inferior  thyroid  plexus.  If  possible,  it  should  be  controlled  by 
pressure-forceps  before  opening  the  trachea  ;  but  this  is  not  abso- 
lutely necessary  in  urgent  cases,  since  it  usually  ceases  as  soon 
as  easy  respiration  through  the  tube  has  been  established.  The 
presence  of   the    left  innominate    vein    in    front    of   the  trachea 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST     851 


must  not  be  forgotten,  although  it  but  rarely  reaches  above  the 
sternum.  In  about  8  per  cent,  of  all  subjects  an  arterial  twig 
(the  thyroidal  una)  courses  upwards  from  the  innominate  artery 
along  the  trachea,  to  reach  the  isthmus  of  the  thyroid  body  ;  if 
divided,  it  can  be  easily  secured  and  tied.  Should  much  blood  be 
inspired,  it  may  determine  the  occurrence  of  septic  pneumonia  at 
a  later  date. 

(4)  The  possibility  of  the  entrance  of  air  into  veins  must  not  be 
overlooked,  although  it  is  an  uncommon  accident,  since  the  intra- 
venous pressure  is  so  great. 

(5)  Not  unfrequently  considerable  mischief  has  been  done  by 
an  incautious  use  of  the  knife,  especially  if  the  operator  forgets  to  fix 
the  trachea  with  a  sharp  hook  before  opening  it.  In  a  child  the 
trachea  is  small  ;  and  if  it  is  moving  rapidly  up  and  down,  as 
happens  in  urgent  dyspnoea,  or  if  the  child  is  restless,  and  not 
completely  under  the  influence  of  an  anaesthetic,  the  difficulty  is 
manifestly  increased.  Many  accidents  have  happened  from  this 
cause,  e.g.,  wounds  of  the  large  veins  or  arteries  of  the  neck,  or 
even  of  the  oesophagus  or  bodies  of  the  vertebrae  ! 

(6)  As  soon  as  the  trachea  is  opened,  a  severe  fit  of  coughing  is 
induced,  which  is  sometimes  so  prolonged  as  to  interfere  with  the 
introduction  of  the  tube.  Under  such  circumstances  the  incision 
in  the  trachea  may  be  opened  up  with  a  tracheal  dilator,  or  by  a 
pair  of  sinus  forceps,  and  a  few  drops  of  cocaine  swabbed  over  the 
mucous  membrane. 

(7)  The  introduction  of  the  tube  is  a  matter  of  no  difficulty  if  the 
surgeon  takes  the  precaution  of  not  removing  the  hook  until  this 
is  satisfactorily  accomplished.  Many  mistakes  have  followed  the 
non-observance  of  this  rule  ;  thus,  the  tube  has  missed  the  trachea 
altogether  and  passed  into  the  fascial  interspace  in  front,  as  also 
to  one  or  other  side  ;  as  before  mentioned,  the  outer  portion  of 
a  bivalve  tube  has  often  been  passed  with  one  limb  within  the 
trachea  and  the  other  outside.  A  very  dense  diphtheritic  mem- 
brane has  also  been  a  cause  of  difficulty,  in  that,  although  the 
tube  has  been  really  passed  into  the  trachea,  it  has  not  penetrated 
the  membrane,  and  thus  has  hindered  rather  than  helped  the 
breathing.  In  all  cases  of  diphtheria  the  trachea  should  be 
freely  opened,  and  the  interior  carefully  examined  by  separating 
the  lips  of  the  incision  before  attempting  to  insert  the  tube. 
In  order  to  prevent  the  downward  passage  of  the  membrane, 
some  surgeons  have  recommended  that  the  lower  portion  of  the 
larynx  should  be  carefully  stuffed  with  antiseptic  gauze  above 
the  tube. 

After-Treatment. — The  patient  is  placed  in  bed,  in  a  room  kept 
at  a  uniformly  warm  temperature  (750  F.),  the  air  being  moistened 
by  the  steam  issuing  from  one  or  more  bronchitis  kettles,  so 
as  to  make  up  for  the  absence  of  nasal  and  oral  respiration. 
Draughts  are  excluded  by  curtains,  and  nothing  should  be  placed 

54—2 


852  A  MANUAL  OF  SURGERY 

over  the  entrance  to  the  tube,  so  that  respiration  may  not  be 
hindered,  nor  the  expectoration  of  mucus,  false  membrane,  etc., 
prevented.  One  of  the  most  frequent  sources  of  extension  of  diph- 
theria to  the  lungs,  or  of  septic  pneumonia,  is  the  re-inspiration  of 
material  which  has  been  coughed  out  upon  a  portion  of  muslin  or 
gauze,  placed  with  excellent  intentions  over  the  mouth  of  the 
tube.  A  nurse  should  be  in  constant  attendance  on  the  patient, 
in  order  to  wipe  away  all  such  material  as  it  is  expelled. 

The  inner  portion  of  the  tube  is  removed  by  the  nurse,  and 
cleaned  two  or  three  times  a  day,  any  inspissated  mucus  upon  it 
being  readily  removed  by  the  use  of  a  solution  of  bicarbonate  of 
soda  (20  grains  to  1  ounce).  The  outer  tube  is  also  removed  once 
a  day  for  cleansing  purposes,  but  only  by  the  medical  attendant. 
Should  the  respiration  become  impeded  by  a  collection  of  mucus 
in  the  trachea,  a  fine  feather  may  be  passed  down  the  tube  in 
order  to  clear  it,  but  never  in  diphtheritic  cases ;  for  such  a  con- 
tingency special  suction-tubes  have  been  devised.  Attempts  have 
been  made  to  clear  the  passages  by  applying  the  lips  to  the  tube, 
and  removing  the  block  by  suction  ;  such  is,  however,  quite  un- 
justifiable, and  several  promising  house-surgeons  have  in  this  way 
lost  their  lives. 

The  period  for  which  the  tracheotomy-tube  is  kept  in  position 
varies  in  different  cases,  but  its  removal  should  always  be  under- 
taken at  as  early  a  date  as  possible,  for  fear  of  leading  to  impair- 
ment of  the  voice.  In  order  to  prevent  this,  the  inner  cannula  is 
made  with  a  hole  in  the  upper  end,  so  that  part  of  the  air  may 
pass  through  the  larynx.  If  the  patient  can  then  breathe  com- 
fortably when  the  finger  is  placed  over  the  entrance  to  the  tube, 
its  presence  is  no  longer  necessary. 

After-complications  of  Tracheotomy. — (a)  The  tube  may  give 
rise  to  ulceration  of  the  trachea  if  it  is  not  correctly  shaped. 
Thus,  if  too  much  curved,  it  tends  to  irritate  the  anterior  wall, 
and  cases  are  known  in  which  it  has  caused  death  by  perforation 
of  the  left  innominate  vein.  If  insufficiently  curved,  the  posterior 
wall  may  become  affected,  and  the  oesophagus  laid  open.  In 
cases  where  a  tracheotomy-tube  has  to  be  worn  for  a  long  time, 
it  may  be  advisable  to  make  use  of  indiarubber  tubes. 

(b)  Various  forms  of  septic  trouble  may  arise  in  the  wound, 
leading  to  cellulitis,  and  even  secondary  haemorrhage  ;  this  is 
especially  dangerous  in  the  low  operation,  since  the  inflammation 
may  extend  to  the  mediastinal  tissues.  In  cases  of  diphtheria 
the  wound  may  also  become  affected  with  the  disease. 

(c)  Inflammation  of  the  trachea,  bronchi,  and  lungs  may  result 
either  from  the  entrance  of  cold,  or  unmoistened  air,  or  from  the 
inspiration  of  septic  or  diphtheritic  material. 

(d)  Difficulty  is  sometimes  experienced  in  leaving  off  the  tube, 
owing  to  the  presence  of  granulations  obstructing  the  lumen  of  the 
trachea,  or  to  stenosis  of  the  larynx  from  contractions  or  adhesions 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST     S53 


of  the  vocal  cords,  or  even  to  paralysis  of  the  abductor  muscles, 
especially  in  diphtheritic  cases.  The  trachea  may  also  be  kinked, 
and  its  calibre  thus  diminished,  by  cicatricial  union  of  the  skin 
and  mucous  membrane.  The  diagnosis  of  the  cause  at  work  in 
any  particular  case  can  only  be  made  by  laryngoscopy,  or  careful 
examination  of  the  wound  and  upper  portion  of  the  trachea. 
Granulations  may  be  scraped  away  under  an  anaesthetic  or 
destroyed  by  caustics,  stenosis  of  the  larynx  is  overcome  by  dilata- 
tion with  an  O'Dwyer's  tube,  whilst  laryngeal  paralysis  must  be 
treated  by  the  use  of  electricity. 


Fig.  309. — O'Dwyer's  Intubation  Apparatus.     (Down  Brothers. 

The  cannulae  are  seen  below  on  the  right  ;  a  hinged  inner  tube  passes 
throughout  the  length  of  each,  and  the  upper  end  of  this  is  screwed 
to  the  extremity  of  the  introducer  seen  in  the  middle  ;  when  it  has  been 
inserted  into  the  larynx,  the  trigger  of  the  introducer  is  drawn,  and  by  this 
means  the  inner  tube  is  loosened  and  can  be  easily  removed,  leaving  the 
cannula  in  position.  To  extract  the  tube,  the  rectangular  forceps  repre- 
sented at  the  top  is  utilized  ;  the  point  of  the  forceps  is  inserted  into  the 
top  of  the  cannula,  and  then  by  opening  the  blades  the  cannula  is  fixed 
and  can  be  withdrawn.  A  useful  type  of  unilateral  gag  is  also  represented, 
and  a  small  gauge  to  indicate  the  size  of  cannula  required  at  different  ages. 

6.  Intubation  of  the  Larynx  is  a  means  of  treating  laryngeal 
obstruction  which  has  been  introduced  in  order  to  obviate  the 
risk  always  present  in  tracheotomy.  It  consists  in  the  passage 
through  the  mouth  of  a  suitably  curved  tube  into  the  larynx,  by 
means  of  a  specially  contrived  introducer.  The  best  patterns 
to  employ  for  the  purpose  are  those  known  as  O'Dwyer's  tubes 
(Fig.  309).  The  lower  end  of  the  cannula  is  oval,  and  not 
circular,  and  passes  between  the  cords  into  the  larynx,  whilst  the 


854  A   MANUAL  OF  SURGERY 

upper  enlarged  end  lies  over  the  entrance  ;  it  requires  changing 
frequently  in  order  to  prevent  erosion  of  the  mucous  membrane. 
It  has  been  used  with  considerable  success  in  cases  of  oedema  of 
the  glottis  and  laryngeal  stenosis,  but  is  scarcely  to  be  recom- 
mended for  diphtheria,  owing  to  the  risk  of  carrying  the  false 
membrane  down  with  it. 

Surgical  Affections  of  the  Lungs. 

Wounds  of  the  Lungs  result  from  violence  applied  to  the  chest, 
with  or  without  fractures  of  the  ribs,  or  in  consequence  of  pene- 
trating injuries. 

Non-penetrating  Wounds  consist  either  of  laceration  or  contusion. 

Contusion  of  the  king  often  follows  some  injury  which  is  not 
sufficiently  severe  to  fracture  the  ribs.  The  symptoms  produced 
are  severe  pain  in  the  side,  with  perhaps  temporary  shock  and 
slight  haemoptysis.  Some  traumatic  inflammation  follows,  both  of 
the  lung  and  of  the  pleura,  as  indicated  by  loss  of  resonance  and 
possibly  friction  sounds.  The  treatment  consists  in  keeping  the 
patient  quiet  in  a  warm  room,  at  the  same  time  carefully  regulating 
the  bodily  functions.  Possibly  pain  may  be  relieved  by  strapping 
the  side  of  the  chest. 

Laceration  of  the  lung  is  usually  secondary  to  fracture  of  the  ribs, 
especially  from  direct  violence.  The  severity  of  the  symptoms 
necessarily  varies  with  the  character  and  extent  of  the  injury. 
The  patient  suffers  from  marked  shock  in  severe  cases,  associated 
with  pain  in  the  side  and  dyspnoea.  Evidences  of  hemorrhage 
soon  follow,  either  in  the  form  of  haemoptysis  or  haemothorax. 
If  the  wound  is  a  small  one,  the  patient  complains  of  an  irritating 
cough,  and  brings  up  a  good  deal  of  blood-stained  frothy  mucus  ; 
but  if  the  laceration  is  extensive,  involving  some  of  the  larger 
pulmonary  trunks,  a  quantity  of  pure  blood  may  be  ejected,  even 
leading  to  death  from  syncope,  or  from  asphyxia,  owing  to  the 
blood  filling  the  larger  bronchial  tubes.  Hemothorax  may  also  be 
so  excessive  as  to  cause  the  patient's  death  from  compression  of 
the  lung.  It  results  in  a  gradually  increasing  area  of  dulness  ex- 
tending from  below  upwards,  together  with  loss  of  breath  sounds 
and  vocal  fremitus,  coming  on  soon  after  the  injury  without  signs 
of  inflammation. 

Owing  to  the  laceration  of  the  pulmonary  vesicles,  air  tends  to 
escape  either  into  the  pleural  cavity,  giving  rise  to  the  condition 
known  as  pneumothorax,  or  into  the  cellular  tissue  of  the  body, 
constituting  surgical  emphysema.  Pneumothorax  is  always  asso- 
ciated with  more  or  less  collapse  of  the  lung,  and  is  almost 
certain  to  lead  to  considerable  interference  with  respiration,  and 
possibly  to  severe  dyspnoea,  or  even  orthopneea.  The  air  which 
finds  its  way  into  the  pleura,  having  been  filtered  through  the 
lungs,    is    free    from    organisms,    and    hence    does    not    cause 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST     S5; 


suppuration  or  putrefaction  of  the  blood-clot  present,  unless 
bronchitis  or  some  other  suppurative  condition  has  existed  pre- 
viously. The  physical  signs  of  pneumothorax  consists  in  a  high- 
pitched  tympanitic  note  on  percussion,  and  on  auscultation 
amphoric  breathing  and  possibly  metallic  tinkling.  As  soon  as 
the  wound  in  the  lung  commences  to  heal,  the  amphoric  sounds 
disappear,  the  effused  air  is  absorbed,  and  the  lung  gradually 
expands — a  process  which  may  take  four  or  five  days.  If  blood 
is  also  present  in  the  thorax,  a  condition  of  haemopneumothorax 
is  produced,  recognised  by  a  splashing  or  succussion  sound  heard 
on  shaking  the  patient.  Surgical  Emphysema  almost  always  indi- 
cates a  wound  of  both  pulmonary  and  parietal  layers  of  the  pleura, 
which  are  slightly  separated  by  air,  constituting  a  localized 
pneumothorax.  At  each  inspiration  a  fresh  amount  of  air  enters 
this  cavity,  and  is  expelled  into  the  areolar  tissues  through  the 
parietal  wound  at  each  expiration,  being  forced  perhaps  to  a  con- 
siderable distance  from  the  spot  where  it  commences,  or  even 
spreading  over  the  whole  body.  It  is  of  no  serious  significance, 
disappearing  rapidly  after  the  wound  in  the  lung  has  commenced 
to  heal,  thus  occluding  the  opened  pulmonary  alveoli.  It  is 
recognised  by  the  parts  becoming  swollen  and  puffy,  and  giving  a 
sensation  of  fine  crackling  crepitus  when  the  hand  is  pressed  over 
them.  Occasionally  emphysema  may  arise  as  an  interstitial  con- 
dition, when  the  parietal  pleura  has  not  been  injured,  the  air 
escaping  from  the  alveoli  along  the  the  inter-alveolar  connective 
tissue  into  the  root  of  the  lung,  and  then  appearing  first  at  the 
lower  part  of  the  neck. 

Such  are  the  ordinary  phenomena  observed  in  the  early  stages 
of  a  ruptured  lung.  The  effects  subsequently  produced  consist 
in  a  localized  traumatic  pleuro-pneumonia,  associated  with  slight 
elevation  of  the  temperature,  possibly  rusty  sputum,  and  often 
severe  dyspnoea.  In  the  worst  cases  death  may  result  from 
asphyxia. 

Penetrating  Wounds  of  the  Lung  are  followed  by  very  similar 
effects,  modified,  however,  by  the  fact  that  the  external  wound 
in  the  chest  wall  allows  of  the  exit  of  blood,  arising  either  from 
an  intercostal  artery  or  from  the  wounded  lung,  whilst  it  also 
permits  the  entrance  of  septic  organisms  with  the  air  into  the 
pleural  cavity,  and  thus  may  change  the  character  of  the  result- 
ing pleuro-pneumonia  from  a  simple  to  an  infective  imflammation. 
Empyema  is  consequently  a  frequent  sequela,  whilst  the  inflam- 
mation of  the  lung  may  be  of  a  spreading  nature,  possibly  termi- 
nating in  suppuration  or  gangrene.  Surgical  emphysema  is  also 
induced  by  air  being  sucked  into  the  wound  during  inspiration, 
and  failing  to  escape  during  expiration,  owing  to  the  lips  of  the 
wound  falling  together.  This  condition  may  ensue  even  when 
the  lung  itself  has  not  been  damaged. 

Treatment. — When  the  rupture  of  the  lung  is  due  to  a  sub- 


S56  A   MANUAL  OF  SURGERY 


cutaneous  injury,  the  patient  should  be  kept  quiet  in  a  warm 
room,  and  the  side  strapped.  The  compression  of  the  chest  wall 
must  sometimes  be  omitted  in  patients  where  the  irregular  ends 
of  fractured  ribs,  broken  by  direct  violence,  are  driven  inwards, 
for  fear  of  increasing  the  mischief  in  the  lung. 

Persistent  haemoptysis  must  be  treated  by  keeping  the  patient 
absolutely  quiet,  and  allowing  him  to  suck  ice  continually. 
Ergotin  may  be  injected  hypodermically,  or  a  mixture  of  ergot, 
opium,  and  sulphuric  acid  administered  ;  the  opium  is  especially 
needed  when  great  restlessness  and  irritability  are  present.  Stimu- 
lants are  necessarily  contra-indicated,  for  fear  of  again  starting 
the  bleeding.  Haemothorax  rarely  needs  special  treatment,  since 
the  blood  soon  clots  and  is  readily  absorbed ;  but  occasionally  it 
may  be  so  abundant  as  to  compress  the  lung  and  lead  to  dyspnoea, 
and  under  these  circumstances  it  may  be  necessary  to  open  up 
the  pleural  cavity  and  remove  it.  Such  must  never  be  under- 
taken until  sufficient  time  has  elapsed  to  permit  of  thrombosis  in 
the  wounded  vessels.  Decomposition  of  the  blood  in  the  .pleural 
cavity  occasionally  happens  even  in  non-penetrating  injuries,  the 
bacteria  reaching  it  either  from  the  blood  or  from  the  lacerated 
bronchi  ;  the  suppuration  and  fever  thereby  induced  necessitate 
the  opening  and  drainage  of  the  pleural  sac. 

Simple  pneumothorax  seldom  requires  surgical  treatment,  since 
the  imprisoned  air  is  quickly  absorbed,  and  the  lung  re-expands  ; 
but  should  it  give  rise  to  severe  dyspnoea,  it  may  be  advisable  to 
remove  the  air  by  aspiration. 

Temporary  dyspnoea  may  be  overcome  by  the  inhalation  of 
oxygen  ;  but  when  of  a  more  decided  character,  and  not  due  to 
any  condition  which  can  be  removed,  the  essential  treatment  is  to 
diminish  the  blood-pressure,  and  thus  decrease  the  amount  of 
blood  carried  to  the  uninjured  lung,  so  as  to  enable  it  to  cope  with 
the  work  of  blood-aeration.  This  may  be  accomplished  by  ad- 
ministering antimonial  wine  (10  to  15  minims  every  four  or  six 
hours)  combined  with  full  doses  of  liquor  ammoniae  acetatis  ;  but 
in  urgent  cases,  where  the  patient  is  becoming  cyanosed,  and  life 
is  threatened  by  asphyxia,  venesection  must  be  adopted.  The 
blood  is  withdrawn  from  the  arm  rapidly  and  freely,  and  as  it 
flows  the  dyspnoea  passes  off.  This  may  be  repeated  once  or 
twice  in  addition  to  the  use  of  the  medicine  before  the  full  effect 
is  obtained  and  respiration  becomes  unembarrassed. 

The  treatment  of  penetrating  wounds  of  the  thorax,  involving  the 
lung,  is  always  a  matter  of  considerable  difficulty.  The  skin 
around  the  opening  is  carefully  purified  and  shaved,  if  necessary, 
and  a  limited  exploration  of  the  wound  with  a  purified  finger  or 
probe  is  permissible,  so  as  to  determine  whether  portions  of  the 
clothing  have  been  carried  in,  or  a  rib  comminuted  ;  all  such  loose 
fragments  must  be  removed,  as  also  any  penetrating  foreign  body, 
such  as  a  bullet,  if  accessible.     The  greatest  gentleness  must, 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST       857 

however,  be  employed,  since  it  is  easy  to  dislodge  clots  lying  in 
the  pulmonary  tissues,  and  thereby  restart  the  bleeding.  As  a 
general  rule,  it  is  unnecessary  to  syringe  out  the  deeper  parts  with 
an  antiseptic,  since  if  one  of  the  main  bronchi  has  been  opened, 
the  lotion  might  then  find  its  way  into  the  air-passages.  The 
insertion  of  a  drainage-tube  is  scarcely  called  for  as  a  routine 
procedure,  but  it  is  advisable  to  lightly  plug  the  wound  with 
gauze. 

The  chief  danger  arises  from  the  loss  of  blood,  and,  as  already 
stated,  this  may  come  from  division  of  an  intercostal  artery,  or 
from  the  lung.  If  of  intercostal  origin,  it  should  be  treated  as 
described  at  p.  244.  Pulmonary  hemorrhage  is,  unfortunately,  not 
so  readily  controlled  ;  and  much  difference  of  opinion  has  been 
expressed  as  to  the  most  satisfactory  means  to  adopt  in  these 
cases.  Probably  the  best  method  consists  in  keeping  the  patient 
absolutely  quiet,  and  trusting  to  the  application  of  cold  to  the 
side,  and  to  the  administration  of  haemostatics,  as  indicated  above 
for  non-penetrating  wounds.  In  bad  cases  the  haemorrhage  may 
only  cease  when  the  patient  is  in  a  condition  of  profound  collapse 
or  syncope  ;  intravenous  infusion  of  saline  solution  may  then 
suffice  to  tide  him  over  the  period  of  danger,  and  lead  to  a 
successful  result. 

Two  other  plans  of  treating  pulmonary  haemorrhage  which 
have  been  recommended  may  be  noted,  viz.,  venesection  from 
the  systemic  circulation  so  as  to  reduce  blood-pressure,  and  thus 
obtain  thrombosis  ;  and  plugging  the  wound  in  the  parietes  so 
as  to  cause  the  blood  to  accumulate  in  the  pleural  cavity,  and 
thus  by  its  pressure  lead  to  a  similar  result.  Neither  of  these 
methods  commends  itself  to  us,  although  both  are  occasionally 
successful,  and  possibly  would  be  the  only  plans  practicable  in 
dealing  with  a  large  number  of  wounded.  The  latter  of  the  two 
has  an  additional  objection  in  that  it  is  almost  certain  to  be 
followed  by  suppuration  and  septic  fever,  necessitating  the  opening 
and  washing  out  of  the  pleural  cavity  at  a  later  date. 

The  question  of  opening  the  thorax  by  resecting  a  considerable 
portion  of  rib,  so  as  to  deal  directly  with  the  injured  lung,  has 
been  raised  of  recent  years,  and  several  cases  in  which  it  has 
been  undertaken  have  been  recorded.  Whether  or  not  such 
practice  is  justifiable  is  a  question  that  further  experience  can 
alone  decide  ;  at  present  all  wTe  can  say  is  that  a  surgeon  should 
be  prepared  to  do  this  operation,  although  only  resorting  to  it  in 
exceptional  circumstances. 

The  later  treatment  of  these  cases  is  much  the  same  as  for 
simple  non-penetrating  injuries.  Should  symptoms  of  septic 
pleurisy  follow,  the  wound  must  be  freely  opened,  a  portion  of 
rib  being  excised,  if  necessary,  and  the  cavity  washed  out  and 
drained,  as  for  empyema. 

Hernia  of  the  Lung,  or  pneumocele,  is  a  rare  condition  in  which 


858  A   MANUAL  OF  SURGERY 

a  portion  of  the  lung  protrudes  through  an  opening  in  the  thoracic 
parietes  beneath  the  uninjured  skin.  It  may  occur  suddenly,  as 
the  immediate  consequence  of  a  laceration  of  the  intercostal 
muscles  and  pleura,  or  more  gradually,  being  then  due  to  the 
yielding  of  a  cicatrix.  It  is  most  usually  seen  about  the  fifth 
intercostal  space,  but  has  been  known  to  occur  in  the  root  of  the 
neck  from  a  lesion  in  the  dome  of  the  pleura.  It  is  recognised 
by  the  appearance  of  a  rounded  swelling,  increasing  in  size  on 
coughing  or  making  expiratory  efforts,  and  possibly  disappearing 
entirely  on  holding  the  breath.  It  imparts  a  crepitant  feeling  to 
the  fingers  when  compressed,  and  on  auscultation  a  loud  vesicular 
murmur  is  heard.  As  a  rule,  no  treatment  is  advisable  in  this 
condition  beyond  the  application  of  a  pad  or  truss. 

A  similar  condition,  arising  as  a  complication  of  an  open 
wound,  is  termed  a  Prolapse  of  the  lung.  An  attempt  should 
always  be  made  to  return  the  protruded  viscus,  and  to  prevent  its 
recurrence  by  suturing  the  aperture  through  which  it  has  escaped. 
If  left  unreduced,  it  is  very  likely  to  become  gangrenous  from 
strangulation,  and  should  then  be  removed  by  the  application  of 
a  ligature,  the  wound  being  subsequently  closed. 

Empyema,  or  suppuration  within  the  pleural  cavity,  results  not 
only  from  traumatism,  but  also  as  a  sequela  of  a  simple  pleurisy, 
or  as  a  complication  of  various  affections  of  the  lungs,  whilst  a 
basal  empyema  is  not  an  uncommon  result  of  intra-abdominal 
suppuration.  A  description  of  the  physical  signs  and  symptoms 
belongs  rather  to  the  physician  than  to  the  surgeon.  It  will  suffice 
to  mention  here  that  the  affected  side  of  the  chest  does  not  move 
on  inspiration,  whilst  there  may  be  some  bulging  of  the  inter- 
costal spaces ;  on  percussion  the  side  is  dull,  except  perhaps 
immediately  below  the  clavicle,  where  tympanitic  resonance  may 
be  elicited.  On  auscultation  breath-sounds  are  absent,  except  in 
the  vertebral  groove,  where  bronchial  breathing  may  be  heard. 
The  loss  of  vocal  fremitus  is  also  an  important  sign.  A  certain 
amount  of  fever  and  dyspnoea  is  usually  present  in  cases  of 
empyema,  whilst  the  other  thoracic  viscera  may  be  displaced. 
Left  to  itself,  an  empyema  usually  finds  its  way  to  the  surface, 
and  perhaps  most  commonly  bursts  through  the  fifth  or  sixth 
costal  interspace,  though  sometimes  through  the  second  in  front, 
owing  to  the  perforating  vessels  being  larger  here  than  elsewhere. 
Occasionally  a  localized  empyema  is  met  with,  giving  rise  to 
similar  effects,  but  on  a  smaller  scale.  When  situated  on  the  left 
side  in  close  proximity  to  the  pericardium,  the  movements  of  the 
heart  may  be  transmitted  through  the  fluid  to  the  surface,  causing 
a  pulsation  which  can  be  seen  or  felt  (pulsating  empyema). 

In  the  early  stages  the  pleura  is  but  little  altered  in  structure, 
although  a  certain  amount  of  lymph  may  be  deposited  on  it ; 
in   old-standing  chronic  cases  it  becomes  very  dense  and  firm, 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST     859 


owing  to  a  development  of  fibro-cicatricial  tissue,  whilst  the 
surface  is  converted  into  a  layer  of  granulation  tissue,  similar  to 
that  found  in  all  chronic  abscesses.  The  lung  collapses  and 
retreats  backwards  towards  the  spine ;  at  first  its  alveolar  texture 
remains  unaltered  and  the  early  removal  of  the  exudation  enables 
it  to  re-expand,  as  a  result  of  the  atmospheric  pressure.  In 
chronic  cases,  however,  there  are  two  hindrances  to  this  expan- 
sion, viz.,  the  density  of  the  thickened  visceral  pleura,  which 
resists  the  atmospheric  pressure,  and  the  infiltration  and  sclerosis 
of  the  lung  tissue  itself.  Under  these  circumstances,  even  when 
the  exudation  is  entirely  removed,  the  lung  may  remain  collapsed, 
and  Nature  then  attempts  in  several  ways  to  remedy  the  mischief 
and  obliterate  the  pleural  cavity:  (a)  The  opposite  lung  undergoes 
expansion  and  hypertrophy,  and  together  with  the  heart  projects 
over  to  the  opposite  side  ;  (b)  the  abdominal  viscera  and  dia- 
phragm are  displaced  upwards  ;  (c)  the  chest  wall  falls  in,  and  the 
spine  becomes  laterally  curved,  with  its  convexity  to  the  sound 
side ;  and  (d)  there  is  an  exuberant  growth  of  granulation  tissue 
from  the  surface  of  the  pleura.  In  a  certain  proportion  of  cases 
these  structural  changes  suffice  to  determine  a  cure,  but  in  others 
a  cavity  still  remains,  lined  with  thickened  pyogenic  membrane, 
and  discharging  pus  or  serum,  according  to  whether  or  not  sepsis 
is  present.  Under  these  circumstances  extensive  operative  inter- 
ference is  necessary. 

The  Diagnosis  of  empyema  is  readily  made  by  attention  to  the 
physical  signs,  and  confirmation  of  such  an  opinion  can  be  obtained 
by  puncture  with  a  sterilized  hypodermic  syringe.  A  medium- 
sized  needle  should  always  be  employed  for  this  purpose,  and  it  is 
well  to  insert  it  along  the  top  of  a  rib  after  drawing  the  skin  up 
or  down,  so  that  on  removal  a  valvular  puncture  results.  The 
character  of  the  organisms  contained  in  the  sample  of  pus  thus 
withdrawn  should,  if  possible,  be  ascertained,  since  it  has  been 
proved  that  the  Prognosis  depends  much  on  this  point.  Thus, 
an  empyema  due  to  the  presence  of  pneumococci,  presumably 
following  a  pneumonia,  runs  a  mild  course,  and  is  readily  cured, 
even  by  aspiration  alone  ;  one  due  to  the  ordinary  pyogenic  cocci 
is  more  acute,  and  requires  drainage  with  or  without  resection 
of  a  piece  of  rib.  The  presence  of  tubercle  bacilli  renders  the 
outlook  much  more  serious,  whilst  the  addition  of  septic  organisms 
to  any  of  the  above  aggravates  the  process  and  much  impedes 
a  cure.  The  chronicity  or  not  of  the  affection  is  also  a  most 
important  element  in  the  prognosis,  since  the  later  the  treatment 
commences,  the  denser  are  the  adhesions  which  bind  down  the 
lung,  and  the  less  the  chance  of  its  re-expansion. 

Treatment  therefore  should  never  be  delayed ;  the  earlier  it  is 
undertaken,  the  better  the  results. 

Aspiration  may  be  adopted  in  the  first  instance,  but  is  generally 
to  be  regarded  as  of  an  exploratory  nature,  though  a  cure  will 


860  A  MANUAL  OF  SURGERY 

occasionally  follow  when  the  empyema  is  of  pneumonic  origin. 
It  is,  however,  sometimes  of  value  in  order  to  relieve  for  a  time 
the  pressure  on  the  other  lung  and  the  resulting  dyspnoea,  and 
thus  allow  of  the  administration  of  an  anaesthetic  for  the  more 
serious  subsequent  operation. 

Drainage  of  the  pleural  cavity  through  an  external  incision  is 
the  treatment  almost  invariably  necessary,  and  the  opening  is 
best  made  either  in  the  mid-axillary  line  or  a  little  in  front  of  it, 
through  the  fifth  costal  interspace.  Under  special  circumstances 
it  may  be  necessary  to  open  the  pleural  cavity  at  a  lower  level, 
and  then  the  ninth  or  tenth  interspace  in  the  scapular  line  is 
selected.  Whether  a  portion  of  rib  need  be  removed  or  not,  is 
merely  a  question  of  mechanical  convenience;  if  the  drainage-tube 
can  be  efficiently  retained  between  the  ribs  without  resection,  well 
and  good  ;  but  if,  as  in  children,  the  space  is  narrow,  then  a 
portion  of  rib  must  be  removed.  An  incision  is  made  along  the 
course  of  a  rib  about  i^  inches  in  length,  and  the  periosteum 
stripped  up  from  both  the  superficial  and  deep  aspects  of  the  bone, 
so  as  to  enable  a  curved  raspatory  to  be  passed  beneath  it ;  at 
least  i  inch  of  the  rib  is  then  cut  away  with  bone  pliers.  The 
parietal  pleura  is  opened  sufficiently  to  enable  the  finger  to  be 
introduced  and  the  cavity  explored.  A  large  drainage-tube  is 
inserted,  just  long  enough  to  project  into  the  pleural  cavity,  and 
the  wound  immediately  covered,  so  as  to  prevent  as  far  as  possible 
the  entrance  of  unfiltered  air. 

Formerly  it  was  considered  desirable  to  thoroughly  wash  out 
the  pus  ;  but  it  has  now  been  demonstrated  that  such  is  unneces- 
sary, and  occasionally  dangerous.  Several  cases  of  sudden  death 
have  followed  this  practice,  probably  due  to  reflex  irritation  of  the 
vagus.  In  chronic  cases,  where  sepsis  has  been  admitted,  irriga- 
tion is  often  beneficial,  but  the  following  points  must  be  attended 
to  :  (i.)  The  fluid  employed  must  be  unirritating,  though  sterile ; 
(ii.)  it  must  be  at  the  temperature  of  the  body,  neither  too  hot  nor 
too  cold  ;  (iii.)  it  must  not  be  injected  with  such  force  as  to  impinge 
against  the  pleura  or  against  the  upper  surface  of  the  diaphragm ; 
and  (iv.)  free  exit  must  be  given  to  it,  so  as  to  prevent  tension 
from  accumulation  within  the  pleural  cavity. 

If  such  treatment  is  undertaken  sufficiently  early,  the  lung  may 
be  expected  to  expand,  the  discharge  steadily  diminishing,  and  the 
wound  ultimately  healing;  but,  as  we  have  already  explained,  such 
does  not  always  occur,  and  then  a  fistula  persists,  leading  into  a 
cavity  lined  with  a  thick  pyogenic  membrane,  discharging  a  variable 
amount  of  pus.  The  best  means  of  obtaining  a  cure  in  these  cases 
consists  in  removal  of  the  rigid  external  wall,  as  by  Estlander's 
operation,  which  is  characterized  by  the  excision  of  portions  of  ribs 
comprising  the  outer  wall  of  the  cavity.  It  is  usually  carried  out 
through  a  vertical  incision  in  the  axillary  line,  the  ribs  being  freed 
from  their  periosteal  connections  ;   the  amount  excised  necessarily 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST    86 1 


varies  according  to  circumstances,  and  is  in  some  cases  very 
extensive.  The  fistulous  track  is  enlarged,  and  the  interior  of 
the  pleura  carefully  curetted  and  washed  out,  so  as  to  remove  all 
necrotic  and  degenerating  tissue  ;  the  parietes  are  then  allowed  to 
fall  back  into  contact,  if  possible,  with  the  deeper  layer,  a  drainage- 
tube  is  inserted,  and  the  side  firmly  bandaged.  A  modification 
of  this  proceeding  is  known  as  Schedes  operation,  in  which  not 
only  are  the  ribs  removed,  but  also  the  intervening  tissues,  so 
that  the  subcutaneous  or  muscular  structures  in  the  flaps  are 
laid  down  upon  the  prepared  surface  of  the  deeper  layer  of  the 
pleura. 

Necessarily,  either  of  these  methods  of  treatment  is  associated 
with  considerable  deformity,  and  also  with  a  terrible  weakening 
of  the  side,  and  plans  have  been  suggested  to  obviate  this  by 
removing  portions  of  a  number  of  ribs  before  and  behind,  so  as 
to  leave  the  intervening  segment  free  to  collapse  without  totally 
destroying  the  osseous  thoracic  boundary.  Another  proceeding 
that  has  been  recently  introduced  and  practised  with  success  is 
the  stripping  of  the  thickened  pleura  away  from  the  collapsed 
lung,  so  as  to  enable  it  to  expand  once  more  (pulmonary  decortica- 
tion). Further  experience  is  needed  before  any  final  opinion  as 
to  the  merits  of  these  operations  can  be  given. 

Various  operative  proceedings  have  been  directed  to  the  lung 
substance  itself,  concerning  which,  however,  we  can  but  suggest 
a  few  points. 

Pueumotomy,  or  incision  of  the  lung,  has  been  undertaken  for 
not  a  few  pulmonary  lesions,  and  the  results  obtained  have  been 
rather  variable,  i.  For  tuberculous  cavities  it  is  of  little  use.  They 
are  usually  situated  at  the  apex  of  the  lung  and  drain  well ; 
the  original  disease  is  not  removed  ;  and  the  general  health  is 
frequently  so  impaired  that  the  shock  of  the  operation  hastens  the 
inevitably  fatal  issue.  Hence  it  is  only  required  in  cavities  located 
in  the  lower  half  of  the  lung,  which  drain  badly,  and  the  difficulty 
of  diagnosing  such  a  condition  is  considerable.  2.  For  bronchiectases 
pneumotomy,  though  prima  facie  desirable,  has  given  but  little 
benefit,  since  it  is  uncommon  for  only  one  dilatation  of  the  bronchus 
to  exist.  In  suitable  cases,  however,  where  there  is  a  good  deal  of 
foetid  secretion,  which  is  with  difficulty  expelled,  it  may  be  useful. 
3.  In  gangrene  of  the  lung  much  benefit  may  be  derived.  4.  The 
same  is  true  as  regards  pulmonary  abscess  following  pneumonia. 
5.  In  hydatid  disease  of  the  lung,  incision  and  drainage  have  so 
considerably  reduced  the  mortality  that  this  method  of  treatment 
should  alone  be  adopted. 

As  to  the  technique  of  the  operation,  the  first  thing  is  to  locate  the 
mischief,  and  this  is  effected  partly  by  a  careful  attention  to  the 
physical  signs,  partly  by  the  use  of  an  exploring  needle  or  syringe. 
An  incision  is   then    made,  and  a  portion  of   one  or    more  ribs 


862  A  MANUAL  OF  SURGERY 

removed.  If  the  lung  is  adherent  to  the  thoracic  walls,  and  shows 
no  signs  of  retracting,  the  operation  may  be  continued  ;  but  if  no 
adhesions  are  present,  it  may  be  well  to  stuff  the  wound  with  gauze 
for  a  day  or  two,  so  as  to  determine  their  formation  and  thus  shut 
off  the  pleural  cavity.  The  lung  itself  may  be  punctured  with  sinus 
forceps  introduced  along  an  exploring  needle,  and  then  opened,  or 
may  be  incised  with  a  cautery.  The  abscess  or  other  cavity  is 
thus  emptied  of  its  secretion,  and  a  drainage-tube  inserted.  As 
a  general  rule  it  is  unwise  to  scrape  or  irrigate  it,  for  fear  of  a 
communication  existing  with  any  of  the  larger  bronchi. 

Pneumectomy,  or  excision  of  a  portion  of  the  lung,  has  been 
attempted  in  a  few  cases  of  tuberculous  disease  limited  to  the 
apex  ;  the  operation  is,  however,  quite  unjustifiable,  since,  if  the 
affection  is  localized  to  the  apex,  it  can  often  be  cured  by  the 
physician,  whilst  if  it  is  more  diffuse  it  cannot  be  extirpated. 
Primary  malignant  tumours  of  the  lung,  moreover,  are  usually 
central,  and  the  diagnosis  can  rarely  be  made  early  enough  to 
warrant  an  attempt  at  removal.  The  only  conditions  under  v/hich 
it  is  justifiable  to  excise  portions  of  lungs  are :  (a)  when  a  hernial 
protrusion  has  become  strangled  through  a  small  opening,  and 
cannot  be  reduced  ;  and  (b)  when  malignant  disease  of  a  rib  has 
invaded  the  superficial  portion.  In  the  former  case,  the  base  of 
the  protrusion  is  transfixed  and  ligatured  prior  to  being  cut  away  ; 
in  the  latter,  the  disease  is  snipped  away  with  scissors,  and  bleeding 
stayed  by  cautery,  ligature,  or  plugging. 

Wounds  of  the  Heart. 

Wounds  of  the  Heart  and  great  vessels  are  so  usually  fatal 
either  immediately  or  within  a  few  hours,  that  it  is  unnecessary 
to  discuss  them  here  in  any  detail.  If  the  patient  does  not  die 
at  once,  he  suffers  from  intense  shock  and  prostration,  combined 
with  a  weak  and  turbulent  action  of  the  heart,  great  pain  in 
the  chest  and  dyspnoea,  whilst  the  pulse  is  scarcely  to  be  felt. 
Free  haemorrhage  occurs  if  there  is  an  external  wound,  but  if 
the  opening  in  the  pericardium  is  small  and  valvular,  the  heart's 
action  may  be  brought  to  a  standstill  by  the  pressure  of  the  blood 
within.  Should  the  patient  survive,  pericarditis  generally  super- 
venes, and  is  often  of  a  purulent  type.  As  to  Treatment,  the  great 
essential  is  to  keep  the  individual  absolutely  quiet,  and  with  the 
head  low.  The  external  wound  should  be  purified,  but  during 
the  stage  of  primary  shock  no  attempt  should  be  made  to  explore 
it,  either  by  finger  or  probe,  for  fear  of  dislodging  a  clot.  Later 
on  the  question  of  exploration  may  be  raised,  and  more  than  one 
case  has  now  been  published  in  which  the  surgeon  has  success- 
fully sutured  a  stab-wound  in  the  ventricle.  To  expose  the  heart 
for  this  purpose  it  is  usual  to  turn  up  a  trap-door  flap  of  the 
chest    wall,    including    portions    of    the    fourth    and    fifth    costal 


surgery  of  the  air-passages,  lungs,  and  chest   863 


cartilages  and  ribs.  Other  cases  are  reported  in  which  a  wound 
of  the  heart  has  healed  spontaneously,  and  the  patient  survived 
for  many  years. 

Effusion  into  the  Pericardium,  whether  serous  or  purulent,  may 
occasionally  require  surgical  treatment  in  order  to  relieve  symp- 
toms of  cardiac  failure,  due  to  the  pressure  of  the  exudation. 
For  serous  pericarditis  all  that  is  needed  is  to  aspirate  the  cavity. 
This  is  usually  undertaken  close  to  the  left  border  of  the  sternum 
in  the  fifth  interspace,  or  i|  inches  from  the  left  margin  of  that 
bone  through  the  fourth  or  fifth  interspace,  so  as  to  avoid  the 
internal  mammary  trunk,  which  courses  down  about  a  finger's 
breadth  from  the  border. 

For  suppurative  pericarditis  an  incision  may  be  made  in  the 


Fig.  310. — Artificial  Respiration  by  Sylvester's  Method  (First  Stage). 

The  arms  are  grasped  just  above  the  elbows,  and  raised  well  above  the  head 
so  as  to  expand  the  thorax. 

same  situation  after  removing  the  fourth  or  fifth  costal  cartilage, 
the  cavity  washed  out,  and  even  a  drainage-tube  inserted.  Care 
must  be  taken  to  prevent  infection  of  the  mediastinal  tissues,  and 
this  can  sometimes  be  accomplished  by  stitching  the  pericardium 
to  the  parietes  before  opening  it. 

Asphyxia. 

Asphyxia,  or  Apncea,  is  the  term  applied  to  indicate  the  condition  arising 
from  interference  with  or  stoppage  of  the  respiratory  act.  If  this  has  not 
proceeded  to  any  great  extent  it  is  termed  Dyspnoea;  when,  however,  the 
obstruction  is  so  marked  that  the  patient  is  obliged  to  maintain  the  upright 
sitting  position,  the  term  Orthopnea  is  applied  to  it. 

The  Causes  of  asphyxia  may  be  classified  as  follows : 

1.  Conditions  arising  from  the  presence  of  abnormal  contents  within  the 


864 


A   MANUAL  OF  SURGERY 


air-passages,  e.g. ,  foreign  bodies,  blood-clot,  or  pus  from  the  bursting  of  an 
abscess  or  aneurism  ;  serum,  as  in  oedema  of  the  lung  ;  mucus  or  muco-pus,  as 
in  bronchitis  ;  the  consolidated  exudation  in  pneumonia ;  diphtheritic  mem- 
brane ;  or  irrespirable  gases  ;  e.g.,  nitrogen,  hydrogen,  carbonic  acid  gas,  etc., 
as  in  suffocation.  Death  by  drowning  usually  arises  from  a  similar  cause, 
viz.,  the  replacement  of  air  by  water  in  the  respiratory  passages. 

2.  Causes  arising  in  the  walls  of  the  air-passages,  such  as  diminution  of 
their  lumen  from  inflammatory  congestion,  as  in  oedema  of  the  glottis; 
cicatricial  stenosis  ;  the  presence  of  new  growths,  or  the  displacement  of  parts, 
as  in  cut  throat  ;  or  the  falling  back  of  the  root  of  the  tongue  after  partial 
excision  of  that  organ. 

3.  Extrinsic  causes,  or  those  arising  outside  the  air-passages,  e.g.,  in  the 
neck  :  strangling,  hanging,  garrotting,  etc.  ;  the  presence  of  tumours,  such  as 


Fig.  311. 


-Sylvester's  Method  of  Artificial  Respiration 
(Second  Stage). 


The  arms  are  brought  down  to  the  side,  and  pressed  firmly  inwards  against  the 
thoracic  parietes  so  as  to  expel  the  air.  These  two  stages  are  alternately 
repeated  about  fifteen  times  in  the  minute. 


goitres  or  aneurisms  ;  a  retro-pharyngeal  abscess  or  tumour,  and,  under 
exceptional  circumstances,  displacement  backwards  of  the  sternal  end  of  the 
clavicle.  Within  the  thorax  gradually  increasing  obstruction  to  the  respiration 
may  be  caused  by  the  presence  of  tumours,  aneurisms,  or  effusion  into  the 
pericardium  or  pleura. 

4.  Nervous  causes,  e.g. ,  paralysis  or  spasm  of  the  larynx,  and  paralysis  of  the 
diaphragm,  either  from  peripheral  lesions,  such  as  the  pressure  of  aneurisms 
or  tumours  on  the  nerve  trunks,  or  from  central  causes,  such  as  a  lesion  in  the 
upper  part  of  the  spinal  cord  or  medulla.  It  may  also  arise  from  paralysis  of 
the  respiratory  centre,  as  from  an  overdose  of  chloroform. 

5.  In  many  forms  of  cardiac  disease  the  lungs  may  become  engorged  with 
stagnant  blood,  leading  gradually  to  dyspnoea,  orthopnoea,  and  finally  asphyxia, 
owing  to  the  increasing  difficulty  in  eliminating  the  excessive  accumulation  of 
carbonic  acid. 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST     865 

The  Treatment  of  the  different  conditions  giving  rise  to  asphyxia  cannot  here 
be  dealt  with  in  extenso.  We  can  only  indicate  the  general  plan  of  treatment 
to  be  adopted.  A  rapid  examination  is  at  once  made,  to  ascertain,  if  possible, 
the  cause  of  the  mischief,  and  whether  its  onset  has  been  gradual  or  sudden. 
If  it  has  been  gradually  developing,  it  is  not  uncommonly  due  to  some  thoracic 
condition  which  cannot  be  relieved  ;  if,  however,  its  onset  has  been  sudden, 
and  not  the  result  of  any  evident  lesion,  the  neck  and  chest  should  be  bared, 
and  examined  for  signs  of  traumatism,  the  mouth  opened,  the  tongue  drawn 
forwards,  and  the  glottis  examined  with  the  finger  to  see  that  the  passages  are 
clear.  The  patient  should,  if  necessary,  be  removed  into  fresh  air,  and  arti- 
ficial respiration  at  once  commenced.  Breathing  can  sometimes  be  excited 
by  alternately  dashing  hot  and  cold  water  over  the  thorax,  whilst  electric 
stimulation  of  the  phrenic  nerve  may  also  be  undertaken,  one  electrode  being 
placed  over  the  neck,  and  the  other  on  the  epigastrium.  The  administra- 
tion of  oxygen  instead  of  air  is  useful  during  the  earlier  stages,  whilst  if  the 
condition  is  due  to  cardiac  disease  with  distension  of  the  right  side  of  the 
heart,  venesection  holds  out  the  best  hope  of  relief.  Obstruction  within  the 
larynx  needs  tracheotomy  or  intubation,  as  also  other  conditions  associated 
with  pressure  on  the  trachea. 

In  cases  of  threatened  death  from  drowning,  the  first  care  must  be  directed 
to  clearing  the  air-passages  and  mouth  of  water,  weeds,  etc.,  by  rapid  inver- 
sion, drawing  the  tongue  well  forwards,  and  swabbing  out  the  pharynx ;  or  the 
patient  is  turned  on  his  face,  with  a  firm  pillow,  or  coat  rolled  up,  placed 
beneath  the  thorax  ;  and  the  chest  is  compressed  so  as  to  help  in  the  evacua- 
tion of  the  water,  which  runs  out  of  the  mouth.  Artificial  respiration  can 
then  be  commenced. 

Artificial  Respiration  is  required  in  a  variety  of  surgical  conditions,  and  is 
best  undertaken  by  what  is  known  as  Sylvester's  method.  In  this  the  patient 
lies  on  his  back,  with  a  pillow  beneath  the  shoulders,  the  mouth  opened,  and 
the  tongue  drawn  forwards.  The  arms  are  then  grasped  just  above  the  elbows 
and  drawn  upwards  above  the  patient's  head,  so  as  to  expand  the  chest  through 
the  action  of  the  great  pectoral  muscles  (Fig.  310).  This  position  is  main- 
tained for  about  two  seconds,  and  then  the  arms  are  lowered  to  the  side,  and 
pressed  firmly  against  the  ribs,  so  as  to  determine  a  forcible  expiratory  act 
(Fig.  311).  At  the  end  of  about  two  seconds  more  the  arms  are  again  elevated, 
and  the  same  cycle  passed  through.  This  should  be  repeated  about  fifteen 
times  a  minute,  and  the  operator  must  be  careful  not  to  use  too  great  violence, 
or  to  unnecessarily  hurry  over  it,  as  harm  rather  than  good  thereby  results. 

Another  less  satisfactory  method  consists  in  alternately  compressing  the 
lower  part  of  the  thorax  and  abdomen  with  the  hands,  so  as  to  drive  out  a 
certain  amount  of  air,  and  then  by  suddenly  relieving  the  pressure  the  elastic 
expansion  of  the  chest  walls  draws  in  a  fresh  supply 


55 


CHAPTER  XXXI. 

DISEASES  OF  THE  BREAST. 

Congenital  Malformations  of  the  breast  are  much  more  common 
than  is  usually  supposed.  One  or  more  accessory  breasts  or 
nipples  are  found  either  below  the  normal  one  or  just  above  it, 
but  sometimes  they  have  been  found  in  the  axilla,  on  the  outer 
side  of  the  thigh,  or  other  curious  situations.  They  are  often  of 
a  most  rudimentary  nature,  but  in  a  few  cases  they  have  secreted 
milk.  The  existence  of  these  structures  probably  explains  the 
occasional  origin  of  cancer  in  unusual  situations,  such  as  the 
axilla.     Very  rarely  the  breasts  are  entirely  absent. 

Affections  of  the  Nipple. 

Fissures  of  the  Nipple  (cracked  nipples)  seldom  occur  apart  from 
lactation,  and  may  usually  be  traced  to  a  want  of  care  and  cleanli- 
ness on  the  part  of  the  mother,  associated  with  a  tender  condition 
of  the  skin,  which  might  have  been  prevented  by  bathing  the 
parts  during  the  later  weeks  of  pregnancy  with  spirit,  so  as  to 
harden  them.  The  actual  lesion  is  brought  about  by  leaving  the 
nipples  wet  after  nursing.  The  superficial  layers  of  epithelium 
become  macerated,  and  are  easily  rubbed  off,  thus  exposing  the 
more  delicate  and  sensitive  deeper  parts,  which  are  irritated  and 
inflamed  by  the  repeated  acts  of  suction.  As  a  result,  nursing 
becomes  painful,  and  if  persisted  in,  the  wound  may  be  infected, 
the  inflammation  spreading  to  the  breast  substance  along  the 
duct  or  lymphatics,  or  extending  along  the  superficial  lymphatics 
to  the  axillary  glands. 

Treatment. — The  best  way  to  prevent  the  occurrence  of  cracks 
is  to  bathe  the  nipples  with  some  dilute  antiseptic,  such  as  boric 
lotion,  immediately  after  nursing,  and  then  to  dry  them  thoroughly. 
If  at  all  tender,  a  little  powdered  boric  acid  and  starch  may  be 
dusted  over  them  in  the  intervals.  When  a  fissure  has  formed, 
it  should  be  dressed  with  cooling  or  antiseptic  lotions — e.g.,  lotio 
plumbi  or  lotio  acidi  borici.  Sometimes  more  stimulating  appli- 
cations are  required,  such  as  a   solution  of  sulphate  of  copper, 


DISEASES  OF  THE  BREAST  867 

or  even  of  nitrate  of  silver.  It  is  also  recommended  to  paint 
the  sore  with  equal  parts  of  glycerine  and  sulphurous  acid. 

Eczema  of  the  Nipple  may  be  of  a  simple  nature,  needing  nothing 
but  ordinary  treatment,  or  it  may  take  on  special  features,  being 
then  known  as  Paget's  Disease  (dermatitis  maligna),  a  condition  by 
some  supposed  to  be  due  to  the  presence  and  action  of  psorosperms. 
It  presents  a  smooth,  red,  raw  surface,  discharging  an  abundant 
yellowish  viscid  fluid,  and  may  occasionally  spread  widely  beyond 
the  areola.  It  is  almost  invariably  a  precursor  of  cancer,  and, 
indeed,  some  authorities  maintain  that  from  the  first  the  disease  is 
malignant,  and  not  eczematous,  in  nature.  The  cancerous  tumour 
is  usually  located  beneath  the  nipple,  and  may  resemble  either  a 
duct  cancer,  or  an  ordinary  scirrhus.  No  local  treatment  is  of  any 
avail,  and  the  disease,  when  once  recognised  with  certainty,  is  best 
treated  by  removal  of  the  breast  and  axillary  glands. 

Abscess  of  the  Areola  is  not  uncommon  in  young  girls  about 
the  age  of  puberty,  arising  in  the  sebaceous  follicles,  and  requiring 
no  special  notice. 

Chancre  of  the  Nipple  is  rarely  seen  in  the  mothers  of  syphilitic 
children  (Colles's  law,  p.  136),  but  much  more  commonly  in  wet 
nurses. 

Primary  Tumours  of  the  Nipple  are  met  with,  such  as  papilloma, 
sebaceous  cysts,  and  occasionally  epithelioma. 

Inflammatory  Affections  of  the  Breast. 

Acub3  Mastitis  is  naturally  most  often  observed  is  puerperal 
women,  owing  to  the  sudden  establishment  of  function  in  the 
breast  after  the  birth  of  a  child,  and  to  its  maintained  activity 
during  lactation.  It  results  most  commonly  from  a  sore  or 
cracked  nipple,  through  which  pyogenic  organisms  find  their 
way  into  the  breast  substance,  either  along  the  lymphatics  or 
the  gland  ducts.  In  the  former  case  the  inflammation  is  mainly 
interstitial  in  character,  the  pus  diffusing  itself  widely  between 
the  lobules ;  in  the  latter  the  pus  forms  primarily  within  the 
alveoli  of  the  glandular  substance,  but  subsequently  spreads 
beyond  it.  Simple  obstruction  to  one  or  more  of  the  ducts  from 
inflammation  of  the  nipple,  without  any  external  wound,  also 
determines  inflammation,  which  is  frequently  non-suppurative  in 
character.  In  non-puerperal  women  acute  mastitis  may  result  from 
injury,  or  may  be  pyaemic  in  origin.  Occasionally  a  metastatic 
inflammation  of  the  breast  occurs  after  the  disappearance  of  the 
parotid  swelling  in  mumps  ;  whilst  in  girls  about  the  age  of 
puberty  a  subacute  inflammation,  involving  both  the  breast  and 
areola,  and  even  terminating  in  suppuration,  has  been  observed. 
In  newly-born  infants  a  similar  inflammation,  occasionally  running 
on  to  suppuration,  has  been  seen,  possibly  resulting  from  an 
infection  of  the  gland  ducts  during  birth  with  cocci  from  the 
maternal  passages.     A  slight  enlargement,  with  congestion  of  the 

55—2 


868  A   MANUAL  OF  SURGERY 

breasts,  often  occurs  after  birth,  and  may  be  due  to,  or  is  certainly 
aggravated  by,  the  foolish  habit  followed  by  ignorant  midwives  of 
pulling  or  forcibly  squeezing  them  in  order  '  to  break  the  nipple- 
strings.' 

Signs  and  Symptoms. — An  inflamed  breast  is  characterized  by  the 
organ  becoming  swollen,  acutely  painful,  and  tender.  The  gland 
lobules  are  felt  to  be  enlarged  and  indurated,  whilst  if  lactation  is 
progressing,  the  secretion  is  to  some  extent  impaired  ;  but  owing 
to  the  inability  of  the  mother  to  allow  the  child  to  relieve  the 
organ,  on  account  of  the  pain  produced  thereby,  considerable  ten- 
sion results  from  accumulation  of  milk.  If  suppuration  follows, 
the  skin  over  the  breast  becomes  red  and  cedematous,  and, 
according  to  the  situation  of  the  pus,  three  different  forms  of 
acute  abscess  of  the  breast  are  described :  (a)  Supramammary 
abscess  is  the  term  applied  to  a  collection  of  pus  in  the  sub- 
cutaneous tissue ;  it  is  often  entirely  unconnected  with  the  organ, 
or  may  originate  in  the  superficial  lobules.  It  is  strictly  limited, 
and  does  not  burrow  deeply,  coming  readily  to  the  surface. 
(b)  An  intvamammavy  abscess  is  that  most  commonly  met  with,  the 
pus  developing  within,  and  distending  the  lobules,  or  infiltrating 
the  cellular  tissue  around  them ;  it  is  usually  diffused  widely 
throughout  the  organ,  and  may  point  at  several  spots.  When 
very  acute,  or  in  debilitated  women,  especially  if  it  has  been 
allowed  to  progress  without  treatment,  the  inflammatory  process 
may  actually  determine  gangrene  of  the  glandular  tissue,  (c)  A 
submammary  abscess  is  one  forming  in  the  cellular  tissue  beneath 
the  breast.  It  may  spread  from  the  deep  lobules,  but  more 
frequently  arises  in  connection  with  disease  of  some  of  the 
adjacent  ribs  or  cartilages,  or  as  a  cellulitis.  In  these  cases  the 
breast  is  pushed  forwards,  and  becomes  prominent,  floating,  as 
it  were,  on  a  bed  of  pus.  The  abscess  usually  points  at  the 
periphery  of  the  organ,  perhaps  in  several  places,  but  most  com- 
monly at  the  lower  and  outer  quadrant. 

Inflammation  of  the  breast  occurs  in  women  who  are  anaemic 
and  weakly.  Even  the  simple  forms  are  associated  with  some 
fever  and  malaise,  and  this  becomes  greatly  exaggerated  if 
suppuration  ensues,  owing  partly  to  the  severe  pain  thereby 
induced,  and  partly  to  the  absorption  of  toxins. 

The  Treatment  of  simple  acute  mastitis  consists,  in  the  first 
place,  in  supporting  the  inflamed  gland  by  means  of  a  sling  or 
bandage,  and  in  binding  the  arm  to  the  side,  so  as  to  keep  at 
rest  the  pectoral  muscle,  on  which  it  lies.  Fomentations  are 
then  applied,  and  any  tension  due  to  retained  secretion  is  relieved 
by  the  breast-pump.  The  bowels  are  opened,  and  the  patient 
placed  on  a  light  and  nourishing  diet,  whilst  stimulants  and 
tonics,  such  as  iron  and  quinine,  may  be  judiciously  administered. 

As  soon  as  the  acute  stage  has  passed,  friction  with  warm 
oil,  or  the  inunction  of  a  belladonna  ointment,  is  advisable. 


DISEASES  OF  THE  BREAST  869 


When  suppuration  is  threatening,  the  breast  may  be  poulticed 
until  fluctuation  is  detected  ;  but  under  no  circumstances  must 
the  abscess  be  allowed  to  burst  into  the  poultice,  and  thus  become 
septic.  If  such  a  practice  is  permitted,  chronic  suppuration 
ensues.,  and  the  breast  may  become  riddled  with  sinuses.  The 
most  rigid  asepsis  must  be  maintained  in  these  cases,  and  as  soon 
as  pus  is  evidently  present,  an  incision  should  be  made  to  permit 
of  its  escape.  In  the  supramammary  variety  it  matters  little  in 
which  direction  the  cat  is  made,  since  the  pus  is  always  superficial 
to  the  breast  tissue.  In  the  true  intvamammary  abscess,  the  incisions 
should  radiate  from  the  nipple.  One  or  more  may  be  needed, 
and  these  should  be  made  with  a  free  hand,  so  as  to  allow  of  the 
insertion  of  the  finger,  and  the  opening  up  of  any  pockets  or 
lobules  which  are  distended  with  matter.  A  drainage-tube  is 
inserted  for  a  time,  and  gradually  shortened  day  by  day,  until 
its  entire  removal  is  permissible.  When  the  chief  incisions  are 
needed  above  the  nipple,  it  is  often  wise  to  make  a  counter-opening 
in  the  lower  half  of  the  breast,  and  generally  on  the  outer  side, 
to  permit  of  more  efficient  drainage.  With  such  treatment  the 
best  of  results  may  be  attained,  and  it  is  interesting  to  note  how 
quickly  the  contour  of  the  breast  is  restored,  and  how  slight  is  the 
permanent  injury  inflicted  on  the  parts.  The  submammary  abscess 
is  best  opened  towards  the  lower  and  outer  side,  but  also  at  any 
spot  where  pus  points. 

If  septic  sinuses  persist  after  an  abscess  has  burst,  their  orifices 
should  be  enlarged,  and  their  walls  thoroughly  scraped  and  dis- 
infected ;  deep  cavities  should  be  efficiently  drained  and  stuffed 
with  gauze,  so  as  to  ensure  the  wounds  healing  by  granulation. 

Chronic  Mastitis  occurs  in  two  forms — one,  a  localized  affection 
of  one  segment  of  the  breast  (chronic  lobar  mastitis),  the  other 
involving  the  smaller  lobules  and  interstitial  tissue  (chronic  lobular 
or  interstitial  mastitis). 

1.  Chronic  Lobar  Mastitis  is  by  no  means  unfrequent  as  a 
result  of  imperfect  involution  of  the  organs  at  the  cessation  of 
lactation,  but  may  arise  from  blows  or  squeezes,  and  especially 
in  young  women  ;  it  may  also  follow  a  subacute  or  acute  attack, 
which  has  not  ended  in  suppuration.  It  is  characterized  by 
an  enlargement  of  one  or  more  lobes  of  the  organ,  which  are 
usually  tender,  and  often  excessively  painful,  the  pain  being  of 
a  neuralgic  character,  and  increased  during  menstruation.  The 
condition  is  of  comparatively  little  importance,  but  may  give  rise 
to  a  great  deal  of  anxiety  and  worry.  All  that  is  necessary  in  the 
shape  of  Treatment  is  to  support  the  part  and  keep  the  arm  at 
rest  in  a  sling,  whilst  an  ointment  containing  belladonna,  or  a 
belladonna  plaster,  may  be  applied. 

2.  Chronic  Lobular  or  Interstitial  Mastitis  is  an  affection  of 
much  interest,  which  occurs  most  frequently  in  women  with  small 
or  atrophic  breasts,  who  have  passed,  or  are  near  to,  the  climacteric, 


870  A  MANUAL  OF  SURGERY 


being  then  merely  an  exaggeration  of  the  sclerosis  which  occurs 
normally  at  that  epoch.  It  is,  however,  sometimes  met  with  at 
an  earlier  age.  Pathologically,  it  is  characterized  by  diffuse  over- 
growth and  infiltration  of  the  connective  tissue,  which  becomes 
sclerosed  and  thickened.  This  is  associated  with  well  marked 
epithelial  proliferation,  so  that  sometimes  in  the  earlier  stages  the 
acini  are  filled  with  a  thick  cheesy  or  grumous  material  which 
can  be  squeezed  out  in  thread-like  masses,  often  of  a  dirty  brown 
or  greenish-yellow  colour.  Cysts  are  formed  in  the  gland  tissue, 
partly  by  liquefaction  of  this  proliferated  epithelium,  partly  by 
exudation  into  the  acini  of  serous  fluid,  which  is  unable  to  find  an 
exit  owing  to  the  pressure  of  the  interstitial  growth.  Such  are 
known  as  '  involution  cysts,'  and  the  fluid  contained  therein  is 
usually  clear  and  limpid  ;  but  may  be  brown  and  turbid,  from 
admixture  of  blood  ;  intracystic  growths  are  not  present.  As  a 
rule,  many  of  these  cysts  are  scattered  widely  through  the  breast 
substance,  but  they  are  small  and  insignificant  ;  occasionally  one 
or  more  of  them  become  notably  enlarged,  and  give  the  patient 
the  impression  of  a  tumour. 

Clinical  History. — The  condition  often  passes  unnoticed  in  the 
early  stages,  until  a  distinct  lump  has  formed,  which  is  nodular 
and  indurated  to  the  touch,  and  often  very  painful.  The  breast 
may  be  somewhat  enlarged,  and  there  is,  perhaps,  some  retraction 
of  the  nipple,  owing  to  contraction  of  the  interstitial  tissue  ;  but 
this  is  by  no  means  an  essential  feature.  A  scanty  serous  dis- 
charge from  the  nipple  is  sometimes  noticed.  The  skin  seldom 
becomes  adherent  to  the  swelling,  whilst  the  lymphatic  glands  in 
the  axilla  may  be  enlarged  and  tender  owing  to  sympathetic 
irritation.  On  careful  examination  of  the  breast,  the  affection  is 
rarely  limited  to  one  particular  region,  for  although  a  distinct 
enlargement  of  one  portion  may  be  present,  yet  the  whole  organ 
feels  more  or  less  '  lumpy,'  and  not  unfrequently  the  other  breast 
participates  in  the  same  change.  Small,  rounded,  elastic  spots 
can  often  be  detected  on  careful  palpation,  and  indicate  the 
presence  of  cysts.  There  may  be  but  little  pain,  although  this 
is  sometimes  one  of  the  most  marked  features  of  the  case ;  it 
is  of  a  neuralgic  type,  and  usually  increased  at  the  menstrual 
periods. 

If  left  to  run  its  course,  the  disease  may  remain  much  in  the 
same  condition  for  many  years,  and  even  in  time  disappear  ; 
but  more  frequently  it  slowly  progresses,  and  then  results  in 
one  of  three  conditions  :  (a)  General  atrophy,  the  breast  becoming 
shrunken,  hard,  and  nodular,  (b)  More  frequently  general  cystic 
disease  follows,  a  condition  in  which  the  organ  becomes  trans- 
formed into  a  number  of  cysts  held  together  by  dense  connective 
tissue,  (c)  There  is  some  question  as  to  whether  or  not  cancer  is 
a  sequela  of  this  disease ;  but  there  is  abundant  evidence  to  prove 
that  any  continued  source  of  irritation  in  an  organ  like  the  breast 


DISEASES  OF  THE  BREAST  S71 

renders  an  individual  with  a  cancerous  tendency  more  liable  to 
its  development. 

The  Diagnosis  is  sometimes  easy,  but  the  condition  often 
simulates  somewhat  closely  a  scirrhous  tumour.  The  chief 
points  of  distinction,  however,  lie  in  the  facts  (i.)  that  the  whole 
breast  is  more  or  less  involved ;  (ii*.)  that  the  opposite  organ 
is  very  often  similarly  affected ;  (hi.)  that  enlargement  of  the 
axillary  glands  is  less  common  than  in  scirrhus,  and  even  if  en- 
larged they  are  not  hard,  as  in  the  latter  disease  ;  (iv.)  that  the 
skin  is  usually  free  from  the  mass ;  (v.)  that  the  tumour  is 
never  adherent  to  the  pectoral  fascia,  nor  is  it  of  the  stony  hard- 
ness of  a  scirrhus;  and  (vi.)  that  it  is  often  more  disseminated 
and  less  defined  than  a  cancerous  growth.  (vii.)  Moreover, 
on  careful  palpation  with  the  flat  of  the  hand,  it  is  often  impos- 
sible to  make  out  any  distinct  lump,  the  so-called  tumour  merging 
into  the  surrounding  tissues  ;  this  never  occurs  in  scirrhus,  the 
growth  always  being  easily  detected  with  the  flat  of  the  hand. 
Small  cysts  can  also  be  felt  as  localized  elastic  spots  in  the  in- 
flammatory mass.  Of  course  it  is  possible  for  the  two  conditions 
to  co-exist,  and  in  doubtful  cases  an  exploratory  incision,  and 
microscopic  examination  of  a  portion  of  the  tissue,  can  alone  be 
depended  on. 

Treatment. — In  the  early  stages  friction  with  some  sedative 
application  may  be  used  at  the  same  time  that  the  breast  is 
supported,  and  freed  from  the  irritation  of  badly-fitting  stays. 
Firm  and  equable  pressure,  as  by  strapping,  is  also  useful  in  some 
cases,  whilst  iodide  of  potassium  may  be  administered.  If  a  definite 
tumour  is  present,  or  if  many  cysts  can  be  detected,  and  especially 
if  the  patient  is  anxious  and  worried  about  herself,  it  is  wise  to 
remove  the  affected  portion,  or  even  better  to  excise  the  whole 
breast,  especially  when  there  is  a  family  history  of  malignant 
disease. 

Localized  or  Encysted  Chronic  Abscess  is  usually  associated 
with  pregnancy,  and  is  characterized  by  the  formation  of  an 
indurated  mass  in  the  breast  substance,  which  slowly  softens, 
giving  rise  to  a  sense  of  fluctuation,  although  when  the  abscess 
walls  are  very  thick,  as  is  often  the  case,  it  may  be  exceedingly 
difficult  to  detect  this.  Retraction  of  the  nipple  is  not  uncommonly 
present,  and  the  axillary  glands  may  be  enlarged.  The  condition 
has  frequently  been  mistaken  for  a  tumour,  but  is  recognised 
from  it  by  its  incorporation  with  the  breast  substance,  by  its  lack 
of  definition,  and  by  the  fact  that  on  careful  examination  elasticity 
can  be  felt  at  its  centre,  which  is  almost  always  less  resistant  than 
the  margin,  whereas  the  opposite  is  the  case  with  a  tumour.  In 
cases  of  doubt  the  insertion  of  a  grooved  needle  or  an  exploratory 
incision  will  settle  the  diagnosis.  Some  few  of  these  chronic 
abscesses  of  the  breast  are  of  a  tuberculous  nature. 


$Ji  A   MANUAL  OF  SURGERY 


Treatment  consists  in  opening  the  abscess  cavity,  scraping  out 
its  interior,  disinfecting  with  pure  carbolic  acid,  if  tuberculous,  and 
draining  or  stuffing  it. 

Diffuse  Tuberculous  Disease  of  the  breast  is  very  uncommon. 
Scattered  nodules  of  caseous  material  are  developed  in  the  inter- 
acinous  tissue,  which  break  down  into  pus,  and  come  to  the  surface 
at  various  spots.  The  breast  may  thus  become  riddled  with  sinuses 
discharging  caseous  pus.  It  may  be  associated  with  tuberculous 
disease  of  the  lungs,  whilst  a  like  affection  may  arise  secondarily 
in  the  axillary  glands  ;  possibly  in  some  cases  the  primary  trouble 
lies  in  the  glands,  the  breast  being  subsequently  involved. 

Treatment  should  be  carried  out,  if  possible,  by  incision,  scraping, 
and  purification  of  the  cavities ;  but  if  the  tuberculous  foci  are 
multiple,  it  is  wiser  to  amputate  the  breast. 

Occasionally  a  chronic  tuberculous  submammary  abscess  forms  as  a 
result  of  a  similar  affection  of  the  ribs  or  costal  cartilages.  It 
develops  slowly,  pushing  the  breast  forwards,  and  is  easily  recog- 
nised, although  the  causative  lesion  can  only  be  ascertained  by 
exploration.  It  must  be  opened  thoroughly,  and  its  wall  scraped 
and  disinfected,  whilst  attention  is  also  directed  towards  the  affected 
bone. 

Syphilitic  Diseases  of  the  Breast. — As  already  pointed  out,  a 
primary  sore  may  be  met  with  on  the  nipple  ;  secondary  mucous 
tubercles,  or  condylomata,  are  found  in  a  similar  situation  or 
beneath  a  pendulous  breast,  whilst  superficial  and  deep  gummata 
have  in  rare  cases  formed  in  the  tertiary  period  of  the  disease. 

Cysts  of  the  Breast. 

When  the  structure  of  the  breast,  its  abundance  of  ducts  and 
alveoli,  and  its  complex  lymphatic  distribution  are  considered,  it 
is  not  surprising  that  many  different  forms  of  cystic  changes  are 
associated  therewith.     The  following  are  the  more  important  : 

i.  Acinous  or  Retention  Cysts  arise,  as  the  name  suggests,  from 
some  obstruction  to  the  ducts  or  lobules,  whereby  the  secretion  of 
the  organ  is  unable  to  escape.  They  are  met  with  most  frequently 
in  women  during  or  after  the  puerperal  period,  a  milk  cyst,  or 
galactocele,  being  then  produced.  It  usually  results  from  compres- 
sion of  one  or  more  of  the  ducts,  connected  with  a  sore  nipple,  and 
contains  inspissated  milk  ;  it  forms  a  rounded  swelling,  and  is 
located  near  the  nipple.  The  wall  is  lined  with  cuboidal  01 
columnar  epithelium,  according  to  whether  a  portion  of  the  lobule 
or  the  duct  itself  is  implicated  ;  if,  however,  it  attains  any  great 
size,  the  epithelium  may  become  flat  and  squamous.  This  is  sur- 
rounded by  a  fibro-cicatricial  layer,  the  thickness  of  which  increases 
with  the  chronicity  of  the  case.  It  is  treated  by  laying  the  part 
open,  removing  the  contents,  and  stuffing  or  draining  the  cavity. 


DISEASES  OF  THE  BREAST  873 


Similar  glandular  cysts  form,  as  already  described,  in  the  course 
of  chronic  interstitial  mastitis,  and  are  then  known  as  involution 
cysts  ;  in  long-standing  cases,  general  cystic  disease  of  the  breast 
may  supervene. 

Retention  cysts  have  also  been  described  as  resulting  from 
irritation  of  the  nipple,  as,  for  instance,  when  a  young  non- 
pregnant woman  constantly  puts  a  baby  to  her  breast ;  the 
organ  becomes  enlarged,  the  epithelium  proliferates,  and  a  thin 
serous  fluid  is  secreted,  which  does  not  entirely  escape  and  by 
its  distension  of  the  lobules  gives  rise  to  what  may  be  termed 
irritation  cysts.  They  may  in  time  undergo  spontaneous  absorp- 
tion, but  Erichsen  describes  a  case  of  this  nature  in  which  the 
swellings  did  not  disappear  until  the  patient  subsequently  became 
pregnant. 

Again,  one  frequently  finds  cystic  dilatation  of  the  ducts  and 
lobules  arising  in  connection  with  certain  tumours  of  the  breast, 
such  as  duct  papilloma,  duct  cancer,  or  cysto-adenoma.  In  the 
latter  cases  haemorrhage  from  the  contained  growth  is  often 
seen,  giving  rise  to  a  blood-stained  discharge  from  the  nipple. 
A  scirrhous  growth  also  occasionally  starts  from  the  wall  of  an 
acinous  cyst. 

In  most  of  these  retention  cysts,  discharge  from  the  nipple 
occurs  on  squeezing  the  organ. 

2.  Interacinous  Cysts  develop  in  the  interstitial  tissue  of  the 
breast. 

(a)  Serous  C/sbs  originate,  it  is  supposed,  from  a  dilatation  of 
lymph  spaces.  They  may  be  uni-  or  multi-locular,  perhaps  more 
frequently  the  latter.  They  are  lined  by  a  smooth,  shiny  layer  of 
endothelium,  and  contain  serum,  perhaps  blood-stained,  and  in 
old-standing  cases  cholesterine  ;  being  separate  from  the  gland- 
substance,  they  never  give  rise  to  a  discharge  from  the  nipple,  and 
intracystic  growths  are  unknown.  They  are  usually  surrounded 
by  a  wall  of  connective  tissue  which  may  become  exceedingly 
thick  and  dense.  Occasionally,  however,  they  project  under  the 
skin,  and  if  the  walls  remain  thin,  fluctuation,  and  even  trans- 
lucency,  can  be  observed,  leading  to  the  condition  sometimes 
badly  termed  a  hydrocele  of  the  breast. 

The  Diagnosis  of  a  serous  cyst,  if  the  wall  is  thick,  is  often  a 
matter  of  considerable  difficulty,  as  it  resembles  in  many  ways  a 
scirrhus.  It  is  recognised,  however,  by  the  facts  that  the  growth 
is  incorporated  with  the  breast  substance,  usually  occurring  near 
its  under  surface  ;  that  on  careful  examination  an  elastic  resistance 
is  transmitted  to  the  fingers,  quite  distinct  from  the  stony  hardness 
of  a  scirrhus  ;  that  there  is  no  retraction  of  the  nipple,  and  no 
enlargement  of  the  axillary  glands,  whilst,  as  a  rule,  the  patient 
complains  of  but  little  pain.  The  diagnosis  in  cases  of  doubt  may 
be  readily  determined  by  inserting  a  grooved  needle,  or  by  an 
exploratory  incision,  which  should  be  made  of  sufficient  depth  to 


874  A  MANUAL  OF  SURGERY 

ensure  the  thorough  division  of  the  mass,  for  fear  that  a  small 
cyst  surrounded  by  walls  of  fibrous  tissue,  half  an  inch,  or  even 
an  inch,  in  thickness,  should  be  mistaken  for  a  solid  tumour. 

Treatment. — Although  it  may  suffice  to  lay  the  cavity  open  and 
drain  it,  it  is  decidedly  wiser  to  remove  it  completely. 

(b)  True  Hydatid  Cysts  are  occasionally  met  with,  manifesting 
the  general  characteristics  described  at  p.  189. 

3.  Cysts  may  also  arise  in  connection  with  cancerous  or  sar- 
comatous tumours,  from  degeneration  of  tissue  in  the  former  case, 
and  from  haemorrhage  into  the  substance  of  the  latter. 

4.  Dermoid  Cysts  are  described;  but  it  is  a  little  doubtful  whether 
old  galactoceles  have  not  been  mistaken  for  them. 

Tumours  of  the  Breast. 

In  investigating  any  case  of  tumour  of  the  breast,  the  surgeon 
must  never  arrive  at  a  hasty  conclusion,  but  only  give  an  opinion 
as  to  its  nature  after  a  careful  and  detailed  examination.  Thus, 
the  age  and  previous  history  of  the  patient  should  be  considered, 
as  also  the  family  history.  Simple  tumours  generally  arise  at  an 
earlier  date  than  the  malignant,  whilst  the  sarcomata  usually 
affect  younger  individuals  than  the  carcinomata.  There  can  be 
little  doubt,  moreover,  as  to  the  occasional  tendency  of  tumours 
to  run  in  families.  The  length  of  time  for  which  the  swelling  has 
been  observed  should  be  ascertained,  and  whether  or  not  it  varies 
in  size  at  the  menstrual  periods.  The  general  appearance  of  the 
patient  should  be  noted,  as  also  the  fact  whether  or  not  pain, 
local  or  neuralgic,  is  experienced.  It  is  not  unusual  for  pain  to 
be  referred  to  that  part  of  the  shoulder  supplied  by  the  posterior 
division  of  the  second  intercostal  nerve,  the  anterior  branch  of 
which  goes  to  the  breast.  A  careful  inspection  of  the  organ 
should  then  be  made,  comparing  it  with  the  opposite  breast,  so 
that  any  signs  of  asymmetry  may  be  noted.  Dimpling  of  the  skin, 
projection  of  the  tumour  or  of  the  whole  gland,  and  the  situation 
and  condition  of  the  nipple,  are  the  chief  points  to  which  attention 
should  be  directed.  Examination  of  the  tumour  with  the  flat  of 
the  hand,  accompanied  by  gentle  pressure  of  the  finger-tips,  must 
then  be  undertaken ;  it  is  not  enough  to  pick  up  the  breast 
substance  between  the  fingers,  as  thereby  false  impressions  are 
obtained.  The  relation  of  the  tumour  to  the  gland,  its  shape,  its 
consistency,  whether  fluctuating  or  not,  and  its  mobility  on  super- 
ficial, deep  and  surrounding  parts  should  all  be  investigated.  To 
this  end  the  breast  must  also  be  examined  with  the  arm  raised 
well  above  the  head,  so  as  to  put  the  fibres  of  the  pectoralis  major 
on  the  stretch  ;  transverse  movement  of  the  organ  across  the 
fibres  is  always  possible,  unless  the  growth  is  fixed  to  the  thoracic 
wall ;  movement  in  the  direction  of  the  fibres  is  at  once  limited  if 
the  tumour  has  invaded  the  muscle,  or  even  if  the  overlying  fascia 


DISEASES  OF  THE  BREAST  875 

is  seriously  involved.  Finally,  the  lymphatic  glands  in  the  axilla 
must  be  carefully  examined,  as  also,  in  suspicious  cases,  the 
supraclavicular  glands  and  the  opposite  breast  and  armpit. 

The  chief  types  of  tumour  met  with  in  the  breast  may  be 
arranged  in  three  groups :  the  adenomata,  the  sarcomata,  and  the 
cancers.  A  few  other  conditions  have  been  observed,  but  are  so 
rare  that  they  need  no  special  description,  e.g.,  lipoma,  fibroma, 
chondroma,  and  osteoma. 

Adenoid  Tumours  of  the  Breast. — Four  different  varieties  of 
tumour  are  included  in  this  group,  viz.,  the  adenoma,  adeno- 
fibroma,  the  so-called  adeno-sarcoma,  and  the  cysto-adenoma. 
Each  of  these  is  characterized  pathologically  by  the  following 
conditions  :  (a)  Spaces  lined  by  cuboidal  epithelium  are  present  in 
all ;  they  may  be  tubular  or  slit-like  in  nature,  simulating  normal 
gland  tissue,  or  they  may  become  distended  and  cystic,  (b)  The 
epithelium  lining  their  walls  is  in  one  or  more  layers,  but  scarcely 
ever  arranged  so  methodically  or  evenly  as  in  the  normal  structure. 
It  is  always  limited  by  the  basement  membrane,  and  has  no 
tendency  to  extend  beyond  it.  (c)  The  spaces  usually  contain 
fluid,  more  or  less  abundant  according  to  the  amount  of  dilatation 
present,  and  generally  serous  in  character,  though  perhaps  brown 
or  reddish  in  colour  from  admixture  with  blood,  (d)  Not  un- 
frequently  intracystic  growths  are  present,  and  in  one  form,  the 
cysto-adenoma,  these  are  a  specially  prominent  feature  of  the 
case,  (e)  The  alveolar  spaces  are  surrounded  by  interstitial  tissue, 
which  may  vary  considerably  in  amount,  and  be  either  simple  or 
complex  in  structure. 

Pure  Adenoma  Mammae  is  said  to  exist  when  the  proportion  of 
interstitial  tissue  to  gland  substance  is  similar  to  that  which  obtains 
elsewhere  in  the  breast.  It  is  very  uncommon  and  requires  no 
special  notice,  the  clinical  characters  not  differing  from  those  of 
fibro-adenoma,  and  its  pathological  nature  being  only  specifically 
recognised  on  microscopic  examination. 

Fibro-adenoma  (or  Adeno-fibroma)  is  the  most  common  mam- 
mary tumour  met  with  in  young  people  before  the  age  of  thirty  ; 
it  is  often  attributed  to  a  blow  or  squeeze,  and  doubtless  correctly. 
It  occurs  as  a  more  or  less  rounded  or  oval  mass,  which,  if  placed 
superficially,  moves  freely  in  the  breast  substance,  and,  indeed, 
may  be  described  as  floating  in  it  (Fig.  312) ;  if  situated  deeply, 
it  still  appears  freely  moveable,  but  its  definition  is  less  evident. 
Sometimes  several  such  growths  are  found  in  the  same  breast. 
A  fibro-adenoma  is  usually  firm,  and  more  or  less  elastic  in  con- 
sistency, of  slow  growth,  whilst  it  may  be  either  painless,  or  in 
anaemic  and  neurotic  women  exceedingly  painful,  the  pain  often 
increasing  at  the  menstrual  periods.  There  is  no  concurrent 
enlargement  of  the  axillary  glands,  unless  arising  from  other 
causes,  and  no  retraction  of  the  nipple,  with  which  it  is  entirely 
unconnected,  whilst  the  skin  over  it  does  not  dimple.     The  general 


S76 


A   MANUAL  OF  SURGERY 


health  is  unimpaired  unless  the  patient  is  suffering  from  an 
associated  anaemia.  On  section  after  removal  the  tumour  is  of 
a  greyish-white  colour,  becoming  pink  on  exposure  to  the  air. 
It  is  more  or  less  foliated  in  texture,  being  compared  by  Virchow 
to  the  section  of  a  cabbage  ;  no  juice  can  be  obtained  on  scraping 
the  cut  surface  with  a  scalpel,  although  on  pressure  some  fluid 
of  a  thick  glutinous  or  mucoid  nature  may  escape.  Microscopi- 
cally, the  tumour  consists  of  imperfectly  developed  glandular 
elemenis,  surrounded  by  a  considerable  amount  of  firm  interstitial 
tissue,  but  ducts  are  never  present.  The  tumour  is  distinctly 
encapsuled,  except  at  the  one  spot,  through  which  vessels  enter, 
and  at  which  it  is  connected  with  the  neighbouring  mammary 
tissue.     It  is  stated   that  fibro-adenomata  are   occasionally  con- 


Fig.  31: 


-flbro- adenoma  mamm.e.     (from  mltseum  of  roval 
College  of  Surgeons.) 


verted  into  sarcomata,  thus  changing  their  type  from  simple  to 
malignant  ;  the  evidence,  however,  as  to  this  is  not  conclusive. 

The  Diagnosis  is  readily  made  if  the  above  signs  are  considered. 
An  adenoma  differs  from  chronic  interstitial  mastitis  or  a  serous 
cyst  by  its  exact  definition  and  free  mobility,  whilst  from  malig- 
nant tumours  it  is  distinguished  by  its  slow  rate  of  growth,  and 
its  freedom  from  adhesions  either  to  the  skin  or  to  surrounding 
parts. 

The  Treatment  consists  in  its  removal,  which  is  easily  effected 
by  cutting  down  upon  the  tumour  in  a  direction  radiating  from 
the  nipple,  until  the  capsule  is  reached,  when  the  mass  is  enu- 
cleated from  its  surroundings  with  a  few  touches  of  the  knife. 

Diffuse  Hypertrophy  of  the  breast  (Fig.  313)  is  usually  fibro- 
adenomatous  in  nature,  and  consists  of  a  general  enlargement  of 
the  organ,  both  gland  substance  and  interstitial  tissue  participating 


DISEASES  OE  THE  BREAST 


877 


in  the  process,  and  hence  the  breast  becomes  firm  and  indurated. 
It  may  be  uni-  or  bi-lateral,  perhaps  more  frequently  the  latter, 
and  generally  occurs  in  adolescents.  The  size  varies  considerably, 
but  the  breasts  may  become  enormous,  hanging  down  by  their 
weight,  and  perhaps  to  such  an  extent  as  to  rest  on  the  knees  of 
the  patient  when  sitting.  They  are  usually  painless,  although 
sometimes  neuralgia  is  noticed.  Functionally  they  are  useless,  as 
even  if  the  patient  becomes  pregnant,  secretion  of  milk  but  rarely 
occurs.     The  only  treatment  is  amputation. 


Fig.  313. — Diffuse  Hypertrophy  of  the  Breasts. 

It  occurred  in  a  girl  aged  sixteen  and  a  half  years,  and  both  organs  had  to  be 
removed.     The  left  breast  weighed  gh  lbs.,  the  right  breast  9  lbs. 


The  so-called  Adeno-sarcoma  is  very  similar  in  type  to  the 
adenoma,  differing  from  it  mainly  in  the  increased  rate  of  growth, 
in  its  soft  consistency,  and  in  the  fact  that  the  interstitial  tissue  is 
of  a  more  embryonic  character,  and,  indeed,  is  often  of  a  mucoid 
nature.  It  is  really  a  soft  fibro-adenoma,  and  usually  occurs  in 
women  at  a  somewhat  earlier  period  of  life  than  sarcoma  or 
cancer — viz.,  between  the  ages  of  twenty-five  and  thirty-five.  It 
may  consist  from  the  first  of  a  localized  tumour,  increasing 
rapidly  in  size,  or  it  may  possibly  commence  as  a  simple  hard  or 
chronic  fibro-adenoma,  which,  after  remaining  quiet  for  a  time, 
takes    on    a    more    active    development.       It    remains,    however, 


878 


A   MANUAL  OF  SURGERY 


throughout  its  course  strictly  encapsuled,  and  when  large  may 
lead  to  pressure  atrophy  of  the  true  gland  substance.  It  is  soft 
and  elastic  in  consistency,  usually  painless,  and  freely  moveable 
on  the  surrounding  breast  tissue.  The  skin  over  it  remains 
healthy,  although  distended  and  atrophic  when  the  tumour  is  of 
large  size  ;  the  nipple  shows  no  sign  of  retraction  ;  the  axillary 
glands  are  not  involved,  and  there  is  no  systemic  invasion.  On 
removal  the  section  is  similar  to  that  of  a  fibro-adenoma,  but  cysts 
are  often  present,  as  also  areas  of  mucoid  softening,  somewhat 
resembling  sago.  It  can  be  readily  removed  in  its  entirety,  and 
does  not  tend  to  recur. 

Cysto-adenoma  (Syn. :  Cysto- sarcoma,  Adenocele,  etc.)  is  a  con- 
dition characterized  by  a  marked  development  of  intracystic 
growths,  fibro-papillomatous  in  nature,  within  the  dilated  acini 


Fig.  314. — Cysto-adenoma  Mamm.t..     (Museum  of  Royal  College  of 

Surgeons.) 

The  fibro-papillomatous  growths  are  seen  projecting  from  a  large  cyst,  into 
which  a  bristle,  passed  down  the  nipple,  enters.  A  glass  rod  has  been 
passed  through  a  perforation  in  the  skin  into  the  cyst. 


of  a  newly-formed  mass  of  adenomatous  tissue,  or  within  the 
smaller  ducts  (Fig.  314).  It  usually  has  a  definite  capsule,  and 
then  the  normal  gland  tissue  may  be  pressed  aside,  and  perhaps 
atrophies.  Several  cysts  are,  as  a  rule,  present,  and  may  be  of 
great  size,  the  intracystic  growths  also  varying  in  amount.  These 
latter  consist  of  branched  processes  something  like  a  cauliflower 
in  appearance,  covered  with  cuboidal  or  columnar  epithelium  ; 
they  are  exceedingly  vascular,  and  haemorrhage  into  the  cavity  of 
the  cyst  frequently  occurs,  as  also  a  blood-stained  discharge  from 
the  nipple.  They  are  due  to  a  proliferation  of  the  interacinous 
tissue,  which  pushes  the  epithelial  wall  of  the   duct  or   acinus 


DISEASES  OF  THE  BREAST  879 


before  it.  The  tumour  produced  is  irregular  in  outline,  owing  to 
the  projection  of  the  cysts ;  it  is  usually  painless,  and  unaccom- 
panied by  enlargement  of  the  axillary  glands  ;  if  of  large  size,  blue 
veins  are  seen  coursing  over  it.  In  the  later  stages  the  capsule 
becomes  adherent  to  the  integument,  and,  finally,  owing  to  the 
pressure  of  the  tumour,  the  skin  may  give  way,  allowing  the 
growth  to  protrude.  Such  will  be  followed  by  the  development 
of  a  fungating  mass,  which  bleeds  readily,  and  becomes  extremely 
offensive.  With  care  a  probe  can  be  passed  between  the  intra- 
cystic  portion  of  the  growth  and  the  thinned  and  stretched  skin, 
which  has  merely  given  way,  and  is  not  incorporated  with  it ;  this 
fact  is  a  ready  means  of  distinguishing  this  condition  from  a  fun- 
gating  encephaloid  cancer.  The  tumour  is  essentially  benign  in 
nature  ;  it  is  never  disseminated  generally,  and  can  be  readily  and 
completely  removed,  so  that  there  is  but  little  tendency  to  recur. 
In  the  early  stages  it  is  unnecessary  to  take  away  the  entire  breast 
if  the  tumour  can  be  efficiently  dealt  with  otherwise,  but  in  the 
later  stages  the  whole  organ  should  be  excised. 

Somewhat  similar  in  nature  to  the  above  is  the  condition  known 
as  a  duct  papilloma.  This  is  characterized  by  the  development  of 
a  soft  polypoid  papillomatous  mass,  generally  of  small  size,  in  the 
interior  of  one  of  the  terminal  galactophorous  ducts,  which  in 
consequence  becomes  dilated.  A  discharge  of  blood-stained  serum 
results,  and  there  is  usually  but  little  tumour  to  be  felt,  although 
the  nipple  may  be  slightly  pushed  forwards  and  rendered  pro- 
minent. It  is  often  the  precursor  of  a  duct  cancer.  Amputation 
of  the  breast  will  in  many  cases  be  needed,  although  it  may  be 
feasible  in  some  to  deal  with  the  tumour  alone. 

Sarcoma  of  the  Breast  is  not  a  common  disease.  It  originates 
in  the  connective  tissue  of  the  organ,  being  deeply  placed  in  its 
substance,  or  perhaps  more  frequently  developing  in  the  outer 
and  upper  quadrant.  It  is  of  two  chief  types  :  (a)  The  round- 
celled  sarcoma  forms  a  soft,  somewhat  elastic  swelling,  which 
grows  rapidly,  and  although  often  limited  at  first  by  a  fibrous 
membrane,  the  capsule  tends  sooner  or  later  to  give  way,  allowing 
the  growth  to  become  diffused  through  the  organ.  It  sometimes 
gives  rise  to  secondary  growths  in  the  axillary  glands,  or  becomes 
disseminated  throughout  the  body  by  means  of  the  bloodvessels. 
Cysts  often  occur  in  its  substance,  resulting  either  from  haemor- 
rhage or  occasionally  from  the  dilatation  of  an  incorporated 
glandular  alveolus  ;  in  the  latter  case  the  cavity  will  be  lined 
with  epithelium.  Myxomatous  changes  are  also  not  ^infrequently 
observed,  and  in  the  more  rapidly  growing  recurrent  tumours 
the  mass  is  often  a  true  myxo-sarcoma.  It  usually  occurs  in 
women  between  the  ages  of  thirty  and  forty,  i.e.,  somewhat  earlier 
than  scirrhus,  whilst  its  rapid  growth  and  the  absence  of 
retraction  of  the  nipple  or  dimpling  of  the  skin  are  useful 
diagnostic  features.     Should  pregnancy  follow,  the  tumour  may 


880  A  MANUAL  OF  SURGERY 

increase  in  size  at  an  alarming  rate.  In  the  infiltrating  forms  it 
is  almost  impossible  to  distinguish  it  from  encephaloid  cancer, 
except  on  microscopic  examination,  (b)  A  spindle-celled  sarcoma, 
or  fibro-sarcoma,  is  also  met  with,  forming  a  rounded  or  oval 
tumour,  more  limited  than  the  above,  and  growing  somewhat  less 
rapidly.  It  somewhat  simulates  an  adenoma,  but  is  more  closely 
connected  with  the  breast  substance.  The  axillary  glands  are 
but  rarely  involved,  and  the  sarcomatous  nature  is  recognised 
by  the  microscope  and  by  the  great  tendency  of  the  growth  to 
recur  even  after  apparently  complete  removal ;  on  account  of  this 
latter  feature,  the  name  of  'recurrent  fibroid  tumour'  (Paget)  was 
formerly  applied  to  it.  The  recurrences  generally  take  place  at 
gradually  diminishing  intervals,  and  the  tumour  may  then  become 
softer  and  more  vascular  ;  occasionally  the  tendency  to  recur  seems 
to  wear  itself  out  after  the  performance  of  several  operations. 

The  Treatment  of  sarcoma  mammae  consists  in  the  removal  of 
the  entire  organ  at  as  early  a  date  as  possible,  together  with  the 
axillary  glands. 

Cancer  of  the  Breast. 

No  organ  of  the  body,  with  the  exception  of  the  uterus,  is  more 
frequently  the  seat  of  cancer  than  the  female  breast  :  it  also  occurs 
in  the  male  subject,  but  is  about  a  hundred  times  less  common 
than  in  the  other  sex. 

etiology. — The  breast  is  an  organ  subject  to  great  changes 
in  functional  activity,  richly  supplied  with  blood,  and  closely 
associated  by  nervous  connections  with  other  organs  of  the  body, 
especially  the  uterus.  At  the  climacteric  its  functions  are  at  an 
end,  and  as  it  always  undergoes  a  certain  amount  of  fibrosis  or 
degeneration,  it  can  be  readily  understood  that  changes  are 
very  likely  to  ensue  which  may  result  in  the  formation  of  a 
cancerous  tumour.  Such  is  usually  met  with  after  the  age  of 
forty,  although  the  disease  may  prove  fatal  at  a  much  earlier 
date.  It  equally  affects  women  who  have  borne  children  and 
nulliparae,  and  the  question  whether  or  not  the  woman  has  nursed 
her  children  seems  to  have  but  little  influence.  The  left  breast 
is  more  often  affected  than  the  right.  It  is  frequently  attributed 
to  some  injury,  such  as  a  blow  or  squeeze  ;  whilst  there  is  little 
doubt  that  badly-fitting  stays  are  responsible  for  a  certain  per- 
centage of  the  cases.  It  not  uncommonly  follows  eczema  of  the 
nipple,  especially  that  variety  known  as  Paget's  eczema ;  chronic 
interstitial  mastitis  may  also  possibly  be  an  occasional  precursor 
of  this  affection.  The  question  as  to  heredity  is  one  exceedingly 
difficult  to  decide,  and,  although  it  may  be  a  marked  feature  of 
some  cases,  it  is  somewhat  doubtful  whether,  as  a  general  rule,  it 
has  any  considerable  influence. 

Two  distinct  types  of  cancer  are  met  with  in  the  breast — viz., 
acinous  or  glandular  cancer  (including  scirrhus  and  encephaloid), 


DISEASES  OF  THE  BREAST 


and  duct  cancer.  Colloid  degeneration  of  either  of  the  former 
varieties  has  been  observed,  but  is  very  uncommon. 

i.  Acinous  Cancer  is  the  form  almost  invariably  seen;  the 
division  into  scirrhus  and  encephaloid  is  entirely  artificial, 
depending  on  the  greater  or  less  amount  of  fibrous  stroma 
present  in  any  particular  case. 

Scirrhus  usually  commences  as  a  hard  circumscribed  mass, 
situated  most  commonly  in  the  outer  half  of  the  organ.  It  is 
closely  united  to,  if  not  absolutely  incorporated  with,  the  breast 
substance,  and  on  careful  digital  examination  its  margin  is  not 
so  accurately  defined  as  at  first  appears.  In  the  early  stages  it 
is  entirely  distinct  from  the  skin,  which  moves  freely  over  its 
surface ;  but  as  growth  proceeds,  the  stroma  contracts,  and,  by 
dragging  on  the  suspensory  ligaments  passing  from  the  mamma 
to  the  skin,  the  latter  structure  becomes  more  or  less  fixed,  and 
hence,  on  attempting  to  move  it  upon  the  tumour,  an  appearance 
of  dimpling  results.  At  the  same  time,  the  whole  breast  is  acted 
upon  in  a  similar  manner,  so  that  the  affected  organ  often  seems 
to  be  smaller  than  the  other ;  and,  since  the  upper  half  of  the 
gland  is  usually  affected,  the  nipple  may  be  drawn  up  so  as  to  lie 
at  a  higher  level  than  its  fellow,  as  well  as  being  retracted  from  the 
tractionof  the  growth  on  the  galactophorous  ducts  (Fig.  315).  The 
tumour  itself  is  rarely  one  of  great  size,  so  long  as  it  retains  its 
scirrhous  nature  ;  it  is  sometimes  extremely  painful  and  tender, 
but  not  uncommonly  the  pain  is  intermittent,  and  of  a  neuralgic 
type,  extending  to  the  shoulder,  and  perhaps  only  elicited  on  mani- 
pulation. As  the  growth  increases  in  size,  it  becomes  adherent  to 
the  pectoral  fascia,  and  may  even  infiltrate  the  underlying  muscular 
substance,  so  that,  on  examination,  with  the  arm  extended  and 
abducted,  it  is  found  that,  although  moveable  across  the  fibres  of 
the  muscle,  the  breast  cannot  be  moved  with  them. 

The  lymphatic  glands  in  the  axilla  soon  become  enlarged,  the 
disease  rarely  lasting  many  months  without  this  complication. 
Those  running  with  the  long  thoracic  vessels  under  cover  of  the 
pectoralis  major  are  first  involved,  and,  as  the  case  progresses, 
the  remaining  axillary  and  subscapular  sets  become  similarly 
affected,  and  even  after  a  time  the  supraclavicular.  When  the 
deeper  part  of  the  breast  is  attacked,  the  disease  may  spread  to 
the  mediastinal  glands  along  the  lymphatics,  which  accompany 
the  nutrient  vessels  arising  from  the  internal  mammary  trunk  ; 
and  thus  intrathoracic  deposits  develop,  which  even  extend  along 
the  subpleural  connective  tissue,  and  affect  the  pleural  cavity  and 
lungs.  In  those  cases  where  the  primary  growth  is  situated  near 
the  inner  border  of  the  breast,  the  free  lymphatic  anastomosis 
across  the  middle  line  allows  of  the  transmission  of  the  disease  to 
the  glands  in  the  opposite  axilla,  and  sometimes  a  similar  affection 
of  the  opposite  breast  arises  from  this  cause. 

The  skin  may  be  implicated  in  many  ways,    (a)  We  have  already 

56 


S82 


A  MANUAL  OF  SURGERY 


mentioned  the  dimpling  which  is  met  with  over  the  tumour  in  the 
early  stages.  As  the  case  proceeds,  the  cancer  extends  outwards 
along  the  suspensory  bands  of  fascia,  so  that  the  skin  itself  becomes 
invaded,  feeling  firm  and  brawny,  and  looking  congested  and 
purplish  in  colour,  whilst  a  branny  desquamation  is  usually  present. 
A  crack  or  fissure  at  length  forms,  giving  exit  to  a  little  serous 
discharge,  which  at  first  scabs  over,  but  finally  leaves  an  ulcerated 
surface,  which  slowly  extends,  and  may  attain  considerable  dimen- 


Fig.  315. — Scirrhus  Mammae.     (From  a  Photograph.) 

The  patient  had  allowed  the  tumour  to  grow  for  two  years.  The  whole  of  the 
left  breast  was  infiltrated  and  raised  above  the  level  of  the  other  organ  ; 
the  nipple  was  retracted. 

sions.  A  typical  scirrhous  ulcer  is  hollowed  out  and  excavated  ;  its 
surface,  if  kept  clean,  is  covered  with  smooth  granulations,  dis- 
charging a  considerable  amount  of  sanious  fluid,  but  if  neglected, 
it  becomes  sloughy  and  offensive  ;  it  is  surrounded  by  a  projecting 
elevation  of  the  tumour  substance,  forming  a  sort  of  rampart  around 
it.  (b)  Less  commonly  the  disease  becomes  disseminated  through 
the  skin,  giving  rise  to  a  series  of  dusky-red,  button-like  masses  of 
cancer,  surrounded  by  skin  which  is  often  apparently  unaffected ; 


DISEASES  OF  THE  BREAST 


or  the  whole  cutaneous  surface  of  the  organ  may  become  infiltrated 
and  thickened,  constituting  the  condition  known  as  cancer  en 
cuirasse.  In  the  earlier  stages  the  skin  is  thickened  and  firmer  than 
usual  ;  but  the  mouths  of  the  sebaceous  glands  are  enlarged  and 
very  evident,  giving  it  a  coarse  appearance  like  'pig-skin,'  or  the 
rind  of  an  orange  (pcau  cT  orange  of  French  authors).  Later  the 
colour  becomes  dusky,  and  the  skin  so  contracted  and  indurated 
that   it   is   impossible    to   wrinkle  it ;  the   sebaceous   glands   may 


Fig.  316. — Side  View  of  the  same  Breast  as  in  Fig.  315. 
The  retracted  nipple  is  well  seen,  as  also  the  commencing  infiltration  of  the 
skin   towards  the  axilla,  whilst  the  lineae  albicantes  are  also  infiltrated 
and  swollen. 

exude  an  abundant  secretion,  which  becomes  inspissated  on  the 
surface  into  crusts  or  scabs,  which  are  independent  of  any  ulcera- 
tion. This  process  often  extends  widely  beyond  the  limits  of 
the  breast,  invading  the  whole  thoracic  wall,  and  even  running 
over  the  shoulder  to  the  back  of  the  head  or  neck ;  it  is  due  to  a 
diffuse  extension  of  the  disease  along  the  cutaneous  lymphatics, 
and  in  its  most  typical  form  is  slow  in  its  development,  the  patient 
perhaps  living  for  many  years.     Localized  buttons  or  nodules  of 

56—2 


A  MANUAL  OF  SURGERY 


cancer  are  often  found  scattered  through  the  affected  area. 
(c)  Occasionally  one  meets  with  a  much  more  rapid  form  of 
cancerous  lymphangitis,  in  which  the  skin  becomes  similarly 
affected,  but  the  growth  is  not  unfrequently  associated  with  what 
is  supposed  to  be  a  '  weeping  '  eczema,  due  in  reality  to  the 
yielding  of  dilated  lymphatics,  that  can  be  easily  seen  on 
examining  with  a  lens.  The  process  spreads  widely  and  rapidly, 
and  cancerous  nodules  appear  here  and  there  in  the  infiltrated 
area ;  the  prognosis  is  of  course  very  grave. 

In  the  later  stages,  the  patient  passes  into  a  state  of  cachexia, 
becoming  emaciated  and  exhausted.  Ulcerated  surfaces  of  con- 
siderable size  may  exist,  and  the  tumour  is  fixed  to  the  thoracic 
wall,  even  invading  the  ribs.  The  arm  on  the  affected  side  is 
swollen  and  brawny,  owing  to  the  pressure  of  the  enlarged  glands 
on  the  main  lymphatics  and  veins  of  the  limb,  constituting  a 
condition  of  lymphatic  or  solid  oedema.  Secondary  deposits  also 
develop  in  the  viscera,  and  may  lead  to  various  symptoms, 
according  to  the  situations  in  which  they  are  placed.  Finally, 
death  from  exhaustion  ends  the  scene. 

Encephaloid  or  Acute  Cancer  occurs  less  frequently  as  a  some- 
what soft,  rapidly-growing  tumour,  which  quickly  infiltrates  the 
whole  organ,  and  gives  rise  to  secondary  lymphatic  and  visceral 
affections  at  a  much  earlier  date  than  scirrhus.  It  does  not  tend 
to  cause  retraction  of  the  nipple  or  dimpling  of  the  skin,  the  latter 
structure  being  distended,  and  with  blue  veins  coursing  under 
it.  The  breast  becomes  enlarged  and  prominent,  the  skin  is 
gradually  invaded  by  the  tumour,  ulceration  follows,  and  a  foul 
fungating  mass  sooner  or  later  sprouts  up  through  the  opening. 
The  cancer  that  attacks  young  women  is  often  of  this  type,  and 
the  prognosis  necessarily  very  grave. 

Finally,  in  elderly  women,  a  chronic  form  of  cancer  is  met 
with,  known  as  Atrophic  Scirrhus,  in  which  the  disease  lasts  for 
many  years  without  much  definite  extension.  Cases  have  been 
known  to  persist  for  fifteen  or  twenty  years,  the  patient  at 
length  dying  of  some  intercurrent  malady,  although  in  the  great 
majority  dissemination  has  ultimately  occurred.  The  special 
characters  are  due  to  the  excessive  contraction  of  the  stroma, 
as  a  result  of  which  the  cellular  elements  become  crushed  and 
practically  destroyed.  The  nipple  is  deeply  retracted,  and  the 
tumour  and  breast  substance  in  the  most  marked  cases  are 
scarcely  discernible. 

2.  Duct  Cancer  is  a  somewhat  rare  form  of  the  disease,  the 
exact  nature  of  which  is  still  under  discussion,  and  there  is  very 
little  doubt  that  several  distinct  types  have  been  described  under 
this  name.  It  is  sometimes  characterized  by  the  development  of 
one  or  more  nodules  of  a  malignant  papillomatous  nature  within 
the  dilated  ducts,  and  usually  situated  not  far  from  the  nipple. 
These  growths  are  covered  with  columnar  epithelium,  and  may, 


DISEASES  OF  THE  BREAST  885 


indeed,  be  looked  upon  as  forms  of  columnar  cancer.  They  are 
exceedingly  vascular,  and  a  blood-stained  discharge  from  the 
nipple  is  usual.  They  always  grow  slowly,  and  when  situated 
near  the  skin  give  rise  to  a  round  dusky-red  swelling.  The  nipple 
is  not  retracted,  and  lymphatic  enlargement  not  constant.  In 
other  cases  the  dilated  alveoli  are  occupied  by  masses  of  pro- 
liferated epithelial  cells  of  a  spheroidal  type,  which  arrange 
themselves  into  more  or  less  definite  papillomatous  growths,  whilst 
cystic  degeneration  also  occurs.  Either  of  these  varieties  may 
be  associated  with  a  development  of  ordinary  scirrhus  in  some 
other  part  of  the  breast.  The  diagnosis  can  only  be  established 
with  certainty  by  microscopic  examination  after  removal. 

The  duration  of  cancer  varies  considerably  in  the  different  forms. 
The  encephaloid  type  runs  a  rapid  course,  and  will  probably 
destroy  the  patient's  life  in  six  to  twelve  months.  Duct  cancer 
is  very  slightly  malignant,  whilst  atrophic  scirrhus  is  similarly 
slow  in  growth,  and  in  both  death  may  be  postponed  for  a  con- 
siderable period,  or  is  often  due  to  some  intercurrent  malady. 
Cancer  en  cuirasse  is  variable  in  its  course,  being  sometimes 
tolerably  rapid,  and  at  others  chronic ;  it  cannot  be  cured  by 
operation,  on  account  of  its  early  and  extensive  dissemination. 
A  circumscribed  scirrhous  tumour  is  stated  to  end  fatally,  on  an 
average,  in  two  or  three  years  if  no  operative  treatment  is  under- 
taken, whilst  removal  of  the  mass  will  probably  add  another 
year  or  eighteen  months  to  the  patient's  life.  These  figures 
are,  however,  derived  from  statistics  of  operations  performed 
before  the  general  adoption  of  the  more  exact  and  extensive 
measures  which  are  now  usually  undertaken,  and  it  is  likely  that 
they  considerably  under-estimate  the  benefits  derived  from  such 
interference. 

The  Pathological  Anatomy  of  cancer  is  discussed  in  Chapter  VII. 

The  Diagnosis  of  scirrhus  from  chronic  interstitial  mastitis  and 
chronic  abscess  or  cyst  has  been  already  considered  (p.  871).  From 
tumours  of  the  adenoid  type  it  is  easily  distinguished.  The  stony 
hardness  of  a  scirrhus,  its  union  with  the  breast  substance,  its 
limited  mobility,  the  dimpling  of  the  skin,  retraction  of  the  nipple, 
and  enlargement  of  the  axillary  glands,  are  the  chief  local  charac- 
teristics to  be  noted.  Non-malignant  tumours  are  more  elastic 
to  the  touch,  more  moveable,  and  usually  quite  circumscribed  in 
outline,  whilst  the  skin,  though  expanded,  does  not  become 
adherent ;  the  nipple  is  rarely  retracted,  and  the  axillary  glands 
remain  of  normal  size.  It  is  often  impossible  to  distinguish  a 
cancerous  from  a  sarcomatous  tumour,  except  on  microscopic  examina- 
tion ;  a  round-celled  sarcoma  closely  resembles  an  encephaloid 
cancer,  although  it  is  usually  more  circumscribed — at  any  rate, 
in  the  early  stages.  The  fibro-sarcoma  may  sometimes  be  mis- 
taken for  scirrhus,  but  it  is  more  defined  in  outline,  does  not  cause 
retraction  of  the  nipple  or  dimpling  of  the  skin,  whilst  lymphatic 


SSf,  A   MANUAL  OF  SURGERY 


enlargement  is  not  a  constant  accompaniment.  A  cysto -adenoma 
presents  no  difficulty  in  diagnosis  if  the  skin  is  entire,  and  the  cysts 
prominent ;  but  when  ulceration  has  taken  place,  and  a  fungating 
bleeding  mass  protrudes,  it  is  not  unlike  the  later  stage  of  an 
encephaloid  cancer  or  fungating  round-celled  sarcoma.  It  can 
be  distinguished,  however,  by  the  fact  that  a  probe  can  some- 
times be  passed  under  the  skin  for  some  distance  into  the  cavity 
of  the  cyst,  whilst  lymphatic  enlargement  is  rare. 

Treatment. — This  necessarily  consists  in  the  removal  of  the 
tumour  by  operation  ;  but  in  order  to  give  the  patient  as  good  a 
chance  as  possible  of  a  permanent  cure,  the  excision  must  include 
the  whole  of  the  breast,  the  greater  portion  of  the  overlying 
integument,  the  subjacent  pectoral  fascia,  possibly  a  part  of  the 
pectoral  muscle,  and  the  whole  of  the  lymphatic  and  connective 
tissues  of  the  axilla.  A  full  description  of  the  operation  is  given 
below,  but  we  desire  here  to  emphasize  the  fact  that  the  pro- 
ceeding should  be  very  radical  if  the  patient  is  to  derive  any  real 
benefit  from  it.  In  the  old  days,  only  the  more  prominent  portion 
of  the  breast  was  removed  with  the  tumour,  and  consequently 
recurrence  was  so  exceedingly  common  that  if  5  or  10  per  cent, 
of  the  patients  were  really  cured,  it  was  thought  to  be  as  much  as 
any  surgeon  could  reasonably  expect.  Since  we  have  learnt  more 
of  the  anatomy  of  the  organ  and  of  the  pathogenesis  of  the  disease 
(for  which  we  are  mainly  indebted  to  Heidenhain  and  Stiles), 
more  extensive  proceedings  have  been  undertaken,  with  a  gradual 
amelioration  in  the  results,  so  that  several  surgeons  have  been 
able  to  report  50  to  60  per  cent,  of  their  cases  as  free  from  recur- 
rence at  the  end  of  three  years.  It  was  suggested  by  Volkmann 
that  any  case  that  remains  free  from  recurrence  for  three  years 
may  be  claimed  as  a  cure,  but  this  is  generally  considered  too 
short  a  period  on  which  to  base  such  an  assumption,  since  experi- 
ence tells  us  that  the  disease  often  reappears  at  a  much  later  date 
(even  nine  or  ten  years). 

It  has  been  proved  that  the  breast  is  a  much  more  extensive 
organ  than  was  formerly  supposed,  and  if  merely  the  projecting 
portion  is  removed,  many  deep  lobules  are  left,  which  may  lead 
to  recurrence.  Moreover,  it  has  been  shown  that  the  deeper 
lymphatics  pass  into  the  fascia  covering  the  pectoralis  major,  and 
so  to  the  axilla  ;  hence,  this  structure  should  always  be  taken 
away,  as  well  as  a  thin  layer  of  the  muscular  fibres  in  certain 
cases.  Again,  lymphatics  travel  along  the  fibrous  bands  reach- 
ing from  the  breast  tissue  to  the  overlying  skin,  and  thus  this 
latter  must  never  be  dissected  back  from  over,  the  tumour.  The 
nipple  should  under  no  circumstances  be  left  behind,  since  all 
the  interlobular  lymphatics  converge  to  a  plexus  around  it,  and 
reach  the  axilla  by  three  or  four  main  trunks.  The  axilla  itself 
should  be  opened  in  every  case,  and  entirely  cleared  of  its  lym- 
phatic contents,  since  deposits  in  the  glands  are  often  found  on 


DISEASES  OF  THE  BREAST  887 


microscopic  examination,  where  no  clinical  evidence  of  their 
presence  had  been  previously  noted.  It  is  also  important  to 
remove  the  breast  and  axillary  tissues  in  one  piece,  so  as  to  avoid 
division  of  the  lymphatics  and  possible  infection  of  the  wound 
with  their  cancerous  contents. 

Of  late  years  Halsted  of  Baltimore  has  been  urging  the  neces- 
sity of  removing  the  pectoral  muscles  with  the  breast  in  all  cases 
of  cancer,  in  order  to  gain  better  access  to  the  axilla,  and  also  to 
ensure  the  extirpation  of  the  lymphatics  which  pass  between  or 
through  them.  This  is  often  termed  the  complete  operation,  and 
is  being  largely  employed.  The  clavicular  portion  of  the  great 
pectoral  is  left,  the  sternal  portion  being  removed  from  within 
outwards,  and  the  tendon  divided  close  to  the  humerus.  Whilst 
admitting  that  this  practice  is  good  and  desirable  in  cases  where 
the  muscle  is  involved,  or  where  there  is  much  axillary  infection, 
we  scarcely  consider  it  necessary  as  a  routine  procedure. 

As  to  the  cases  in  which  operation  should  or  should  not  be 
undertaken,  the  following  facts  must  be  noted  :  Cancer  en  cuivassc 
should  never  be  touched,  since  it  is  impossible  to  eradicate  the 
disease,  owing  to  its  wide  dissemination  through  the  cutaneous 
lymphatics.  Atrophic  scirrhus  also  is  often  left  alone,  on  the 
plea  that  the  prognosis  is  so  favourable  as  to  render  operation 
unnecessary ;  if,  however,  the  patient  is  fairly  strong,  there  is  no 
objection  to  it,  and  it  certainly  seems  wise  to  remove  a  cancerous 
focus,  however  chronic  it  be.  Apart  from  these,  all  cases  in 
which  there  is  a  reasonable  prospect  of  eradicating  the  disease 
may  be  subjected  to  operation.  The  following  grave  conditions, 
however,  require  the  most  serious  consideration :  (i.)  Where  the 
supraclavicular  glands  are  enlarged,  it  seems  hopeless  to  expect 
that  the  whole  disease  can  be  eliminated,  and  yet  one  likes  to  give 
the  patient  her  only  chance.  The  operation  must  then  include  the 
supraclavicular  fossa  in  its  scope,  as  recommended  by  Halsted  ; 
he  indeed  goes  so  far  as  to  maintain  that  the  posterior  triangle 
should  be  cleared  of  its  lymphatic  contents  in  all  cases,  whether 
or  not  enlarged  glands  can  be  detected  beforehand,  and  states  that 
in  a  considerable  percentage  of  cases  cancerous  invasion  will  have 
already  occurred.  The  cervical  incision  is  a  curved  one,  extend- 
ing along  the  posterior  border  of  the  sterno-mastoid,  and  outwards 
along  the  clavicle.  This  flap  is  dissected  up,  and  all  the  fat  and 
glands  are  removed  from  before  backwards,  the  internal  jugular 
vein  being  the  starting-point.  Of  course,  the  greatest  care  is 
taken  to  avoid  the  thoracic  duct  or  right  lymphatic  trunk, 
(ii.)  If  the  tumour  is  adherent  to  the  thoracic  parietes,  no  opera- 
tive interference  is  advisable,  (iii.)  Evidence  of  pressure  on,  or 
implication  of,  the  axillary  nerves  also  precludes  such  treatment ; 
slight  oedema  of  the  arm  due  to  pressure  on  the  main  vein  need 
not  deter  the  surgeon  from  proceeding,  since  the  whole  vein  has 
been  successfully  excised  ;  in  such  cases  the  collateral  circulation 


888 


A   MANUAL  OF  SURGERY 


has  evidently  been  opened  up  previously,  (iv.)  Profound  cachexia 
and  evidence  of  visceral  deposits  also  contra-indicate  operation, 
except  to  give  relief  to  the  local  pain,  (v.)  Extensive  ulceration 
and  fungation,  and  general  diffusion  of  the  tumour  through  the 
breast,  are,  as  a  rule,  prohibitory  signs,  (vi.)  Disease  of  both 
breasts,  although  rendering  the  prognosis  more  grave,  is,  ceteris 
paribus,  no  hindrance,  since  both  organs  have  been  removed  suc- 
cessfully, even  at  one  operation.  Speaking  generally,  rapidly- 
growing  tumours  in  vigorous  patients  are  exceedingly  unfavourable 
cases  to  deal  with,  whilst  slow  growth  of  the  tumour,  and  definite 
limitation  of  its  outline,  are  favourable  signs. 

Amputation  of  the  Breast  is  an  operation  which  is  performed 
not  only  for  the  removal  of  cancerous  or  sarcomatous  growths, 


Fig.  317. — Incisions  for  Amputation  of  the  Breast  in  Cancer. 

but  also  for  diffuse  hypertrophy,  for  diffuse  septic  or  tuberculous 
disease  when  the  organ  is  riddled  with  sinuses,  and  occasionally 
for  interstitial  mastitis.  The  proceeding  is  a  very  simple  one  in 
non-malignant  cases.  The  incisions  usually  employed  are  semi- 
lunar, and  placed  obliquely,  as  on  the  right  side  in  Fig.  317;  in 
simple  cases,  however,  there  is  no  need  to  include  so  much  of 
the  integument.  The  skin  is  dissected  up  on  either  side  from  the 
glandular  tissue,  and  the  organ  freed  from  its  attachments  to  the 
pectoral  fascia ;  the  axilla  need  not  be  opened. 

Operation  for  Cancer. — The  patient  lies  on  the  back,  with  the 
head  directed  towards  the  opposite  side,  and  the  arm  raised,  so  as 
to  put  the  pectoralis  on  the  stretch.  An  aseptic  towel  should  be 
wrapped  round  the  head,  so  as  to  keep  the  hair  out  of  the  way, 
and  a  similar  carbolized  towel  may  be  placed  below  the  chin,  to 


DISEASES  OF  THE  BREAST 


form  a  barrier  between  the  anaesthetist  with  his  apparatus  and  the 
field  of  operation.  The  axilla  should  be  previously  shaved,  and 
the  skin  carefully  purified.  The  incisions  employed  vary  with  the 
size  and  position  of  the  tumour,  one  great  essential  being  that  no 
portion  of  skin  which  lies  immediately  over  the  tumour  should  be 
left ;  where  it  is  located  in  the  outer  and  upper  quadrant,  as  is  so 
commonly  the  case,  incisions  somewhat  similar  to  those  repre- 
sented in  Fig.  317  (right  side)  will  do  very  well.  In  other  cases 
the  incisions  may  be  placed  horizontally,  extending  backwards  as 
far  as  the  posterior  axillary  fold,  and  then  the  axilla  is  dealt  with 
through  a  vertical  incision  running  up  along  its  anterior  border 
(Fig.  317,  left  breast).  It  is  the  usual  custom  to  make  the  lower 
incision  first,  so  that  the  view  of  the  surgeon  may  not  be  inter- 
fered with  by  the  blood  trickling  from  the  upper  wound,  but  this 
is  by  no  means  essential  or  always  convenient.  The  skin  is  dis- 
sected back  on  either  side  from  the  glandular  substance,  keeping 
well  clear  of  breast  tissue.  The  inner  side  is  then  dealt  with  first, 
the  wound  being  carried  down  until  the  pectoral  is  exposed,  and 
the  gland,  together  with  the  deep  fascia,  dissected  off  the  muscle 
from  within  outwards  until  its  outer  border  is  reached.  It  is 
always  wise  to  remove  the  superficial  layer  of  muscle  fibres,  even 
if  one  does  not  go  further.  Attachment  to  or  infiltration  of  the 
muscle,  of  course,  involves  the  removal  of  a  considerable  portion 
of  its  substance.  During  this  stage  of  the  operation  all  bleeding- 
points  are  secured  temporarily  by  Spencer-Wells'  forceps.  The 
breast,  together  with  the  fascia,  and  perhaps  part  of  the  muscle, 
is  now  lying  turned  outwards,  merely  connected  to  the  trunk  by 
its  axillary  attachments.  The  surgeon  then  carries  on  the  dis- 
section along  the  under  surface  of  the  pectoral  muscles,  opening 
up  freely  the  axillary  cavity,  and  if  need  be  increasing  the  cutane- 
ous incision  for  this  purpose.  The  axillary  vessels  are  first  cleaned, 
the  vein  often  coming  prominently  into  view.  The  apex  of  the 
space  is  then  dealt  with,  all  lymphoid  tissue  and  fat  being  removed, 
and  finally  the  inner  and  posterior  walls  are  similarly  treated,  until 
when  the  dissection  is  complete  nothing  remains  within  the  cavity 
but  the  main  vessels  and  nerves ;  whenever  possible,  the  sub- 
scapular branches  should  be  spared. 

When  the  complete  operation  is  undertaken,  the  skin  is  dis- 
sected back  from  the  incisions  beyond  the  extreme  limits  of  the 
breast.  The  division  between  the  sternal  and  clavicular  por- 
tions of  the  pectoralis  major  is  then  opened  up  along  its  whole 
length,  and  its  insertion  divided  about  an  inch  from  the  humerus; 
the  finger  is  then  passed  under  its  sternal  origin  from  above  down- 
wards, so  as  to  raise  it  from  the  underlying  structures  and  allow 
of  its  division  with  the  knife.  The  pectoralis  minor  next  comes 
into  view,  and  is  divided  at  its  costal  attachments,  and  also  close 
to  the  coracoid  process.  The  finger  next  sweeps  down  the  outer 
surface  of  the  serratus  magnus  (sparing  the  nerve  of  Bell),  detach- 


890  A   MANUAL  OF  SURGERY 


ing  the  axillary  fat  from  it,  and  then  the  main  axillary  vessels  and 
nerves  are  dissected  out.  Finally,  the  subscapularis  is  cleared 
from  above  downwards,  and  the  whole  mass,  including  breast, 
pectoralis,  and  axillary  contents,  is  freed  from  its  attachments  to 
skin  and  muscles  on  the  outer  side. 

Having  thus,  it  is  hoped,  eliminated  the  disease,  all  bleeding- 
points  are  ligatured,  the  wound  is  closed  by  a  continuous  suture, 
aided  by  one  or  two  deep  tension  stitches,  and  a  drainage-tube  is 
usually  inserted  for  a  day  or  two  ;  it  may  be  placed  with  advantage 
through  a  special  opening  made  in  the  posterior  axillary  wall. 
Where  much  skin  has  been  removed,  there  will  be  some  difficulty 
in  bringing  the  edges  of  the  incision  together,  but  by  judicious 
undercutting  and  sliding  an  open  wound  can  usually  be  avoided. 
If,  however,  it  cannot  be  closed,  skin-grafting  by  Thiersch's 
method  must  be  resorted  to. 

The  immediate  results  of  this  operation  are  exceedingly  satis"- 
factory,  the  mortality  being  slight,  probably  not  5  per  cent. 
Patients  often  used  to  complain  of  impairment  in  the  movements 
of  the  arm  when  the  axilla  had  been  opened  and  the  wound  allowed 
to  heal  with  the  arm  fixed  to  the  side  ;  this  is  entirely  obviated 
by  keeping  the  arm  away  from  the  side  at  right  angles  to  the 
body.  Healing  is  assisted  by  this  position,  since  drainage  is 
facilitated  and  better  pressure  can  be  exerted  upon  the  wound, 
and  there  is  consequently  less  oozing.  Even  when  the  pectorals 
have  been  sacrificed,  the  patient  is  still  able  to  lift  the  arm  to  the 
back  of  the  head,  and  the  movements  of  the  limb  seem  but  little 
impaired.  The  final  results  necessarily  vary  with  the  period  at 
which  operation  was  undertaken,  and  with  the  care  and  skill  of 
the  surgeon. 

Local  recurrence  after  operation  is  always  due  to  incomplete  re- 
moval of  the  growth,  or  to  infection  of  the  wound  during  the 
operation.  The  operator  must  ever  keep  in  mind  that  although 
in  a  healthy  organism  the  implantation  of  cancerous  material  has 
apparently  but  little  or  no  effect,  yet  in  a  cancerous  individual 
positive  results  are  only  too  certainly  obtained.  The  recurrence 
appears  either  in  the  neighbourhood  of  the  cicatrix,  the  most 
usual  situation,  or  in  adjacent  lymphatic  glands.  The  progress 
is  often  slow,  but  occasionally  the  disease  spreads  more  rapidly 
than  if  no  operation  had  been  undertaken.  Another  attempt 
should  always  be  made  to  remove  the  growth,  if  such  be  feasible. 

Recently  a  proposal  has  been  made  by  Beatson  of  Glasgow 
to  deal  with  inoperable  cases  of  cancer  by  oophorectomy,  com- 
bined with  the  administration  of  thyroid  extract,  and  two  or  three 
cases  of  apparent  recovery  under  this  regime  have  been  recorded. 
Certainly,  if  the  patient  is  made  to  fully  understand  what  is 
involved  by  such  a  proceeding,  there  can  be  no  objection  to 
trying  it,  although  our  present  experience  seems  to  indicate  that 
the  improvement,  often  unquestionable  at  first,  is  only  temporary. 


CHAPTER  XXXII. 
ABDOMINAL  SURGERY. 

Injuries  of  the  Abdominal  Walls. 

These  may  be  divided  into  three  main  classes — contusions,  non- 
penetrating and  penetrating  wounds. 

Contusions  of  the  abdominal  walls  vary  in  their  results  with 
the  cause  and  character  of  the  injury,  and  with  the  condition 
of  the  subjacent  viscera.  If  due  to  a  slight  blow,  the  effects  are 
probably  not  serious,  the  patient  merely  suffering  from  pain  and 
bruising,  as  in  any  other  part  of  the  body.  If  the  blow,  although 
slight,  falls  upon  a  distended  viscus,  such  as  the  stomach  or 
bladder,  the  organ  may  be  torn,  and  the  contents  extravasated 
into  the  abdominal  cavity,  with  fatal  results  from  peritonitis.  If 
a  solid  viscus,  such  as  the  liver  or  spleen,  is  injured,  alarming 
haemorrhage  may  occur  into  the  peritoneal  cavity,  from  which  the 
patient  may  die.  An  account  of  these  visceral  injuries  is  given 
seriatim  under  the  appropriate  headings  in  this  chapter.  Any 
sudden  sharp  concussion,  especially  if  directed  to  the  epigastrium, 
is  liable  to  be  followed  by  severe  shock  from  irritation  of  the 
subjacent  solar  plexus  of  the  sympathetic  nerves,  and  life  itself 
may  be  destroyed  in  this  way  by  syncope  without  the  appearance 
of  an  evident  lesion. 

If  the  injury  is  limited  to  the  abdominal  walls,  rupture  of  one 
or  more  of  the  constituent  muscles,  especially  the  rectus,  may 
occur.  A  haematoma  of  considerable  size  usually  follows,  and 
this  is  especially  liable  to  suppuration  and  the  formation  of  an 
abscess,  which  may  point  directly  at  the  injured  spot,  or  burrow 
widely  between  the  muscular  planes.  The  smell  of  the  pus  is 
always  suggestive  of  the  presence  of  the  Bac.  coli,  and  this  organism 
probably  finds  its  way  into  the  extravasated  blood  from  some 
slightly  damaged  coil  of  intestine  in  the  neighbourhood.  As  a 
further  complication,  laceration  of  the  parietal  peritoneum  may 
be  mentioned,  causing  shock  and  intraperitoneal  extravasation  of 
blood  ;  if  the  latter  is  abundant,  as  from  a  large  vessel,  peritonitis 
is  almost  certain  to  follow. 


892  A   MANUAL  OF  SURGERY 


The  Treatment  of  an  abdominal  contusion  is  always  a  matter 
of  some  anxiety  to  the  surgeon,  as  it  is  difficult  at  first  to  make 
certain  of  the  exact  nature  of  the  injury,  and  as  to  whether  or  not 
visceral  complications  are  present.  In  the  more  simple  cases 
all  that  is  needed  is  to  put  the  patient  to  bed,  combating  shock 
in  the  usual  way  by  the  application  of  warmth,  but  stimulants 
should  be  avoided,  if  possible,  for  fear  of  restarting  haemorrhage. 
In  the  more  severe  cases,  a  decision  has  to  be  made  as  to  whether 
expectant  treatment  is  to  be  depended  on,  or  whether  an  explora- 
tory laparotomy  is  to  be  undertaken.  No  absolute  rules  can  be 
laid  down  as  to  when  operation  is  necessary,  but  the  surgeon 
should  remember  that  exploration  in  a  doubtful  case  will  probably 
do  far  less  harm  than  delaying  operation  until  the  diagnosis  is 
made  certain  by  an  outbreak  of  diffuse  inflammation,  providing 
always  that  the  patient  is  not  so  profoundly  collapsed  as  to  contra- 
indicate  all  interference.  The  examination  of  the  abdomen  and 
of  the  patient  may  bring  to  light  facts  which  make  operation  essen- 
tial, such  as  (a)  severe  intraperitoneal  haemorrhage,  (b)  general 
tympanites  or  free  gas  in  the  peritoneal  cavity,  as  indicated  by  loss 
of  the  area  of  hepatic  dulness,  (c)  blood-stained  vomiting,  or  (d)  the 
phenomena  due  to  a  lacerated  bladder.  Under  such  circum- 
stances, no  delay  is  justifiable,  and,  even  if  severe  shock  is 
present,  operation  should  be  commenced,  unless  death  is  evidently 
imminent.  A  large  intravenous  injection  of  hot  saline  solution 
will  usually  rally  the  patient  sufficiently  to  warrant  the  surgeon 
in  proceeding,  whilst  freely  washing  out  the  peritoneal  cavity  with 
the  same  hot  solution  has  often  a  similar  effect.  If,  however, 
well-marked  shock  is  present,  with  perhaps  localized  pain,  but 
with  no  absolute  evidence  of  visceral  lesions,  expectant  treatment 
should  be  adopted.  The  patient  is  kept  warm  in  bed  ;  perhaps 
a  little  opium  is  administered  to  allay  pain  and  restlessness  and 
to  check  peristalsis,  but  as  little  as  possible  should  be  given,  since 
symptoms  are  so  completely  masked  thereby.  If  there  is  any 
vomiting,  rectal  alimentation  should  be  employed  after  the  lower 
bowel  has  been  washed  out.  If,  at  the  end  of  twenty-four  hours, 
the  patient  is  still  in  a  condition  of  collapse,  and  especially  if 
manifestations  of  intraperitoneal  haemorrhage  or  of  commencing 
peritonitis  have  made  themselves  evident,  operation  can  still  be 
undertaken  with  some  prospect  of  success. 

Non-Penetrating  Wounds  of  the  Abdominal  Wall  do  not  demand 
separate  attention,  since  there  is  no  special  significance  about 
them,  and  if  uncomplicated  by  contusions  are  treated  on  general 
principles.  If  the  epigastric  artery  is  divided,  extensive  extrava- 
sation is  likely  to  ensue  ;  the  wound  must  then  be  enlarged, 
and  the  bleeding-points  secured.  It  must  also  be  remembered 
that  the  sheath  of  the  rectus  is  divided  anteriorly  by  the  lineae 
transversae  into  separate  compartments  ;  but  as  these  do  not 
extend  through  the  whole  thickness  of  the  muscle,  collections  of 


ABDOMINAL  SURGERY  S93 

blood  or  pus  may  be  limited  anteriorly,  whilst  behind  they  become 
diffuse.  If  the  abdominal  muscles  are  widely  divided,  steps 
should  be  taken,  after  thorough  purification,  to  draw  together  the 
severed  muscular  or  aponeurotic  fibres  by  deep  stitches,  so  as  to 
diminish  the  tendency  to  a  ventral  hernia. 

Penetrating  "Wounds  of  the  Abdominal  Wall  may  occur  with  or 
without  injury  or  protrusion  of  the  abdominal  viscera.  In  all 
cases  there  is  a  certain  amount  of  haemorrhage,  greater  or  less 
according  to  the  size  of  the  vessels  divided,  and  of  shock,  which 
latter  is  very  marked  when  the  viscera  are  injured,  whilst  mere 
protrusion  without  injury  may  cause  but  little  effect.  Thus,  cases 
are  on  record  in  which  a  patient  has  walked  to  the  surgeon  for 
treatment,  supporting  some  coils  of  intestine  in  his  hands.  The 
protruded  viscera,  usually  small  intestine  or  omentum,  are  often 
large  in  amount  compared  with  the  size  of  the  opening,  causing 
them  to  be  more  or  less  congested,  or  even  strangled.  Neces- 
sarily, in  all  cases  the  great  danger  is  that  of  diffuse  septic 
peritonitis,  caused  either  by  rupture  of  the  intestine  or  by 
infection  from  without.  It  is  an  interesting  point  to  note  that 
the  peritoneum  that  covers  the  viscera  has  but  little  sensation 
of  pain,  whilst  the  parietal  peritoneum  and  that  forming  the 
mesentery  are  very  sensitive  ;  on  the  other  hand,  the  visceral 
peritoneum  is  much  more  liable  to  bacillary  invasion. 

The  Treatment  of  these  abdominal  wounds  has  been  entirely 
altered  in  recent  years,  as  a  result  of  increased  confidence  in 
antiseptic  methods.  The  external  wound  is  carefully  cleansed, 
whilst  protruding  viscera  are  similarly  purified.  If  omentum  has 
escaped,  it  is  wise  to  ligature  and  remove  it,  whether  it  is  injured 
or  not.  Intestine  should  be  carefully  washed  with  warm  saline 
solution,  or  with  weak  antiseptic  lotions,  such  as  boric  acid  lotion, 
or  sublimate  (1  in  4,000),  and  then  replaced  ;  if  slightly  bruised,  it 
may  be  returned,  but  the  external  wound  should  not  be  entirely 
closed  and  a  drainage  wick  of  gauze  inserted,  so  that  if  faecal  extra- 
vasation occurs  a  ready  exit  is  provided.  Small  incisions  or  punc- 
tures must  be  sutured,  but  when  intestine  is  hopelessly  damaged, 
enterectomy  should  be  undertaken  if  the  patient's  general  con- 
dition is  sufficiently  good  ;  but  if  unfit  to  undergo  such  an  opera- 
tion, the  gut  must  be  fixed  in  the  wound  as  in  colotomy,  and 
the  defect  dealt  with  at  a  subsequent  period. 

In  cases  where  it  is  not  certain  whether  the  peritoneum  has 
been  implicated,  the  surgeon  should  always  enlarge  the  wound  so 
as  to  make  sure,  and  if  the  serous  membrane  has  been  involved, 
he  should  carry  his  investigations  still  further,  and  ascertain,  if 
possible,  whether  any  damage  had  been  done  to  the  viscera. 

The  external  wound  must  (with  the  exception  mentioned  above) 
be  carefully  closed  with  sutures,  so  as  to  minimize  the  risk  of  a 
subsequent  ventral  hernia.  The  peritoneum  and  divided  muscles 
are  united  by  buried  stitches  of  catgut  or  well-boiled  silk,  and 


894  A  MANUAL  OF  SURGERY 


finally  the  skin  is  brought  together  with  a  continuous  suture.     A 
drain-tube  may  need  to  be  inserted  for  a  time. 

There  are  but  few  other  conditions  of  the  abdominal  wall  which 
require  notice.  The  rectus  muscle  may  be  torn  as  a  result  of 
injury  or  tetanic  convulsions,  and  a  hernia  is  very  likely  to  follow. 
One  of  the  segments  may  become  spasmodically  contracted, 
constituting  what  is  known  as  a  '  phantom  tumour,'  usually 
occurring  in  hysterical  females,  and  disappearing  under  an  anaes- 
thetic. 

Affections  of  the  Umbilicus. 

The  various  forms  of  umbilical  hernia  are  described  at  p.  991. 

Inflammation  and  Ulceration,  perhaps  running  on  to  eczema, 
may  arise  from  want  of  cleanliness  after  separation  of  the  cord. 
Tetanus  neonatorum  probably  owes  its  infection  to  this  source, 
as  also  the  erysipelas  of  infants,  both  of  which  diseases  are  ex- 
ceedingly fatal,  whilst  the  latter  is  often  accompanied  by  sloughing 
of  the  neighbouring  abdominal  parietes.  The  eczematous  con- 
dition merely  requires  cleanliness,  and  the  application  either  of  an 
antiseptic  dusting-powder  or  of  some  simple  ointment. 

Occasionally  a  Polypoid  Excrescence  is  met  with  growing  from 
the  umbilicus,  and  is  probably  derived  from  the  remains  of  the 
umbilical  vesicle.  On  microscopic  examination,  it  is  found  to 
consist  of  a  number  of  tubular  glands  held  together  by  connective 
tissue.  All  that  is  required  is  to  ligature  the  base  and  cut  it 
away. 

Warts  and  Nsevi  are  also  found  here,  but  need  no  special  notice, 
as  also  syphilitic  and  epitheliomatous  disease. 

Umbilical  Fistulae  not  unfrequently  occur,  and  may  be  congenital 
or  acquired.     Three  varieties  are  described  : 

(a)  A  Fecal  Fistula  of  congenital  origin  arises  from  non-closure 
of  the  vitello-intestinal  duct,  and  either  opens  into  the  intestine 
directly,  or  by  means  of  a  passage  of  greater  or  less  length,  which 
corresponds  to  Meckel's  diverticulum,  and  is  connected  with  the 
lower  part  of  the  ileum.  Acquired  cases  are  usually  due  to  per- 
foration of  the  bowel  following  strangulation  of  an  umbilical 
hernia,  or  to  tuberculous  peritonitis. 

(b)  A  Congenital  Urinary  Fistula  is  due  to  non-closure  of  the 
urachus  ;  occasionally  merely  a  sinus  persists,  leading  towards  the 
bladder,  but  not  opening  into  it.  It  may  be  dealt  with  by  excision 
of  the  mucous  membrane,  its  destruction  by  the  galvano-cautery, 
or  by  freshening  the  edges  and  subsequent  suture. 

(c)  A  Biliary  Fistula  sometimes  forms  at  the  umbilicus,  resulting 
from  an  abscess  connected  with  the  gall-bladder. 

In  Ectopia  Vesicae  the  umbilicus  is  absent,  the  extroverted 
portion  of  the  bladder  extending  up  to  what  should  normally  be 
its  situation. 


ABDOMINAL  SURGERY  895 


Affections  of  the  Peritoneum. 

Inflammation  of  the  peritoneum,  or  Peritonitis,  arises  from  a 
variety  of  conditions,  and  presents  many  diverse  manifestations. 
It  is  a  disease  which  may  be  limited  to  some  particular  locality, 
or  may  involve  the  whole  serous  membrane.  In  discussing  the 
subject,  we  shall  avail  ourselves  of  the  large  mass  of  information 
gathered  together  by  Sir  Frederick  Treves  in  the  Lettsomian 
Lectures  for  1894. 

From  an  etiological  point  of  view,  it  may  be  stated  that  peri- 
tonitis is  almost  invariably  due  to  the  action  of  micro-organisms, 
the  symptoms  being  largely  those  of  toxic  poisoning,  death, 
when  it  occurs,  resulting  from  toxaemia  rather  than  from  the 
inflammation. 

The  following  forms  may  be  distinguished  : 

1.  Peritonitis  due  to  infection  from  the  intestine,  the  organism 
usually  present  being  the  Bacillus  coli  communis.  Entrance  to  the 
peritoneal  cavity  may  be  gained  either  through  some  actual  breach 
of  surface,  such  as  a  penetrating  wound  or  perforating  ulcer,  or 
through  an  intestinal  wall,  the  resisting  powers  of  which  have 
been  diminished  by  inflammation  or  injury.  The  peritonitis 
associated  with  appendicitis,  or  secondary  to  strangulated  hernia, 
is  of  this  type. 

2.  Peritonitis  due  to  infection  from  without,  the  ordinary 
pyogenic  organisms  being  present,  especially  the  Streptococcus 
pyogenes.  This  variety  occurs  in  penetrating  or  operation  wounds 
where  the  bowel  is  uninjured,  as  also  in  puerperal  peritonitis. 

3.  Peritonitis  may  be  due  to  the  gonococcus,  which  has  travelled 
up  the  Fallopian  tube  from  the  vagina. 

4.  Tuberculous  peritonitis  also  occurs,  and  is  usually  chronic 
in  type. 

5.  There  is  a  group  of  cases  in  which  peritonitis  is  of  doubtful 
origin,  possibly  arising  from  chemical  or  local  irritants,  rheumatism, 
etc. ;  but  it  is  still  a  moot  point  whether  such  can  be  caused  apart 
from  the  activity  of  micro-organisms. 

Clinical  History.  —From  a  purely  clinical  standpoint,  peritonitis 
may  be  discussed  under  two  main  headings — the  acute  and  the 
chronic.  The  acute  is  again  divided  into  the  diffuse  and  localized, 
and  the  chronic  into  the  simple  and  the  tuberculous. 

Acute  Diffuse  Peritonitis. — The  onset  varies  somewhat  with 
the  cause  of  the  affection  ;  but  when  due  to  traumatic  infection 
from  without,  the  symptoms  usually  commence  with  abdominal 
pain  and  distension,  together  with  flatulence  and  vomiting.  The 
pain  may  at  first  be  localized  to  some  particular  region,  or  referred 
to  the  umbilicus ;  it  soon,  however,  becomes  diffuse,  and  is 
associated  with  exquisite  tenderness  and  great  distension.  In 
a  typical  case  the  phenomena  are  very  characteristic.     The  patient 


896  A   MANUAL  OF  SURGERY 


lies  on  his  hack  with  the  knees  drawn  up,  partly  to  relax  the 
abdominal  muscles,  partly  to  prevent  the  bedclothes  touching  the 
body.  The  abdomen  is  distended,  hard,  and  extremely  tender  ; 
it  is  at  first  generally  tympanitic,  but  later  on,  if  effusion  should 
become  marked,  dulness  may  be  noted  in  the  flanks,  although  this 
is  not  a  common  feature.  The  pulse  is  quick,  hard,  and  wiry  in 
the  early  stages,  though  later  it  becomes  weak,  rapid,  and  com- 
pressible. The  respirations  are  quick,  shallow,  and  thoracic  in 
character.  The  temperature,  raised  at  first,  tends  to  become 
subnormal  from  toxaemia  before  the  end  is  reached.  Vomiting  is 
usually  a  prominent  symptom,  associated  perhaps  with  hiccough  ; 
to  commence  with,  the  contents  of  the  stomach  alone  are  expelled, 
but  later  on  they  may  be  mixed  with  bile,  or  even  faecal  material. 
Though  very  constant  and  troublesome,  it  is  much  less  distressing 
than  that  which  arises  from  intestinal  obstruction,  and,  owing  to 
the  pain  induced  by  any  sudden  contraction  of  the  abdominal 
muscles,  the  patient  ejects  the  vomit  with  but  little  force.  Con- 
stipation and  arrest  of  flatus  are  always  present  in  peritonitis, 
owing  to  the  cessation  of  peristalsis  induced  by  the  inflammation. 
As  the  case  progresses,  the  patient's  strength  rapidly  diminishes, 
his  face  becomes  pinched  and  drawn  (fades  Hippocratica),  the 
extremities  are  cold,  the  temperature  is  usually  subnormal,  and 
death  results  from  collapse  and  toxaemia. 

When  due  to  sudden  perforation  of  the  bowel,  the  onset  of  the 
symptoms  is  associated  with  profound  shock,  and  the  course  is 
very  rapid  if  the  opening  is  large,  and  the  intestinal  contents 
early  extravasated.  Vomiting,  too,  is  usually  more  marked  than 
when  due  to  other  causes.  If,  however,  the  perforation  is  small, 
the  immediate  shock  is  less,  and  the  symptoms  progress  more 
gradually. 

The  Post-mortem  Phenomena  of  acute  diffuse  peritonitis  consist 
in  an  exudation  into  the  peritoneal  cavity  of  turbid  serum  or  pus, 
mixed  with  flocculi  of  lymph.  The  serous  coat  of  the  intestine 
is  roughened,  and  adjacent  coils  may  be  matted  together  by 
greenish  semi-puriform  lymph.  The  effusion  is  mainly  found  in 
the  pelvis  and  lower  part  of  the  abdominal  cavity,  and  is  not 
always  very  abundant  ;  it  is  intensely  infective,  and  any  wounds 
caused  during  the  performance  of  the  post-mortem  examina- 
tion are  likely  to  be  followed  by  severe  cellulitis  or  even  fatal 
septicaemia.  The  omentum  sometimes  forms  a  barrier  shutting 
off  the  lower  from  the  upper  portion  of  the  peritoneal  cavity,  and 
limiting  the  mischief  to  one  or  other  section. 

Treatment  of  Acute  Diffuse  Peritonitis. — In  former  days  treat- 
ment consisted  in  fomenting  the  abdomen,  and  keeping  the  patient 
fully  under  the  influence  of  opium,  whilst  abstinence  from  food 
was  enforced,  and  possibly  calomel  given  as  an  absorbent ;  but 
since  peritonitis  is  very  rarely  idiopathic  in  nature,  and  usually 
results  from  some  very  definite  local  lesion,  such  measures  are 


ABDOMINAL  SURGERY  897 

rarely  adequate.  In  diffuse  peritonitis,  expectant  treatment  of 
this  character  is  almost  certain  to  be  followed  by  a  fatal  issue ; 
and  although  treatment  by  operation  has  no  great  results  to  boast 
of,  it  is  the  only  rational  plan  to  adopt.  The  virulent  nature  of 
the  toxins  produced  by  the  inflammatory  process,  and  the  late 
date  at  which  operation  is  usually  performed,  fully  suffice  to 
explain  the  high  death-rate  associated  with  it.  An  exploratory 
laparotomy  should  therefore  be  undertaken  as  early  as  possible, 
the  incision  being  made  in  the  linea  alba,  and  usually  below  the 
umbilicus,  unless  there  is  tolerably  clear  evidence  that  the  causative 
lesion  is  in  the  upper  part  of  the  abdomen.  The  effusion  is  allowed 
to  escape,  and  by  gently  separating  the  coils  of  intestine  localized 
pockets  of  fluid  may  be  evacuated.  Collections  of  blood  or  pus 
should  be  swabbed  out  by  gentle  sponging,  or  possibly  general 
irrigation  of  the  abdominal  cavity  with  sterilized  salt  solution 
(o*6  per  cent.)  may  be  adopted.  In  this  proceeding  care  must  be 
taken  to  maintain  the  fluid  at  a  constant  temperature  (1050  to 
1  io°  F.),  to  prevent  abdominal  distension,  and  not  to  allow  the  fluid 
to  play  on  the  under  surface  of  the  diaphragm  for  fear  of  causing 
respiratory  embarrassment.  If  the  original  lesion  can  be  reached 
without  much  difficulty,  it  must  be  dealt  with  according  to  the 
rules  given  hereafter,  provided  that  the  patient's  general  condition 
is  sufficiently  satisfactory.  Drainage  of  the  peritoneal  cavity  by 
a  glass  drainage-tube,  or  perhaps  better  by  strips  of  gauze  passed 
amongst  the  intestines  in  different  directions,  is  usually  essential. 

In  cases  of  threatening  peritonitis  following  abdominal  opera- 
tions, as  indicated  by  pain,  distension  and  vomiting  (peritonism), 
the  chief  causative  factor  is  often  a  paralytic  condition  of  the  gut, 
which  permits  of  the  retention  and  decomposition  of  the  intestinal 
contents,  thus  assisting  the  activity  of  the  Bac.  coli.  In  such  cases 
a  smart  saline  purgative  (e.g.,  sodii  sulphas,  gr.  xx.-xxx.,  every 
hour)  is  often  useful,  in  order  to  free  the  intestine  from  its 
irritating  contents.  When,  however,  general  septic  peritonitis 
is  present,  purgatives  can  only  do  harm. 

Acute  Localized  Peritonitis  usually  arises  in  connection  with 
some  limited  lesion  of  the  abdominal  contents,  which  is  of  such 
a  nature  as  to  permit  of  the  general  peritoneal  cavity  being  shut 
off  by  adhesions  between  adjacent  coils  of  intestine,  the  process 
being  thereby  localized.  It  is  usually,  although  not  invariably, 
followed  by  suppuration,  the  abscess  being  thus  intraperitoneal, 
although  not  involving  the  general  peritoneal  cavity.  The 
abscesses  arising  in  connection  with  appendicitis  or  pelvic  peri- 
tonitis are  not  uncommonly  of  this  nature.  They  may  burst 
through  the  barrier  of  adhesions,  and  thus  light  up  a  diffuse  in- 
flammation of  the  peritoneal  sac,  or  they  may  burrow  to  the 
surface  and  burst,  or  open  into  one  of  the  hollow  viscera. 

The  Symptoms  complained  of  are  deep  pain  and  tenderness, 
more  or  less  localized  to  the  affected  area,  together  with  fever, 

57 


.J    MANUAL  OF  SURGERY 


vomiting,  and  constipation.  At  first  no  swelling  or  tumour  is 
to  he  made  out,  but  a  feeling  of  resistance  may  be  noticed  in 
the  abdominal  wall,  which  is  held  tense  and  rigid,  as  if  guarding 
some  focal  point  of  mischief.  As  the  effusion  increases  in 
amount,  a  tumour  dull  or  tympanitic  on  percussion  usually 
becomes  evident  ;  it  is  mainly  due  to  a  matting  together  of  the 
intestines,  but  associated  with  a  variable  amount  of  effusion.  If 
the  abscess  travels  towards  the  surface,  the  abdominal  wall 
becomes  infiltrated,  red,  and  cedematous,  the  component  tissues 
being  brawny  to  the  touch,  and  cutting  like  bacon.  Finally,  a 
fluctuating  area  presents  itself  in  the  midst  of  this  indurated  mass, 
and  the  abscess  either  discharges  itself  or  is  opened.  The  pus 
contained  therein  may  be  thin  and  offensive,  or  it  may  be  free  from 
odour,  and  then  is  often  somewhat  inspissated,  and  like  custard 
in  consistency.  Of  course  this  process  is  attended  with  con- 
siderable increase  in  the  pain  and  constitutional  disturbance.  If 
the  cavity  is  treated  antiseptically,  it  rapidly  contracts  and  a  cure 
is  accomplished,  although  intraperitoneal  adhesions  may  persist 
and  lead  to  trouble  later  on  from  hampering  the  intestinal  move- 
ments. If  a  communication  is  established  with  the  intestine,  a 
faecal  fistula  is  very  apt  to  follow  ;  whilst  if  the  cavity  becomes 
septic,  chronic  suppuration  may  result,  and  thereby  the  patient's 
health  and  strength  are  undermined. 

Treatment  of  Acute  Localized  Peritonitis. — In  these  cases, 
resolution  can  be  obtained  in  favourable  cases  by  keeping  the 
patient  quiet  and  on  a  low  diet,  with  perhaps  a  little  morphia, 
and  by  applying  fomentations  locally,  whilst  the  lower  bowel  is 
emptied  by  an  enema.  Such  a  course  must,  however,  not  be  per- 
sisted in  for  too  long  when  suppuration  is  likely  to  have  occurred, 
for  fear  of  the  inflammation  spreading  to  the  general  peritoneal 
cavity,  or  of  the  abscess  bursting  into  it.  An  early  exploratory 
laparotomy  is  advisable  under  such  circumstances.  The  line  of 
treatment  marked  out  for  appendicitis  (p.  950)  is  that  which 
should  always  be  followed. 

Simple  Chronic  Peritonitis  in  itself  rarely  requires  surgical 
attention,  since  it  is  to  be  looked  on  rather  as  a  protective  than 
as  a  destructive  process.  It  is  characterized  by  infiltration  and 
thickening  of  the  peritoneum,  giving  rise  to  adhesions,  whereby 
the  intestinal  wall  is  strengthened,  and  bacterial  invasion  limited. 
It  is  localized  or  diffuse  in  character,  and  arises  either  as  a  result 
of  pre-existing  acute  inflammation  or  as  a  primary  affection.  In 
the  more  diffuse  forms  the  intestines  are  hopelessly  matted  together, 
and  the  omentum  may  be  rolled  up  and  contracted  into  a  rounded 
cord-like  mass,  lying  transversely  across  the  upper  part  of  the 
abdomen  ;  chronic  obstruction  is  almost  certain  to  arise  sooner  or 
later  from  this  condition.  Occasionally  the  existence  of  persisting 
localized  pain  may  indicate  the  presence  of  a  solitary  adhesion, 
passing  between  the  abdominal  wall  and  one  of  the  viscera,  such 


ABDOMINAL  SURGERY  899 


as  the  anterior  wall  of  the  stomach.  In  such  cases  an  explanatory 
laparotomy  is  permissible,  the  adhesion  if  found  being  divided 
between  ligatures.  The  importance  of  dealing  with  such  adhe- 
sions, where  possible,  is  evident  from  the  fact  that  internal 
strangulation  beneath  them,  or  acute  kinking  of  the  gut  over 
them,  is  one  of  the  commonest  forms  of  acute  obstruction. 

Tuberculous  Peritonitis. — This  disease  is  almost  limited  to 
young  people,  and  is  usually  secondary  to  some  other  focus  of 
intra-abdominal  tuberculosis,  e.g.,  in  the  intestine,  mesenteric 
glands,  Fallopian  tube,  etc.  It  is  sometimes  limited  in  its 
development  to  a  portion  of  the  peritoneal  cavity,  especially  when 
it  is  of  pelvic  origin,  but  is  more  frequently  diffuse.  It  manifests 
itself  in  several  different  ways:  (1)  In  the  ascitic  variety  the 
peritoneum  becomes  thick  and  hyperaemic,  and  studded  over  with 
tubercles,  some  of  them  small,  grey  and  translucent,  others  larger 
and  undergoing  caseation.  The  effusion  is  generally  abundant, 
and  consists  of  straw-coloured  or  opalescent  serum,  perhaps 
blood-stained  in  the  more  active  cases.  Flakes  of  fibrin  may  be 
found  covering  the  membrane  here  and  there,  but  there  is  no 
extensive  matting  of  the  intestines.  Occasionally  the  effusion 
becomes  encapsuled,  giving  rise  to  cystic  swellings  shut  in  between 
the  coils  of  intestine.  (2)  In  the  fibrous  variety  the  intestines 
become  matted  together  by  extensive  adhesions,  and  between 
them  foci  of  tubercle  are  found.  The  mesentery  may  become 
infiltrated  and  shrink,  fixing  the  intestines  back  en  bloc  to  the 
posterior  abdominal  wall.  The  omentum  is  often  invaded,  and 
contracts  upwards  to  form  a  sausage-like  tumour  lying  transversely 
above  the  umbilicus.  There  is  but  little  effusion,  and  that  is  usually 
encapsuled.  It  is  obvious  that  such  a  condition  is  very  likely  to 
lead  to  obstructive  phenomena,  due  to  kinking  of  the  intestine. 
(3)  The  ulcerous  variety  is  characterized  by  an  exaggeration  of  the 
above  phenomena.  Tuberculous  foci  are  found  between  the 
coils  of  intestine,  and  open  into  them,  giving  rise  to  various  inter- 
intestinal  fistula?  (Vistula  bimucosa),  or  even  opening  externally. 

In  each  of  these  varieties  acute  manifestations  may  develop  at 
any  time  as  a  result  of  infection  from  the  bowel  with  the  Bac.  coli, 
and  then  the  symptoms  of  acute  diffuse  peritonitis  may  supervene. 

The  symptoms  are  very  variable.  Any  and  every  form  of  diges- 
tive disturbance  may  occur,  including  diarrhoea,  or  alternating 
attacks  of  constipation  and  diarrhoea,  with  some  amount  of  colic 
and  vomiting.  The  onset  is  generally  gradual,  but  intermissions 
and  relapses  are  of  frequent  occurrence.  Wasting  is,  however, 
always  a  marked  feature.  The  abdomen  is  enlarged,  perhaps 
tender  to  the  touch,  and  may  contain  free  fluid  or  not. 

Treatment  in  the  early  stages  is  often  successfully  undertaken 
by  the  physician  ;  but  if  the  condition  is  progressing,  the  surgeon 
may  be  called  upon  to  deal  with  it  by  laparotomy.  When  marked 
ascitic  accumulation  is  present,  all   that  is  needed  is  to  remove 

57—2 


900  A  MANUAL  OF  SURGERY 


the  fluid  and  close  the  wound  with  or  without  irrigation,  and  in 
nearly  75  per  cent,  of  the  cases  a  cure  may  be  anticipated.  Where 
diffuse  or  localized  suppuration  is  present,  adhesions  which  can 
be  reached  may  be  gently  broken  down,  exit  given  to  the  pus, 
and  the  peritoneal  cavity  washed  out  ;  but  no  prolonged  search 
after  suppurating  foci  should  be  made,  or  the  intestine  may  be 
torn.  The  results  of  treatment  in  this  variety  are  not  nearly  as 
satisfactory  as  in  the  former,  at  least  40  per  cent,  of  the  cases 
dying.  As  to  the  way  in  which  cure  is  established,  opinions 
differ,  some  authorities  considering  that  it  is  due  merely  to  the 
admission  of  atmospheric  air,  some  to  the  alteration  produced 
thereby  in  the  intra-abdominal  tension,  whilst  others  maintain 
that  it  is  simply  in  consequence  of  the  removal  of  the  exudation 
and  its  contained  toxins.  The  most  plausible  idea,  however, 
attributes  it  to  a  flushing  of  the  intra-abdominal  tissues  with 
blood  serum  (a  well-ascertained  fact  after  laparotomy)  and  the 
effect  of  the  antitoxic  substances  contained  therein,  the  tubercles 
thereby  having  their  vitality  destroyed.  In  this  connection  one 
may  note  the  statement  that  too  early  a  laparotomy  does  but 
little  good,  an  insufficient  amount  of  antitoxin  having  presumably 
developed  in  the  system. 

Paracentesis  Abdominis  is  required  in  cases  of  general  or 
encysted  ascites.  The  usual  plan  adopted  is  to  seat  the  patient 
on  a  chair,  and  to  encircle  the  abdomen  with  a  flannel  binder, 
the  ends  of  which  are  split  to  within  6  inches  of  the  middle  line. 
The  unslit  portion  is  placed  over  the  abdominal  wall  in  front, 
whilst  the  divided  portions  cross  behind,  and  are  held  by  assistants, 
so  as  to  make  continuous  pressure  upon  the  abdominal  contents. 
The  abdomen  is  carefully  percussed,  and  a  spot  of  absolute  dul- 
ness  selected  ;  here  a  small  skin  incision  is  made  with  a  scalpel, 
and  a  suitable  trocar  and  cannula  inserted.  The  median  line 
below  the  umbilicus  is  the  place  usually  chosen  for  the  puncture, 
but  there  is  no  objection  to  inserting  the  trocar  through  the 
flanks.  Some  surgeons  prefer  to  withdraw  the  fluid  more  slowly, 
so  as  to  prevent  the  shock  often  experienced  from  its  rapid 
removal.  Two  or  three  Southey's  trocars  and  cannula'  may  then 
be  inserted. 

Subphrenic  Abscess  is  the  term  applied  somewhat  loosely  to  a 
suppurating  focus  which  is  in  more  or  less  intimate  relation  with 
the  under  surface  of  the  diaphragm.  Two  main  varieties  are 
described,  viz.,  the  intraperitoneal,  which  is  much  the  more 
common,  and  the  retro-  or  extra-peritoneal.  The  causes  are  very 
diverse,  and  the  manifestations  vary  somewhat  with  the  causative 
lesion.  1.  The  stomach  is  the  most  frequent  source  of  the  trouble, 
the  infection  being  due  to  the  extension  of  a  chronic  ulcer.  If  the 
anterior  wall  is  involved,  the  pus  will  be  limited  by  the  lesser 
omentum  and  stomach  behind,  by  the  diaphragm  and  left  lobe  of 


ABDOMINAL  SURGERY  901 

the  liver  above,  by  the  falciform  ligament  on  the  right,  and 
by  adhesions  between  the  stomach  or  omentum  and  anterior 
abdominal  wall  below.  This  type  of  abscess  usually  points  to  the 
left  of  the  ensiform  appendix.  Should  the  ulcer  be  situated  on  the 
anterior  wall  near  to  the  fundus,  the  abscess  may  get  into  close 
relationship  with  the  spleen,  and  point  beneath  the  left  costal 
margin.  When  the  abscess  arises  in  relation  with  the  posterior  wall, 
the  lesser  sac  of  the  peritoneum  may  be  filled  with  pus,  which  is 
prevented  from  escaping  from  the  foramen  of  Winslow  by  adhe- 
sions, whilst  the  stomach  itself  is  pushed  forwards,  and  the  pus 
travels  up  and  presents  above  it  to  the  left  of  the  middle  line. 
More  often  the  lesser  sac  has  been  previously  obliterated,  and  the 
abscess  develops  in  the  retroperitoneal  tissues.  2.  Ulcer  of  the 
duodenum  may  give  rise  to  very  similar  conditions.  If  the  abscess 
is  intraperitoneal,  it  is  bounded  by  the  liver,  colon,  omentum,  and 
anterior  abdominal  wall  ;  occasionally  it  has  also  tracked  up 
behind  the  liver.  Retroperitoneal  suppuration  also  occurs  in  con- 
nection with  the  duodenum,  the  pus  then  travelling  up  between 
the  liver  and  diaphragm,  or  downwards  towards  the  loin.  3.  The 
append/'. >•  vermiformis  is  also  a  cause  of  subphrenic  abscess,  the  pus 
burrowing  behind  the  peritoneum,  or  finding  its  way  along  the 
inner  or  outer  walls  of  the  ascending  colon.  4.  It  may  also  be 
caused  by  extension  of  suppuration  from  the  liver,  colon,  intestine, 
or  from  retroperitoneal  structures,  such  as  the  kidney,  ribs,  or 
vertebrae.  According  to  Fenwick,  however,  80  per  cent,  of  all 
cases  of  subphrenic  abscess  are  due  to  ulceration  of  the  stomach  or 
duodenum. 

The  abscess  thus  induced  may  contain  pus  alone  or,  in  addition, 
gas,  which  is  derived  either  from  a  direct  communication  with  the 
bowel,  or  from  the  activity  of  the  Bacillus  colt  without  any  direct 
opening  being  present.  It  wras  to  this  condition  that  Leyden 
originally  gave  the  name  of  subphrenic  pyo-pnciimothorax.  The 
extension  of  the  abscess  along  the  under  surface  of  the  diaphragm 
often  leads  to  that  structure  being  displaced  considerably  upwards, 
and  to  a  secondary  infection  of  the  pleura,  either  by  lymphatic 
absorption  and  extension,  or  by  an  actual  solution  of  continuity. 
The  effect  is  an  effusion  of  serum  or  pus  into  the  base  of  the 
pleural  cavity,  the  latter  constituting  a  basal  empyema. 

The  symptoms  vary  considerably.  They  may  commence  ab- 
ruptly, as  from  a  perforated  stomach,  or  come  on  more  gradually. 
Ordinary  febrile  phenomena,  and  perhaps  one  or  more  rigors,  may 
occur,  whilst  the  patient  complains  of  pain  in  the  upper  portion  of 
the  abdomen,  where  a  swelling,  dull  or  tympanitic  according  to 
circumstances,  appears,  over  which  the  abdominal  muscles  are 
rigidly  contracted.  The  condition  is  very  liable  to  be  mistaken 
for  an  empyema  or  pneumothorax,  but  one  most  important  dis- 
tinguishing feature  is  that  the  heart  is  displaced  directly  upwards 
and  not  to  one  side,  as  in  the  pulmonary  conditions,  whilst  the 


902  A   MANUAL  OF  SURGERY 

liver  is  pushed  downwards.  Left  to  itself  the  abscess  may  burst 
into  the  general  peritoneal  cavity,  or  into  one  of  the  hollow  viscera, 
or  may  open  externally. 

The  treatment  of  subphrenic  pyo-pneumothorax  consists  in 
opening  the  abscess  wherever  it  is  most  accessible.  Opinions 
differ  as  to  whether  it  is  necessary  to  make  a  counter-opening 
behind ;  in  all  probability,  it  is  wiser  not  to  attempt  this  at 
first,  but  if  the  temperature  still  keeps  up,  and  the  cavity  does 
not  seem  to  drain  well  after  a  few  days,  then  further  interference 
will  be  reqviired.  The  best  situation  for  a  counter-opening  is 
behind  the  mid-axillary  line,  a  portion  of  the  eighth  or  ninth  rib 
being  excised.  If,  as  often  happens,  there  is  also  an  empyema, 
this  is  readily  accomplished,  and  an  additional  opening  can  be 
made  through  the  diaphragm  if  one  does  not  already  exist  ;  if, 
however,  the  pleural  cavity  is  not  affected,  then  the  serous  mem- 
brane covering  the  upper  surface  of  the  diaphragm  must  be  stitched 
to  the  parietal  pleura  before  the  diaphragm  is  incised. 

Affections  of  the  Stomach. 

Rupture  of  the  Stomach  results  from  blows  or  falls  upon  the 
epigastrium,  especially  after  a  heavy  meal,  and  then  usually  in- 
volves the  pyloric  end  or  the  greater  curvature  near  the  cardiac 
orifice.  It  may  also  follow  a  penetrating  injury,  such  as  a  stab 
or  a  fall  upon  a  spike  or  railings.  Neighbouring  viscera  are  not 
unfrequently  involved  in  the  lesion,  especially  the  liver  or  spleen. 

The  Symptoms  are  those  of  severe  and  prolonged  shock,  with 
epigastric  pain  and  vomiting,  the  ejected  material  often  containing 
blood  ;  acute  septic  peritonitis  usually  ensues  in  a  very  short  time, 
destroying  the  patient's  life  in  a  few  days.  Occasionally,  when 
the  wound  is  small,  or  the  organ  empty  at  the  time  of  the  accident, 
there  is  but  little  or  no  extravasation,  and  then  a  localized  intra- 
peritoneal abscess  may  form,  shut  off  from  the  general  peritoneal 
cavity  by  adhesions,  and  sooner  or  later  bursting  and  discharging 
into  the  stomach,  colon,  or  one  of  the  hollow  viscera,  or  else 
tracking  along  the  parietal  wound  so  as  to  reach  the  surface,  or 
even  sometimes  breaking  down  the  barrier  of  adhesions,  and 
originating  a  late  general  peritonitis.  If  the  posterior  wall  of  the 
stomach  is  alone  injured,  the  resulting  phenomena  are  very  similar 
to  those  due  to  the  perforation  of  an  ulcer  (q.v.). 

Treatment. — When  a  wound  perforating  the  abdominal  parietes 
is  present  in  the  region  of  the  stomach,  it  is  always  the  surgeon's 
duty  to  enlarge  the  opening,  and  ascertain  what  amount  of  internal 
damage  has  been  done  ;  but  if  there  is  no  external  wound,  or 
merely  a  superficial  one,  a  certain  diagnosis  cannot  be  made 
unless  blood-stained  vomiting  is  present.  In  doubtful  cases  the 
persistence  of  shock  for  some  considerable  time  and  the  onset  of 
peritonitis    indicate   that    an   exploratory  laparotomy  should  be 


ABDOMINAL  SURGERY  9°3 

undertaken.  No  time  must,  however,  be  lost  in  cases  where  the 
diagnosis  is  tolerably  certain,  since  the  only  hope  of  saving  the 
patient's  life  lies  in  early  interference.  A  median  incision  is  made 
above  the  umbilicus,  the  situation  of  the  injury  in  the  stomach 
ascertained,  and  the  aperture  clamped  by  forceps  so  as  to  prevent 
any  further  exit  of  the  gastric  contents  whilst  the  peritoneum  is 
being  cleansed.  All  extravasated  material  should  be  carefully 
sponged  or  swabbed  away,  and  if  the  general  cavity  has  not  yet 
become  inflamed,  irrigation  should  be  avoided  for  fear  of  carrying 
infective  material  to  other  regions.  The  wound  in  the  stomach 
is  closed  by  a  row  of  Lembert's  sutures,  which  tuck  the  margins 
inwards,  and  these  must  extend  a  little  beyond  the  lesion  on  either 
side  (Figs.  328  and  329).  If  the  posterior  wall  is  also  injured,  as 
by  a  bullet  wound,  an  opening  should  be  made  through  the  omen- 
tum so  as  to  explore  and  cleanse  the  lesser  sac  of  the  peritoneum. 
If  the  case  has  been  operated  on  early  and  there  is  but  little 
peritoneal  inflammation,  it  may  be  possible  to  close  the  parietal 
wound  entirely  ;  but,  as  a  rule,  it  is  necessary  to  drain  the  upper 
part  of  the  serous  cavity  by  inserting  a  plug  of  gauze  down  to  and 
around  the  site  of  the  injury.  If  the  general  cavity  is  inflamed,  the 
treatment  suitable  to  acute  peritonitis  must  be  instituted  (p.  897). 
It  will  probably  be  wise  under  these  circumstances  to  place  a 
drainage-tube  immediately  above  the  symphysis  pubis,  as  well  as 
leaving  the  upper  incision  partly  open. 

Foreign  Bodies  in  the  stomach  consist  either  of  those  which 
have  been  swallowed  accidentally  or  intentionally,  or  of  con- 
cretions, e.g.,  hairs,  wool,  etc.,  due  to  the  constant  ingestion  of 
small  portions  which  remain  in  the  viscus,  and  may  after  a  time 
form  large  masses.  The  presence  of  the  former  is  known  from 
the  history,  whilst  the  latter  may  give  rise  to  symptoms  of  gastric 
irritation,  the  cause  of  which  is  inexplicable  until  the  mass  has 
attained  such  a  size  as  to  suggest  the  presence  of  a  tumour.  The 
only  treatment  possible  where  the  foreign  body  is  of  any  size  is 
to  open  the  organ  and  remove  it  (gastrotomy)  ;  where,  however, 
it  is  of  small  dimensions  e.g.,  a  coin,  it  may  be  allowed  to  pass 
onwards. 

Ulcer  of  the  Stomach  is  an  exceedingly  common  ailment,  the 
consequences  of  which  are  often  very  serious,  a  considerable 
mortality  being  associated  with  it,  its  complications,  or  its 
sequelae.  Two  chief  types  may  be  mentioned  here,  although 
others  are  not  unknown  : 

(a)  The  acute  ulcer  is  rarely  larger  than  a  sixpenny-piece,  and 
'  develops  with  almost  equal  frequency  at  any  spot  between  the 
cardia  and  the  pylorus  along  the  upper  margin  of  the  stomach, 
and  more  frequently  on  the  posterior  than  on  the  anterior 
surface '  (Fenwick).  It  is  not  unusually  multiple,  two  ulcers 
being  often  found  exactly  opposite    one    another,  suggesting   an 


904  A   MANUAL  OF  SURGERY 

infective  origin  of  the  trouble.  They  are  of  a  circular  shape, 
and  with  the  edges  sharply  defined  and  clearly  cut ;  each  succes- 
sive coat  is  destroyed  to  a  lesser  degree  than  the  one  internal  to 
it,  so  that  the  sore  is  truncated  or  funnel-shaped.  Should  per- 
foration occur,  the  opening  is  not  central,  but  slightly  to  one  side. 
These  acute  ulcers  heal  without  much  difficulty,  as  is  evident 
from  the  number  of  radiating  cicatrices  seen  on  the  post-mortem 
table.  They  give  rise  to  no  stenosis,  except  perhaps  when  they 
are  situated  within  the  pyloric  orifice.  Haemorrhage  from  this 
variety  is  not  uncommon,  but  is  rarely  fatal.* 

(b)  The  chronic  ulcer  may  attain  considerable  dimensions, 
perhaps  many  square  inches  of  each  surface  being  involved.  It 
is  usually  single,  and  situated  on  the  posterior  wall  near  the 
pyloric  orifice,  which  may  be  involved  in  the  trouble  by  extension. 
Its  shape  is  very  variable,  though  in  the  earlier  stages  it  is 
rounded  ;  one  important  type  is  the  horseshoe  ulcer,  which 
spreads  down  along  either  surface  from  the  lesser  curvature,  and 
may  subsequently  cause  an  hour-glass  contraction  of  the  organ. 
The  edges  are  often  raised,  hard,  and  infiltrated,  whilst  the  gastric 
wall  is  generally  thick  and  sclerosed.  In  old-standing  cases  there 
may  be  considerable  destruction  of  tissue,  external  viscera,  such 
as  the  pancreas,  being  sometimes  exposed  in  the  wound. 
Haemorrhage  is  not  uncommon,  and  may  prove  fatal ;  one  of 
the  larger  branches  of  the  coronary  artery,  or  perhaps  the 
splenic,  is  then  involved,  or  the  bleeding  may  arise  from  one  of 
the  enlarged  varicose  gastric  veins  which  are  often  found  in  the 
neighbourhood  of  an  old  ulcer.  Perigastric  inflammation  of  an 
adhesive  or  suppurative  type  is  almost  certain  to  occur,  and 
cicatricial  contraction  of  various  forms  is  likely  to  follow. 

Women  are  much  more  liable  to  gastric  ulcer  than  men,  in  the 
proportion  of  three  to  one  ;  but  it  is  the  acute  variety  to  which 
they  are  most  prone,  and  from  which,  apart  from  perforation, 
they  seldom  die.  The  usual  age  of  such  patients  is  from  fifteen 
to  thirty  years.  Men,  on  the  other  hand,  are  more  liable  to 
chronic  ulcers,  and  though  acute  perforation  is  less  common,  they 
are  subject  to  a  number  of  serious  complications  which  may 
prove  fatal.  Their  average  age  when  attacked  is  from  thirty  to 
fifty  years. 

Into  the  aetiology,  general  symptoms,  and  routine  treatment  of 
gastric  ulcers  it  is  unnecessary  to  enter ;  they  are  sufficiently 
described  in  medical  text-books.  A  number  of  complications, 
however,  arise  which  may  require  surgical  assistance,  whilst  it 
must  be  remembered  that  the  mere  persistence  of  symptoms  may 
justify  operative  measures,  especially  since  the  observation  has 

*  See  Fenwick,  '  Ulcer  of  the  Stomach  and  Duodenum,'  J  and  A. 
Churchill,  1900  ;  and  Mayo  Robson  and  Moynihan,  '  Diseases  of  the  Stomach 
and  their  Surgical  Treatment,'  Bailliere,  Tindall  and  Cox,  1901. 


ABDOMINAL  SURGERY  905 


been  made  and  confirmed  that  malignant  disease  may  commence 
on  the  site  of  an  old-standing  ulcer. 

1.  Excessive  and  Persistent  Hemorrhage  is  responsible  for  quite 
a  considerable  proportion  of  the  deaths  from  gastric  ulcer.  It  may 
arise  from  arteries,  veins,  or  capillaries,  and  at  first  it  is  difficult 
to  say  from  what  source  it  is  derived.  Inasmuch,  however,  as  in 
over  go  per  cent,  of  the  cases  it  can  be  stopped  by  medical  means, 
it  is  obvious  that  the  capillary  origin  is  most  common.  It  is  like- 
wise unusual  for  the  patient  to  succumb  as  the  result  of  the  first 
attack  of  bleeding,  and  hence  the  rule  of  practice  which  is  usually 
adopted,  viz.,  to  treat  the  first  acute  haemorrhage  by  medical 
means  ;  but  should  it  recur  or  persist  unduly,  surgical  assistance 
may  be  required. 

Under  the  latter  circumstances  the  abdomen  is  opened  and  the 
stomach  carefully  explored.  Some  puckering  or  thickening  of  the 
coats  may  indicate  the  situation  of  the  ulcer;  failing  this,  a  free 
opening  is  made  through  the  anterior  wall,  and  the  interior  of  the 
viscus  methodically  examined.  When  the  bleeding-point  has 
been  found,  it  may  be  possible  to  pick  it  up  and  tie  it  ;  or  the 
whole  ulcer  may  be  picked  up  and  ligatured  en  masse  ;  or  the 
base  of  the  ulcer  may  be  cauterized  ;  or  excision  of  the  ulcer 
may  be  practicable.  Failing  these  measures,  gastroenterostomy 
will  be  indicated,  in  order  to  give  the  organ  as  much  rest  as 
possible. 

2.  Perforation  of  the  Ulcer  is  by  no  means  an  uncommon  occur- 
rence in  connection  with  the  acute  type  of  ulcer,  and  is  therefore 
seen  most  frequently  in  young  women  ;  it  is  always  fraught  with 
the  greatest  danger.  The  anterior  wall  is  that  most  frequently 
involved,  owing  to  its  greater  mobility,  which  prevents  the  forma- 
tion of  protective  adhesions.  The  cardiac  end  is  more  often 
affected  than  the  pyloric.  The  character  of  the  symptoms  varies 
with  the  size  of  the  perforation,  and  with  the  distension  or  not 
of  the  viscus.  If  a  large  opening  is  produced  in  the  anterior  wall, 
so  that  the  gastric  contents  are  allowed  a  free  entrance  into  the 
peritoneal  cavity,  the  patient  is  seized  with  severe  epigastric  pain 
and  profound  shock,  and  this  is  followed  by  acute  septic  peri- 
tonitis, which  rapidly  proves  fatal  if  surgical  interference  is  not 
at  hand.  When  the  perforation  is  small,  and  only  a  gradual 
leakage  occurs,  the  onset  is  subacute  ;  the  primary  shock  is  then 
inconsiderable,  but  epigastric  pain  and  tenderness  are  present, 
and  steadily  increase  until  the  characteristic  features  of  general 
peritonitis  supervene. 

The  Prognosis  of  gastric  perforation  is  exceedingly  grave,  since, 
unless  active  surgical  interference  is  obtainable  within  a  compara- 
tively short  time,  hopeless  peritonitis  ensues.  Barling  states  that 
95  per  cent,  of  patients  that  are  untreated  are  sure  to  die,  whilst 
the  later  the  operation,  the  worse  the  results. 

Treatment.  —  Should  it  be  decided  for  any  particular  reason  not 


9o6  A   MANUAL  OF  SURGERY 


to  operate  in  a  given  case,  the  horizontal  position,  rectal  feeding, 
and  the  use  of  morphia  to  check  peristalsis,  are  the  only  means 
which  hold  out  any  prospect  of  benefit.  Operation,  as  already 
indicated,  must  be  undertaken  at  as  early  a  period  as  possible, 
although  it  is  often  wise  to  delay  for  an  hour  or  two  to  allow  the 
patient  to  recover  in  measure  from  the  initial  shock.  The  median 
incision  is  the  best  to  employ,  since  it  is  not  possible  to  be  certain 
as  to  the  situation  of  the  lesion.  The  rules  given  above  as  to  the 
treatment  of  a  penetrating  injury  hold  good  in  connection  with 
this  subject,  especially  as  to  the  use  of  swabs  for  the  removal 
of  any  extravasated  gastric  contents,  and  as  to  the  value  of 
peritoneal  irrigation.  There  is  no  need  to  excise  the  ulcer  when 
found  ;  all  that  is  required  is  to  close  the  aperture  by  means  of 
Lembert's  sutures,  applied  perhaps  in  a  purse-string  fashion,  so 
as  to  bury  the  ulcerated  surface.  In  some  cases  it  may  seem 
unwise  to  attempt  closure  of  the  lesion,  whilst  in  others  it  may  be 
so  situated  as  to  render  such  closure  impossible  ;  a  drainage-tube, 
free  from  lateral  openings,  is  then  introduced  into  the  stomach, 
and  gauze  packed  around  it  so  as  to  lessen  the  risk  of  intra- 
peritoneal leakage.  The  patient  is  fed  by  the  rectum  for  some 
time,  and  the  fistula  usually  closes  without  much  difficulty  at  a 
subsequent  date. 

3.  Perigastric  inflammation  is  a  common  result  of  ulceration  ;  it 
may  be  either  adhesive  or  suppurative  in  character. 

Adhesive  perigastritis  is  in  the  first  place  protective  in  nature, 
consisting  of  a  localized  thickening  of  the  serous  wall.  It  is  more 
marked  in  connection  with  chronic  than  with  acute  ulcers.  The 
posterior  gastric  wall  is  often  adherent  across  the  lesser  sac  of 
the  peritoneum  to  the  serous  membrane  lying  in  front  of  the 
pancreas,  and  this  fixity  may  be  one  of  the  factors  which  prevent 
the  ulcer  from  healing,  even  as  fixation  to  the  periosteum  over 
the  tibia  delays  healing  in  an  ulcer  of  the  leg. 

In  a  few  cases  adhesions  form  between  the  anterior  wall  of 
the  stomach  and  the  parietal  peritoneum.  Such  give  rise  to  a 
localized  fixed  epigastric  pain,  usually  increased  considerably  by 
distension  of  the  organ.  It  may  be  treated  safely  by  abdominal 
section,  and  division  of  the  adhesion  between  ligatures.  If  left 
alone,  not  only  may  it  cause  inconvenience  by  the  pain  induced, 
but  it  may  also  determine  internal  strangulation  or  obstruction. 

Suppurative  Perigastritis  may  follow  a  small  perforation  with 
limited  leakage,  but  is  more  usually  due  to  an  extension  of  the 
ulcer  and  an  invasion  of  the  perigastric  tissues  by  organisms  which 
escape  from  the  stomach.  The  result  of  this  is  the  formation  of 
what  has  been  already  described  as  a  subphrenic  abscess  (p.  900), 
which  may  or  may  not  contain  gas.  It  may  burst  anteriorly 
through  the  abdominal  wall,  or  may  perforate  the  diaphragm, 
giving  rise  to  a  basal  empyema  ;  and  this  in  turn  may  burst  into 
the  lung  or  through  the  chest  wall,  so  that  fistulae  may  appear  in 


ABDOMINAL  SURGERY  907 

various  places,  through  which  the  contents  of  the  stomach  may 
be  discharged. 

The  abscess  should  be  opened  and  drained  in  the  way  already 
indicated,  but  should  a  fistula  form,  it  is  almost  hopeless  to 
attempt  to  deal  with  it  locally,  so  that  it  would  be  wise  to  perform 
a  gastro-enterostomy. 

4.  Stenosis  is  always  liable  to  occur  after  ulcers  of  the  stomach, 
as  in  other  situations.  If  it  is  located  near  the  pylorus,  that 
orifice  may  become  contracted,  giving  rise  to  special  symptoms, 
and  necessitating  treatment  of  a  particular  character  (p.  911). 
Occasionally,  however,  the  cicatrisation  of  a  horseshoe  ulcer 
leads  to  an  hour-glass  contraction  of  the  body  of  the  viscus,  which 
in  some  cases  is  so  marked  as  almost  to  divide  the  organ  into  two 
halves,  only  a  narrow  neck  persisting  between  the  two.  The 
symptoms  of  such  a  condition  are  almost  identical  with  those  of 
pyloric  stenosis,  and  the  treatment  required  consists  either  in 
excision  of  the  sulcus  and  reunion  of  the  gastric  walls,  or  in 
establishing  an  artificial  opening  between  the  two  segments,  as  by 
a  Murphy  button.  In  still  other  cases  the  contraction  may  be 
situated  near  the  cardiac  orifice,  the  symptoms  then  being 
similar  to  those  of  a  stricture  at  the  lower  end  of  the  oesophagus. 
The  clinical  phenomena  of  an  hour-glass  stomach  vary  with  the 
situation  of  the  contraction,  resembling  sometimes  those  of 
pyloric  stenosis,  at  others  those  of  contraction  at  the  cardiac 
orifice.  The  diagnosis  is  best  made  by  inflating  the  organ  with 
air,  when  its  shape  can  be  easily  detected. 

Treatment  of  stenosis  at  the  cardiac  end  consists  in  gastrostomy. 
An  hour-glass  stomach  may  possibly  be  treated  by  excision  of  the 
stricture,  or  by  its  division  and  suture  by  a  method  similar  to 
that  employed  for  the  pylorus  (see  Pyloroplasty,  p.  916),  or  the 
two  segments  may  be  united  below  the  contraction  by  a  Murphy 
button,  or  a  double  gastro-enterostomy  may  be  performed  to 
connect  each  segment  to  the  jejunum. 

5.  Finally,  cases  are  met  with  in  which  the  symptoms  of  gastric 
ulcer  persist  or  recur  in  spite  of  the  most  careful  dieting  and 
treatment,  and  it  is  now  considered  quite  justifiable  to  submit  such 
cases  to  operation.  Two  lines  of  treatment  are  possible,  (a)  The 
ulcer  may  be  excised,  if  it  be  in  a  convenient  position  for  such  a 
procedure,  and  if  the  infiltration  around  it  be  not  too  extensive. 
(b)  In  other  cases  gastro-enterostomy  (p.  918)  maybe  undertaken 
with  a  view  to  relieve  symptoms  by  enabling  the  viscus  more 
readily  to  empty  itself  after  the  ingestion  of  food.  The  results 
of  this  latter  procedure  have  been  very  satisfactory. 

Cancer  of  the  Stomach.  —  The  stomach  is  more  frequently 
invaded  by  cancer  than  any  other  organ  in  the  body  in  the  male 
sex,  whilst  in  females  it  comes  next  to  the  breast  and  uterus  in 
order  of  frequency.     Any  and  every  part  of  the  viscus  may  be 


9o8 


A   MANUAL  OF  SURGJ-hV 


affected,  but  in  60  per  cent,  of  the  cases  the  tumour  starts  in  or 
about  the  pylorus,  and  is  of  a  scirrhous  nature.  When  the  cardiac 
end  is  attacked,  the  disease  may  spread  from  the  (rsophagus  and 
is  a  squamous  epithelioma,  but  when  the  body  of  the  organ  is 
invaded,  the  condition  is  usually  a  columnar  carcinoma. 

Cancer  occasionally  starts  at  the  site  of  an  old  ulcer,  but 
there  is  generally  no  assignable  cause  for  its  onset,  except  an 
indefinite  history  of  injury.  It  may  occur  as  a  nodular  outgrowth, 
perhaps  covered  with  papillomatous  projections  and  early  under- 
going ulceration  ;  if  it  is  of  a  hard  type,  the  ulcerated  surface  has 
a  characteristic  everted  margin.  Sometimes  the  whole  organ 
becomes  infiltrated  by  a  diffuse  carcinomatous  growth,  con- 
stituting a  firm  mass  incapable  of  dilatation  or  much  contraction, 
which  has  been  aptly  termed  the  'leather-bottle  stomach.'     At 


Fig.  318. — Cancer  of  Pyloric  End  of  Stomach.     (King's  College 

Museum.) 

The  abrupt  limitation  of  the  growth  at  the  commencement  of  the  duodenum  is 

well  seen. 

the  pyloric  end  (Fig.  318)  the  growth  is  always  of  a  hard  nature, 
and  forms  an  annular  constriction,  through  which  it  may  be 
difficult  to  pass  even  a  small  catheter ;  it  is  sharply  limited  on  its 
duodenal  aspect,  but  spreads  into  the  body  of  the  organ,  and 
especially  towards  the  lesser  curvature,  following  the  main  line  of 
the  lymphatic  stream.  The  lymphatic  glands  lying  along  the 
lesser  curvature  are  involved,  usually  extending  as  far  as  the 
point  where  the  coronary  artery  reaches  the  stomach,  whilst  those 
along  the  pyloric  end  of  the  great  curvature  are  implicated  to  a 
less  degree.  Thence  the  affection  spreads  to  the  liver  and  to  the 
coeliac  glands,  and  there  may  compress  the  inferior  vena  cava  and 
thoracic  duct.  Adhesions  form  around  the  growth,  tending  to  fix 
it  to  the  under  surface  of  the  liver,  to  the  head  of  the  pancreas, 
the  colon,  and  even  when  of  large  size  to  the  anterior  abdominal 


ABDOMINAL  SURGERY  909 

wall.  These  adhesions  often  prepare  the  way  for  an  extension  of 
the  disease  to  the  peritoneum,  over  which  disseminated  nodules 
of  cancer  may  be  scattered,  often  giving  rise  to  a  considerable 
effusion  of  serous  fluid.  The  omentum  also  becomes  infiltrated, 
and  colloid  degeneration  is  not  unusual  in  this  region,  the  omentum 
being  converted  into  a  solid  translucent  mass,  looking  sometimes 
like  firm  sago  pudding. 

Speaking  generally,  the  malignancy  of  gastric  carcinoma  is 
decidedly  less  than  that  of  such  organs  as  the  breast  or  uterus,  in 
that  secondary  glandular  affections  are  later  in  developing,  and 
even  when  the  nearest  group  is  involved  it  may  be  some  time 
before  the  affection  spreads  to  distant  parts. 

Clinical  Phenomena. — Gastric  cancer  often  begins  with  certain 
indefinite  symptoms,  the  significance  of  which  is  easily  overlooked 
in  the  early  stages  ;  the  case  is  then  often  allowed  to  run  on 
with  the  idea  that  it  is  merely  one  of  '  dyspepsia,'  '  internal 
influenza  '  or  the  like,  so  that  a  thorough  and  exhaustive  examina- 
tion is  not  made,  and  the  time  for  radical  interference  passes 
without  the  disease  being  recognised.  Pain  is  often  the  first 
symptom,  slight  at  first,  but  gradually  increasing,  and  referred  to 
the  epigastrium  or  back.  Food  may  increase  or  relieve  it,  but  as 
time  progresses  the  pain  comes  on  independently  of  meals.  Acid 
eructations  and  a  sense  of  epigastric  oppression  soon  follow,  and 
these  in  time  give  place  to  actual  attacks  of  vomiting,  the  ejecta 
perhaps  containing  blood,  but  usually  not  till  late  in  the  case. 
Loss  of  appetite  and  steady  wasting  are  also  marked  features  in 
the  early  stages.  The  persistence  of  such  a  group  of  symptoms 
should  always  lead  to  a  complete  investigation  of  the  stomach 
and  its  functions,  (i.)  The  epigastric  region  is  carefully  palpated 
and  the  nature  and  position  of  any  unusual  swelling  noted.  It 
may  be  desirable  to  inflate  the  organ  with  air  or  gas  and  ascertain 
its  exact  size  ;  by  this  means  it  is  sometimes  possible  to  detect  a 
tumour  which  would  otherwise  escape  notice,  (ii.)  The  composi- 
tion of  the  gastric  juice  may  be  investigated  by  the  use  of  a  test 
meal  and  the  stomach  tube.  In  cancer  the  amount  of  HC1  is 
usually  diminished,  whilst  that  of  lactic  acid  is  increased.  The 
latter  is  probably  a  fermentation  product,  (iii.)  The  motor  power 
of  the  viscus  is  very  considerably  lessened,  so  that  the  passage  of 
its  contents  into  the  duodenum  is  delayed ;  this  can  be  demon- 
strated by  the  salol  test,  (iv.)  A  blood  count  in  carcinoma  usually 
reveals  a  well  marked  diminution  in  the  amount  of  haemoglobin, 
sometimes  fewer  red  corpuscles,  and  a  moderate  leucocytosis, 
especially  involving  the  mononuclear  leucocytes,  (v.)  Microscopic 
examination  of  the  vomit  may  also  throw  light  on  the  case. 

To  these  general  signs  certain  special  ones  may  be  added, 
varying  with  the  location  of  the  growth.  1.  If  the  cardiac  end  is 
involved,  a  tumour  can  rarely  be  detected,  the  stomach  being 
small   and  contracted.     The  patient  complains  chiefly  of  pain  on 


9io  A   MANUAL  OF  SURGERY 

swallowing,  and  the  vomiting  occurs  immediately  alter  each  meal. 
The  symptoms  are  practically  those  of  oesophageal  cancer. 

2.  When  the  pylorus  is  affected  a  tumour  can  often  be  felt  a 
little  above  and  to  the  right  of  the  umbilicus,  which  is  at  first 
rounded  and  definitely  limited,  except  on  the  left  side,  where  it 
shelves  off  into  the  stomach  ;  it  is  moveable  in  the  early  stages, 
but  later  on  becomes  fixed  ;  it  is  firm  in  consistence,  and  some- 
what tender  on  manipulation  and  pressure,  and  may  receive 
pulsation  from  the  underlying  aorta.  Owing  to  the  stenosis  of 
the  pylorus,  which  almost  invariably  accompanies  this  condition, 
the  stomach  becomes  dilated,  and  its  great  curvature  displaced 
downwards,  perhaps  almost  into  the  pelvis.  In  this  a  large 
accumulation  of  fluid  takes  place,  which  can  be  heard  splashing 
about  when  the  patient  is  moved  ;  every  two  or  three  days  he 
brings  up  a  large  quantity  of  fluid  and  decomposing  food,  covered 
with  a  yeast-like  scum,  and  containing  sarcinae  in  abundance. 
Haematemesis  is  not  uncommon. 

3.  When  the  body  of  the  organ  is  involved,  a  tumour  may  or 
may  not  be  felt,  according  to  its  situation.  The  '  leather-bottle  ' 
stomach  can  be  sometimes  detected  as  a  solid  mass  projecting 
forwards  from  under  the  left  costal  margin.  The  organ  is  not 
dilated,  and  the  vomiting  has  no  special  characters  ;  haematemesis 
may  or  may  not  be  present. 

In  the  later  stages  pressure  phenomena  manifest  themselves. 
Ascites  may  result  from  compression  of  the  portal  vein  ;  jaundice, 
from  implication  of  the  common  bile  duct ;  oedema  of  the  legs 
and  varix  of  the  superficial  abdominal  veins  may  arise  from  pres- 
sure upon  the  inferior  vena  cava,  whilst  the  peritoneal  cavity  may 
be  distended  with  chyle  owing  to  the  pressure  of  lymphatic  glands 
on  the  receptaculum  chyli  or  thoracic  duct.  All  these  later  signs 
are  indications  that  the  time  has  passed  when  radical  treatment 
is  possible. 

Treatment. — So  many  cases  of  this  affection  reach  the  surgeon 
too  late  that,  at  the  risk  of  wearying  our  readers,  we  would 
reiterate  what  has  been  already  stated.  When  the  symptoms  of 
chronic  gastritis  persist  in  spite  of  careful  dieting  and  treatment, 
and  the  patient  is  losing  flesh,  one  should  always  look  on  the  case 
with  suspicion.  Granted  that  the  examination  of  the  gastric  juice 
reveals  the  characteristic  changes  referred  to  above,  and  still 
more  when  a  blood  count  indicates  leucocytosis  and  a  diminishing 
quantity  of  haemoglobin,  then  an  exploratory  operation  is  quite 
justifiable.  On  the  other  hand,  we  would  give  a  word  of  warning 
against  the  common  practice  of  considering  that  the  mere  presence 
of  a  tumour  in  the  epigastrium  warrants  an  operation.  When  a 
well-marked  tumour  is  present,  the  probability  is  that  the  disease 
has  extended  beyond  the  reach  of  surgery,  and  therefore,  unless 
there  are  distinct  indications  for  palliative  treatment,  e.g.,  the 
signs  of  pyloric  stenosis,  the  patient  is  often  better  left  to  the  care 


ABDOMINAL  SURGERY  911 


of  the  physician.  Of  course,  in  many  cases  an  operation  is  under- 
taken in  the  almost  vain  hope  of  being  able  to  do  something  to 
prevent  the  patient  being  condemned  to  certain  death  ;  but  when 
ascites,  jaundice,  or  definite  evidences  of  dissemination  are  present, 
the  surgeon  should  be  very  chary  of  interfering. 

For  cancer  of  the  cardiac  orifice,  gastrostomy  may  possibly  be 
desirable,  the  artificial  stoma  being  placed  nearer  to  the  pylorus 
than  usual. 

For  cancer  of  the  body  of  the  stomach,  a  partial  or  total 
gastrectomy  may  be  feasible  in  the  absence  of  massive  adhesions  ; 
but  the  conditions  which  permit  of  such  procedures  are  unusual. 
If  the  patient's  nutrition  is  seriously  failing,  and  no  radical 
operation  is  possible,  jejunostomy  (or  the  formation  of  an  artificial 
opening  into  the  jejunum)  may  enable  the  patient  to  be  fed 
without  utilizing  the  stomach. 

For  cancer  of  the  pylorus,  operation  is  more  frequently  possible, 
whilst,  even  if  removal  is  impracticable,  palliative  measures  to 
short-circuit  the  growrth  may  be  desirable.  If  the  mass  is  compara- 
tively moveable,  and  there  are  but  few  adhesions,  pylorectomy  or 
removal  of  the  diseased  portion  of  the  organ  may  be  undertaken, 
and  even  should  secondary  deposits  be  present  in  the  liver,  the 
patient  is  probably  better  off  after  such  a  procedure  than  if  left 
alone.  When  the  growth  has  extended  beyond  the  bowel  to 
adjacent  viscera,  and  extensive  adhesions  are  present,  gastro- 
enterostomy is  alone  practicable,  and  will  do  much  good  by  per- 
mitting of  the  passage  of  food  into  the  bowel  without  passing 
through  the  pylorus.  It  will  also  allow  the  dilated  organ  to  be 
more  completely  emptied,  and  consequently  the  patient  will  not 
be  so  likely  to  absorb  toxic  material. 

Simple  Stenosis  of  the  Pylorus  generally  results  from  the  healing 
of  a  simple  gastric  ulcer  of  the  usual  type,  situated  within  or 
close  to  the  pyloric  orifice  ;  it  is  sometimes  due  to  the  contraction 
of  adhesions  around  an  inflamed  gall-bladder  (cholecystitis),  and  is 
occasionally  caused  by  hypertrophy  of  the  muscular  tissue  of  the 
sphincter.  The  effects  produced  are  hypertrophy  and  dilatation  of 
the  stomach,  which  becomes  enlarged  downwards,  and  forms  a  sac, 
in  which  food  collects  perhaps  for  days,  and  undergoes  fermenta- 
tive changes,  being  finally  ejected  in  large  quantities,  mixed  with 
frothy  mucus  and  a  yeast-like  scum  containing  an  abundance  of 
sarcina;.  The  stomach  may  in  time  almost  reach  the  pelvis,  the 
pylorus  being  dragged  down  with  it.  Succussion  or  splashing 
sounds  are  heard  on  shaking  the  patient's  abdomen. 

The  Treatment  consists  at  first  in  washing  out  the  stomach 
regularly,  but  when  that  fails  to  give  relief  one  of  the  following 
proceedings  may  be  undertaken,  (a)  Loretas  Operation  consists 
in  dilating  the  stenosed  orifice  with  the  finger.  The  viscus  is 
opened  midway  between  the  curvatures  and  about  2  inches  from 


912  A   MANUAL  OF  SURGERY 


the  pylorus,  and  first  one  finger  is  introduced,  slowly  and  care- 
fully, then  two,  and  even  perhaps  three  ;  no  violence  is  admissible, 
or  the  walls  of  the  orifice  may  be  torn  or  ruptured.  The  results 
of  this  procedure  have  been  on  the  whole  encouraging,  but  it  is 
now  being  replaced  by  other  more  certain  and  satisfactory 
methods,  (b)  Excision  of  the  Pylorus  can  be  undertaken  in  suitable 
cases,  and  the  results  have  been  so  much  improved  by  the  use  of 
the  Murphy  button  and  other  similar  contrivances  that  it  need 
not  be  greatly  feared.  Of  course,  when  the  stomach  is  much 
dilated  and  very  atonic,  it  is  possible  that  this  operation  may  not 
succeed  in  improving  the  function  of  the  organ,  (c)  Pyloroplasty 
is  useful  in  cases  where  the  stricture  is  free  from  adhesions,  and 
where  it  is  narrow  and  annular,  but  will  be  useless  in  conditions 
similar  to  those  under  which  pylorectomy  is  contra-indicated. 
(d)  Under  such  circumstances  Gastro-cntevostomy  should  be  under- 
taken, and  may  be  expected  to  give  admirable  results. 

Operations  upon  the  Stomach. 

i.  Washing  oub  the  Stomach  is  needed  in  cases  of  poisoning,  in 
chronic  catarrh,  in  dilatation  of  the  organ,  and  as  a  preliminary  to 
operations  in  which  its  cavity  is  to  be  laid  open.  It  may  be  accom- 
plished by  the  ordinary  stomach-pump,  or  by  the  simpler  method 
of  passing  a  long  tube  of  good-sized  calibre,  to  the  upper  end  of 
which  is  attached  a  funnel.  Fluid  is  introduced  through  the 
funnel,  and  syphoned  out  by  lowering  it  below  the  level  of  the 
stomach.  Before  open  operations,  a  warm  solution  of  boric  acid 
should  be  employed  as  the  agent  for  irrigating  the  viscus. 

2.  Gastrotomy,  or  opening  the  stomach,  is  required  for  the 
removal  of  foreign  bodies  from  it  or  from  the  lower  end  of  the 
oesophagus,  for  exploratory  purposes,  and  as  a  means  of  dilating 
simple  strictures  of  either  the  pyloric  or  cardiac  orifices  (Loreta's 
operation).  It  has  also  been  employed  with  advantage  for  the 
removal  of  masses  of  cancerous  disease  by  curetting. 

Operation. — When  a  foreign  body  can  be  distinctly  felt  within 
the  viscus,  any  incision  that  seems  to  promise  ready  access  may 
be  employed  ;  but  it  is  generally  made  on  the  left  side,  parallel 
to,  and  about  a  finger's  breadth  from,  the  edge  of  the  costal 
cartilages,  and  about  i\  inches  in  length  (Fig.  319,  A).  The 
position  of  the  left  lobe  of  the  liver  must  be  previously  ascertained 
by  percussion,  and  the  centre  of  the  incision  is  best  placed 
about  \  inch  below  it.  The  abdominal  wall  is  completely  divided, 
and  the  peritoneum  opened.  The  fingers  are  then  introduced, 
and  the  stomach  sought  for ;  it  is  recognised  by  its  position  im- 
mediately under  the  liver,  and  by  the  thickness,  pink  colour,  and 
opacity  of  its  wall.  If  the  omentum  or  transverse  colon  presents 
in  the  wound,  it  must  be  pushed  down,  and  the  stomach  looked 
for  above.     The  spot  where  the  stomach  is  to  be  opened  is  now 


ABDOMINAL  SURGERY 


9IJ 


decided  on,  and  two  silkworm  gut  sutures  introduced  through 
the  serous  and  muscular  coats,  so  as  to  enable  the  organ  to  be 
kept  against  the  abdominal  wall,  a  careful  packing  with  a  known 
number  of  sponges  or  gauze  swabs  being  also  interposed  between 
the  viscus  and  the  parietes,  so  as  to  prevent  any  escape  of  fluid 
into  the  general  peritoneal  cavity.  An  incision  is  made  in  the 
long  axis  of  the  stomach,  and  the  finger  inserted.  The  removal 
of  a  foreign  body  must  be  undertaken  with  great  care,  so  as  not 
to  inflict  injury  on  the  organ,  the  wound  being  enlarged,  if 
necessary.  It  is  subsequently  closed  by  the  Lembert  or  prefer- 
ably the  Czerny-Lembert  suture.     The  stomach  is  now  replaced 


Fig.  319. — Incisions  utilized  in  Various  Abdominal  Operations. 

A,  Fenger's  incision  for  exposing  the  stomach  ;  A,,  additional  incision  in 
Frank's  gastrostomy;  B,  incision  for  exposing  gall-bladder;  C,  iliac 
colotomy  ;  D,  incision  for  operations  on  appendix;  E,  median  incision 
for  ovariotomy  or  supra-pubic  cystotomy  ;  F,  for  radical  cure  of  inguinal 
hernia  or  varicocele. 

in  position,  and  all  traces  of  blood,  etc.,  removed,  the  external 
wound  being  closed  in  the  usual  way. 

If  the  surgeon  desires  to  reach  the  cardiac  orifice,  a  somewhat 
larger  opening  in  the  parietes  is  needed,  in  order  to  allow  of 
greater  space  for  the  introduction  of  the  hand  into  the  abdomen, 
since  the  orifice  lies  deeply  just  in  front  of  the  aortic  opening  in 
the  diaphragm.  When  this  is  accomplished,  the  opening  may 
be  dilated  by  the  fingers  or  by  suitable  dilators,  and  a  foreign 
body  can  by  this  means  be  removed  from  the  lower  end  of 
the  oesophagus.  The  utmost  gentleness  must  be  observed  in  this 
proceeding,  as  serious  symptoms  may  be  caused  by  irritation 
and  damage  of  the  pneumogastric  nerves,  the  terminations  of 
which  pass  through  this  opening  in  the  diaphragm. 

58 


9'4 


A    MANUAL  OF  SURGERY 


The  operations  on  the  pyloric  orifice  are  dealt  with  below. 

3.  Gastrostomy  consists  in  the  formation  of  a  permanent  artificial 
opening  into  the  stomach,  through  which  the  patient  can  be  fed. 
It  is  needed  in  cases  of  malignant  disease  or  intractable  stenosis 
of  the  cesophagus,  where  the  patient  is  exposed  to  the  risk  of 
starvation,  owing  to  his  inability  to  take  nourishment. 

Not  many  years  back  the  only  operation  performed  was  one  in 
which  a  direct  opening  was  made  into  the  viscus  without  any 


*N\/j 


J 


V- 


V ,/ 


/'i 


m^i/ 


# 


V*""'      ;//', 
f       / 

yJ 


Figs.  320,  321. — Gastrostomy  (Modified  Frank's  Operation). 

In  Fig.  320  the  base  of  the  cone  is  seen  sutured  to  the  peritoneum  and  sheath 
of  the  rectus;  in  Fig.  321,  the  stomach  has  been  opened,  a  tube  stitched  in, 
and  the  sutures  passed  through  the  rectus  are  in  place. 

attempt  to  form  a  valve,  trusting  to  various  flanged  tubes  or 
umbrella-like  plugs  to  close  the  aperture.  The  results  were  most 
unsatisfactory,  since  even  if  the  patient  survived,  he  usually 
suffered  great  inconvenience  from  the  prolapse  of  the  mucous  mem- 
brane, and  from  irritation  and  ulceration  of  the  surrounding  skin, 
owing  to  escape  of  the  acid  gastric  juice  and  its  digestive  powers. 
During  the  last  few  years  a  number  of  excellent  operations 
have  been  introduced  so  as  to  prevent  these  complications,  most 
of  them  depending  on  the  formation  of  a  muscular  valve  or 
sphincter,  and  there  can  be  no  doubt  that  the  improvements  thus 
effected  have  been  very  great.  Two  chief  methods  have  been 
suggested — viz.,  Witzel's  and  Frank's ;  the  latter  of  these  is,  to 
our  minds,  the  preferable,  and  the  results  gained  thereby  are  so 
satisfactory  as  to  warrant  us  in  describing  it  in  detail. 


ABDOMINAL  SURGERY 


9*5 


Frank's  Operation. — The  usual  oblique  incision  (Fig.  319,  A)  for 
exposure  of  the  stomach  is  first  made,  the  viscus  withdrawn  and 
examined,  and  a  silk  sling  passed  through  the  serous  and  muscular 
coats  at  the  site  selected  for  the  artificial  opening,  so  that  a  cone- 
shaped  portion  of  the  wall  can  be  drawn  up  into  the  wound. 
The  parietal  peritoneum  is  then  sutured  all  round  to  the  base  of 
the  cone,  so  as  to  shut  it  off  from  the  general  serous  cavity.  A 
second  incision  (Aj),  about  1  inch  in  length,  is  now  made  on  the 


*f3& 


Figs.  322,  323. — Gastrostomy  (Frank's  Operation  Modified). 

In  Fig.  322  the  sutures  in  the  rectus  have  been  tied,  and  only  a  small  portion 
of  the  stomach  projects  ;  in  Fig.  323  the  operation  is  completed. 

outer  side  of  the  first  wound,  parallel  to  it,  and  about  1^  inches 
from  it.  The  bridge  of  skin  and  subcutaneous  tissue  between  the 
two  is  separated  from  the  subjacent  structures,  and  the  apex  of 
the  cone  of  gastric  wall  drawn  under  the  bridge  into  the  second 
wound.  A  small  opening  is  then  made  into  the  viscus  through  the 
apex,  in  which  the  silk  sling  is  located,  and  the  mucous  membrane 
stitched  accurately  to  the  skin  in  the  centre  of  the  incision.  The 
remainder  of  this  incision  is  then  closed  in  the  ordinary  way,  as 
also  the  first.  Healing  readily  occurs,  and  thus  a  valvular 
opening  is  established,  which  passes  in  an  angular  fashion  round 
the  margin  of  the  costal  cartilages,  tending  to  prevent  regurgita- 
tion of  the  gastric  contents.  The  patient  may  be  fed  by  the 
artificial  opening  at  once. 

We  have  somewhat  modified  this  operation  of  late,  and  the 
results  have  been    still    better    than   when  we    utilized    Frank's 

58-2 


9,6  A   MANUAL  OF  SURGERY 


original  method.  Instead  of  the  oblique  incision,  a  vertical  one 
(as  suggested  by  Kocher)  is  employed,  extending  for  3  or  4  inches 
downwards  from  the  eighth  costal  cartilage  and  passing  through 
the  substance  of  the  rectus  muscle  (Fig.  320),  which  is  split  by  the 
ringers  or  handle  of  the  knife  into  two  portions.  The  peritoneum  is 
opened,  and  the  stomach  withdrawn  ;  a  cone-shaped  portion  is 
selected,  and  its  base  stitched  to  the  parietal  peritoneum  and  pos- 
terior layer  of  the  sheath  of  the  rectus.  A  small  hole  is  made  in 
the  apex  of  the  cone,  and  through  this  is  passed  a  piece  of  rubber 
drainage-tube,  free  from  lateral  openings,  and  about  the  size  of  a 
No.  10  catheter,  fitting  the  opening  in  the  stomach  exactly  ;  it 
should  project  1 J  inches  inside  the  cavity,  and  about  6  inches  of  it 
should  remain  outside  (Fig.  321).  This  is  stitched  firmly  to  the 
stomach  wall,  and  the  apex  of  the  cone  is  then  drawn  to  the  upper 
angle  of  the  incision.  The  halves  of  the  rectus  muscle  are  freed 
from  the  posterior  layer  of  the  sheath  and  drawn  together  by 
sutures,  so  as  to  cover  in  all  the  exposed  gastric  wall  except  the 
apex  of  the  cone,  which  with  the  tube  forms  a  nipple-like  projection, 
around  which  the  muscle  fits  like  a  sphincter  (Fig.  322).  The  in- 
cision in  the  skin  is  then  closed,  and  finally  the  serous  and  muscular 
coats  of  the  projecting  portion  are  carefully  stitched  to  the  skin. 
The  results  of  this  procedure  have  been  most  satisfactory,  many 
cases  having  run  their  course  without  a  drop  of  gastric  juice  escap- 
ing. The  amount  of  food  at  first  administered  is  small,  and  rectal 
feeding  may  be  required  in  addition  ;  but  it  is  gradually  increased 
until  perhaps  17  oz.  can  be  retained  four  times  a  day.  The  patient 
should  be  kept  in  the  recumbent  posture  for  three  weeks.* 

WitzeVs  Operation. — This  consists  in  making  a  valvular  opening 
into  the  stomach  by  introducing  and  stitching  a  tube  into  it  as  in 
the  last  proceeding,  and  then  burying  the  projecting  portion  as  far 
as  possible  by  suturing  the  serous  and  muscular  coats  together 
over  it.  The  stomach  is  then  fixed  to  the  abdominal  parietes  and 
the  skin  closed.  The  functional  result  of  this  operation  is  very 
good,  but  the  fixation  to  the  abdominal  wall  is  not  so  secure  as  in 
the  former  plans. 

4.  Gastrectomy. — A  good  many  cases  have  now  been  reported 
in  which  a  limited  portion  of  the  gastric  wall  has  been  removed 
successfully,  either  for  simple  or  malignant  ulcers  or  growths. 
Incisions  are  made  so  as  to  include  the  mass,  and  the  wound  is 
subsequently  closed  by  Lembert  or  Czerny-Lembert  sutures. 

Total  excision  of  the  stomach  is  a  proceeding  which  has  only 
recently  been  attempted,  but  several  successful  cases  are  now  on 
record.  It  has  been  undertaken  for  extensive  malignant  disease, 
which,  however,  has  left  enough  of  the  oesophageal  end  free  to 
allow  of  its  apposition  and  fixation  either  to  the  upper  end  of  the 
duodenum,  or,  if  that  cannot  be  brought  across  to  it,  to  a  suitable 

*  For  further  details,  see  Carlcss,  '  On  Gastrostomy,'  King's  College  Hospital 
Reports,  vol.  v.,  1897-1898,  and  in  Edinburgh  Medical  Journal,  July,  1902. 


A  BDOMINA  L  SUliGER  Y 


917 


coil  of  the  jejunum.     The  actual  union  has  been  effected  either  by 
simple  suturing,  or  by  introducing  a  Murphy  button. 

5.  Pyloroplasty  consists  in  exposing  the  pylorus  and  clearing 
it  from  adhesions.  A  longitudinal  incision  is  then  made  through 
the  stricture,  and  by  a  little  careful  manipulation  this  wound  can 
be  opened  out  and  brought  together  in  a  transverse  manner  so  as 


Fig.  324. — Pyloroplasty. 

The  contracted  bowel  is  divided  longitudinally,  and  the  aperture  thus  made 
opened  out,  so  that  it  can  be  brought  together  transversely. 

to  greatly  increase  the  lumen  of  the  orifice  (Fig.  323).  Two  rows 
of  stitches  are  inserted,  one  through  the  mucous  membrane,  and 
the  other  through  the  muscular  and  serous  coats. 

6.  Pylorectomy  is  an  operation  which  has  been  performed  both 
for  simple  and  malignant  stricture  of  the  pylorus,  but  until  quite 
recently  the  mortality  connected    therewith    was  so  great  as  to 


~^^€^.i~^^^^^  Fig.  325B.  —  Method  of   suturing 

Fig.  325A— Malignant   Growth  of  the      Unequal      Wounds      left 

the    Pylorus,    and   Incisions    in  a"er  Removal  of  the  Growth 

Stomach  and  Duodenum  needed  (Iillmanns.) 

for  its  Removal.      (Tillmanns.)       The  upper  end  of  the  gastric  incision 

is  first  closed,  so  as  to  render  the 
openings  in  the  stomach  and  duo- 
denum of  equal  size. 

render  it  almost  a  hopeless  procedure.  Thus,  in  seventy-two 
cases  deal  twith  for  malignant  disease  by  the  old  plan  of  operating, 
fifty-five  died  from  the  immediate  effects,  whilst  in  ten  cases 
of  simple  stricture  only  four  recovered.  The  latest  statistics  of 
operations  in  which  the  Murphy  button  was  employed  are,  how- 
ever, much  more  encouraging.  (a)  In  Billroth' s  operation  the 
abdomen  is  opened  by  an  incision  which  suits  the  exigencies  of 
the  case,  though  perhaps  the  best  to  employ  is  a  median  one  or  an 


9i8 


A   MANUAL  OF  SURGERY 


oblique  one  4  or  5  inches  long,  extending  from  the  median  line 
above  downwards  towards  the  right,  nearly  parallel  to  the  right 
costal  margin  (Fig.  319,  B).  The  diseased  area  is  now  explored, 
and  a  final  decision  made  as  to  the  practicability  or  not  of  reriioving 
it.  If  an  operation  is  determined  on,  the  growth  is  carefully 
isolated  from  surrounding  parts  by  dividing  the  attachments  of 
the  great  and  lesser  omenta,  any  enlarged  glands  being  also 
enucleated.  Clamps  are  then  applied  to  the  stomach  and  duode- 
num, and  the  operation  area  well  packed  round  with  sponges.  The 
mass  is  now  removed  (Fig.  325A),  the  incision  being  so  placed 
as  to  extend  beyond  the  pylorus  about  f  inch  into  the  duodenum 
on  the  one  side,  and  on  the  other  so  as  to  remove  the  greater 
portion  of  the  lesser  curvature,  thereby  including  the  lymphatic 
glands.  The  divided  ends  are  apposed  and  united  (Fig.  32513), 
but  for  exact  details  we  must  refer  to  larger  text-books  of  operative 
surgery.  The  operation  is  prolonged  and  difficult,  and  profound 
shock  is  usually  experienced.  Carefully  regulated  stomach- 
feeding  should  not  be  too  long  delayed  after  the  operation,  the 
best  results  having  occurred  in  those  cases  where  it  was  started 
early,  (b)  When  the  Murphy  button  is  employed,  the  same  steps 
are  followed  until  the  growth  is  isolated,  and  then  the  mass  is 
cut  away  at  once.  The  gastric  wound  is  then  entirely  closed 
by  a  row  of  Czerny-Lembert  sutures.  The  heavier  male  end 
of   a    Murphy  button    is    inserted    into    the  open  mouth  of   the 

duodenum,  and  the  purse- 
string  suture  tied,  as  de- 
tailed below  (p.  936), 
whilst  the  female  half  is 
placed  in  a  new  opening 
made  for  it  in  the  posterior 
wall  of  the  stomach,  as  for 
a  lateral  anastomosis  (p. 
938).  The  two  halves  are 
united,  and  the  operation 
is  then  completed  by  the 
usual  toilette  of  the  peri- 
toneum and  the  closure  of 
the  parietal  incision. 

7.  Gastro  -  enterostomy 
may  be  undertaken  by 
simple  suturing  of  the 
required  viscera  together 
(Worrier's  operation),  or 
by  the  use  of  the  Murphy 
button.  The  portion  of  bowel  which  is  selected  as  the  site  of  the 
artificial  opening  should  be  the  upper  part  of  the  jejunum,  since 
if  the  communication  is  established  too  low,  a  much  greater  ab- 
sorbing surface  is  isolated,  with  the  result  that  even  if  the 
operation  is  successful  the  patient  gradually  emaciates  owing  to 


Fig      326. 


Anterior     Gastro -enteros- 
tomy. 

A,  Transverse  colon  ;  B,  jejunum  dragged 
up  over  the  colon  and  omentum  (pur- 
posely omitted)  to  be  brought  into  apposi- 
tion with  the  stomach 


ABDOMINAL  SURGERY 


919 


lack  of  nutriment ;  and  the  rapidity  of  the  emaciation  will  increase 
as  the  communication  is  placed  further  from  the  duodenum. 

The  incision  employed  is  usually  one  in  the  middle  line  through 
the  linea  alba.  The  stomach  is  readily  found,  and  the  condition 
of  the  growth  examined  so  as  to  determine  whether  or  not  it  is 
removeable.  Formerly  it  was  the  practice  to  unite  the  bowel  to 
the  anterior  wall  of  the  stomach  (Fig.  326),  but  there  are  two 
obvious  objections  to  this  method  :  (a)  The  jejunum  is  drawn  up 
over  the  transverse  colon,  and  is  likely  to  constrict  it  and  lead  to 
obstruction  ;  and  (b)  the  necessary  drag  of  the  gut  is  apt  to  bring 
the  two  ends  parallel  to  each  other,  and  thus  produce  a  spur  or 
kink,  by  means  of  which  the  bile  is  directed  into  the  stomach 
instead  of  into  the  efferent  limb.  Severe  bilious  vomiting  results, 
which  may  prove  fatal. 

Hence  the  majority  of  surgeons  nowadays  follow  with  advantage 
the  plan  recommended  by  Von  Hacker  of  utilizing  the  posterior 
gastric  wall  for  this  purpose.  It  is  accomplished  in  the  following 
manner  :  The  transverse  colon  is  withdrawn  from  the  wound, 
together    with    part    of     the 


omentum.  By  tracing  down 
the  transverse  meso-colon  to 
its  attachment  to  the  pos- 
terior abdominal  parietes,  the 
termination  of  the  duodenum 
is  reached  as  it  crosses  the 
middle  line  along  the  lower 
border  of  the  pancreas,  and 
with  the  superior  mesenteric 
vessels  lying  in  front  of  it  ; 
by  this  means  the  upper 
portion  of  the  jejunum  is 
easily  found,  and  a  suitable 
spot  for  making  the  anasto- 
mosis selected.  A  hole  is 
then  made  through  the  trans- 
verse meso-colon  (Fig.  327), 
so  as  to  open  into  the  lesser 
sac  of  the  peritoneum,  and 
enable  the  posterior  wall  of 
the  stomach  to  be  reached. 
A  clamp  is  placed  on  either 
side  of   the   selected   portion 


Fig.  327. — Posterior  Gastroenteros- 
tomy.    (Von  Hacker's  Operation.) 

A,  Transverse  colon  turned  up  together 
with  the  omentum  (which  is  omitted 
from  the  drawing)  ;  B,  coil  of  small 
intestine,  which  is  brought  into  con- 
tact with  the  posterior  wall  of  the 
stomach  through  C,  a  hole  in  the  trans- 
verse meso-colon,  the  margins  of  which 
are  fixed  down  by  stitches  to  the  back 
of  the  stomach. 


of  bowel,    so   as  to  prevent 

the  escape  of  intestinal  contents  when  the  gut  is  opened ;  but, 
of  course,  it  is  impossible  to  do  the  same  to  the  stomach  ;  the  latter 
viscus  ought,  therefore,  to  be  thoroughly  washed  out  with  some 
dilute  antiseptic,  such  as  boric  acid,  before  the  operation  com- 
mences. Sponges  are  also  packed  around  the  site  of  operation, 
so  as  to  receive  any  fluid  which  may  escape. 


920  A   MANUAL  OF  SURGERY 


If  Wolfler's  plan  of  simply  suturing  is  adopted,  two  incisions 
about  an  inch  long  are  made,  one  in  the  stomach  and  the  other  in 
the  jejunum,  involving  at  first  only  the  serous  and  muscular 
coats.  In  the  stomach  it  is  made  parallel  to  the  great  con- 
vexity, and  about  i^  inches  from  its  lower  edge,  whilst  in  the 
jejunum  the  incision  is  longitudinal,  and  situated  along  the  anti- 
m  jsenteric  border.  Both  of  these  wounds  gape  to  such  an  extent 
as  to  allow  of  the  union  of  the  divided  coats  on  the  lower  side  by 
the  insertion  of  a  row  of  fine  catgut  stitches.  The  mucous  mem- 
branes are  then  incised,  and  a  row  of  catgut  sutures  is  introduced 
to  unite  them  to  the  same  extent,  the  knots  being  located  within 
the  lumen  of  the  bowel.  The  surgeon  then  deals  with  the  remain- 
ing unconnected  lateral  and  upper  segments  of  the  openings, 
taking  up  the  mucous  membranes  and  serous  coats  separately  by 
a  double  row  of  stitches,  the  knots  being  placed  on  the  outer 
aspect  of  the  viscera.  Thus,  the  deeper  parts  of  the  opening  are 
scaled  by  what  is  known  as  Wolfler's  suture  (Fig.  332,  p.  930), 
and  the  upper  and  more  accessible  portions  by  the  Czerny- 
Lembert  stitch  (Fig.  330). 

If  the  Murphy  button  is  employed,  one  of  medium  size  should 
be  selected,  and  it  is  introduced  according  to  the  rules  given 
below  (p.  938)  for  lateral  anastomosis. 

The  operation  is  completed  by  suturing  the  margins  of  the 
opening  in  the  meso-colon  to  the  stomach,  so  as  to  prevent  any 
subsequent  contraction,  by  cleansing  the  peritoneum,  and  closing 
the  parietal  incision  in  the  usual  way. 

The  after-treatment  consists  in  abstaining  from  stomach-feeding 
for  at  least  forty-eight  hours,  if  practicable,  rectal  alimentation 
being  resorted  to  in  the  interval.  Not  unfrequently  there  will  be 
some  regurgitation  of  bile  into  the  stomach,  and  this  may  lead  to 
troublesome  vomiting  for  a  few  days  ;  but  if  the  junction  is  satis- 
factory, it  soon  passes  off,  especially  when  food  is  administered 
by  the  mouth,  as  may  usually  be  undertaken  on  the  third  day.  At 
first  only  fluid  nourishment  should  be  permitted,  but  in  a  week's 
time  soft  solids  may  be  given,  and  gradually  a  more  liberal  diet  is 
ordered.  The  effect  of  the  operation  is  necessarily  only  palliative 
when  cancer  is  present,  but  the  general  condition  often  improves 
considerably  for  a  time,  and  the  final  exitus  lethalis  is  associated 
with  less  suffering. 

In  comparing  Wolfler's  and  Murphy's  methods,  the  great 
advantage  of  the  former  consists  in  its  introducing  no  foreign 
body,  which  may  give  rise  to  trouble  by  slipping  back  into  the 
stomach  or  by  impaction  lower  down  the  gut ;  hence  it  should 
always  be  used  in  non-malignant  cases.  The  proceeding  is, 
however,  much  more  tedious,  and  the  shock  caused  by  the 
prolonged  operation  is  often  sufficient  in  itself  to  turn  the  balance 
against  a  patient  whose  powers  have  been  considerably  dimin- 
ished  by  a  malignant    growth   associated    with    semi-starvation. 


ABDOMINAL  SURGERY  921 


Murphy's  operation,  though  placing  a  solid  body  of  some  size 
within  the  intestinal  canal,  has  the  great  advantage  of  rapidity, 
and,  on  the  whole,  we  are  inclined  to  recommend  this  proceed- 
ing as  the  better  in  malignant  disease.  The  results  hitherto 
obtained  have  been  most  encouraging,  Murphy  being  able  to 
report  twenty-nine  cases,  with  only  eight  deaths,  and  we  our- 
selves have  had  several  successful  cases.  The  button,  if  all 
goes  well,  should  appear  in  the  motions  about  a  fortnight  after 
the  operation. 

Ulcer  of  the  Duodenum  is  occasionally  met  with  after  burns,  as 
already  described  at  p.  87.  It  may  also  occur  in  the  same  way 
as  a  gastric  ulcer — i.e.,  more  or  less  spontaneously,  and  without 
any  apparent  cause.  The  symptoms  to  which  it  gives  rise  are 
deep  pain  in  the  right  hypochondrium,  worse  after  food,  together 
with  vomiting.  Haemorrhage  may  be  caused  by  the  ulcer  laying 
open  some  branch  of  one  of  the  pancreatico-duodenal  vessels, 
and  this  may  prove  fatal.  Perforation  is  sometimes  induced, 
and,  according  to  its  situation  and  size,  it  gives  rise  to  acute  or 
chronic  suppurative  peritonitis,  or,  if  it  opens  posteriorly,  to  a 
subphrenic  abscess,  which  tends,  however,  to  come  to  the  surface 
to  the  right  of  the  suspensory  ligament  of  the  liver  ;  in  fact,  the 
symptoms  and  results  are  very  similar  to  those  of  perforating 
gastric  ulcer  (q.v.).  Stenosis  of  the  duodenum  may  follow  this 
lesion. 

Affections  of  the  Intestine. 

Congenital  Conditions  are  occasionally  met  with  affecting  the 
intestines,  and  perhaps  giving  rise  to  serious  complications. 
(a)  The  most  common  of  these  consists  in  what  is  known  as 
Meckel's  diverticulum.  It  occurs  as  an  outgrowth  from  the  lower 
end  of  the  ileum,  which  may  be  patent  for  1  or  2  inches,  terminat- 
ing possibly  in  a  fibrous  cord,  which  floats  free  amongst  the  intes- 
tines, or  may  contract  adhesions,  and  thus  determine  an  internal 
strangulation  ;  sometimes  it  persists  as  an  open  tube  as  far  as  the 
umbilicus,  giving  rise  to  a  congenital  faecal  fistula.  It  is  due  to  non- 
obliteration  of  the  omphalo-mesenteric  duct,  (b)  Congenital  stenosis 
of  the  duodenum  also  occurs  opposite  the  entrance  to  the  common 
bile-duct,  and  a  similar  condition  may  arise  in  the  lower  part  of  the 
ileum  at  a  spot  corresponding  to  the  site  of  Meckel's  diverticulum. 

Injuries  of  the  Intestine. 

Contusion  of  the  Intestine  may  result  from  any  serious  blow  on 
the  abdomen,  and  necessarily  varies  in  its  effects  with  the  nature 
and  force  of  the  injury,  the  amount  of  distension  of  the  gut,  and 
the  strength  and  power  of  resistance  of  the  parietes.  In  its 
simplest  form,  it  merely  produces  a  little  bruising  of  the  intestinal 


922  A   MANUAL  OF  SURGERY 


wall,  followed  by  a  subacute  or  chronic  enteritis,  from  which  with 
care  the  patient  quickly  recovers.  In  the  more  severe  cases,  an 
acute  enteritis  ensues,  due  to  bacillary  invasion,  which  may  even 
run  on  to  ulceration  or  sloughing  of  the  coats  of  the  bowel. 
The  latter  result  is  more  likely  to  follow  if  the  mesentery  has 
also  been  involved  in  the  injury  so  as  to  produce  thrombosis  of 
the  mesenteric  vessels.  Under  these  circumstances,  the  final 
issue  depends  largely  upon  the  rapidity  of  the  inflammatory  pro- 
cess. If  adhesions  have  had  time  to  form  between  the  parietes 
and  the  injured  gut,  the  mischief  is  limited,  and  the  patient  may 
recover  with  an  artificial  anus  or  faecal  fistula,  the  formation  of 
which  has  been  preceded  by  a  localized  intraperitoneal  abscess, 
containing  extremely  offensive  pus,  owing  to  the  presence  of  the 
Bac.  coli,  which  has  migrated  through  the  intestinal  wall.  If, 
however,  the  inflammatory  affection  is  rapid  in  its  onset,  and 
adhesions  have  not  had  time  to  develop,  acute  diffuse  peritonitis 
is  almost  certain  to  follow.  When  the  injured  portion  of  the  bowel 
is  retroperitoneal,  as  in  the  duodenum  or  colon,  a  retroperitoneal 
abscess  may  form. 

The  Symptoms  of  intestinal  contusion  consist  primarily  of  shock 
and  pain.  The  amount  of  shock  varies  necessarily  with  the 
severity  of  the  injury  and  the  nervous  susceptibility  of  the  patient. 
The  pain  may  not  be  severe  during  the  period  of  shock,  but  is 
always  very  marked  subsequently,  and  increased  by  examina- 
tion, movement,  or  during  violent  respiratory  efforts.  To  limit 
such  movement,  the  abdominal  parietes  are  maintained  in  a 
state  of  firm  contraction,  and  can  be  felt  hard  and  resistant. 
Vomiting  may  be  present,  but  is  not  a  marked  feature.  The  later 
symptoms  necessarily  vary  with  the  course  taken  by  the  case,  and 
need  not  be  described  in  further  detail. 

Treatment  is  conducted  along  the  same  lines  as  that  of  contu- 
sions of  the  abdominal  wall  (p.  892),  viz.,  where  there  is  no 
absolute  evidence  of  rupture,  an  expectant  attitude  must  be 
adopted.  If,  however,  at  the  end  of  twenty-four  or  forty-eight 
hours  signs  of  acute  peritonitis  manifest  themselves,  an  exploratory 
laparotomy  is  justifiable.  Acute  enteritis  induces  diarrhoea  and 
the  passage  of  blood-stained  mucus,  and  such  symptoms  will 
indicate  the  use  of  bismuth,  and  perhaps  a  little  morphia,  whilst 
a  fluid  diet  is  alone  permissible. 

Rupture  of  the  Intestine  follows  abdominal  injuries  of  a  more 
severe  character  than  those  causing  contusion,  such  as  when  a 
cart  or  cab  has  traversed  the  abdomen,  or  when  the  patient  has 
been  tightly  squeezed.  The  amount  of  distension  of  the  gut  is  a 
most  important  factor  in  the  aetiology,  since  it  is  obvious  that  a 
distended  coil  is  much  more  likely  to  give  way  than  one  that 
is  empty  ;  in  the  latter  case  it  is  quite  possible  for  a  small 
wound  to  occur,  through  which  the  intestinal  contents  are  unable 


ABDOMINAL  SURGERY  923 

to  escape.  The  bowel  does  not  always  give  way  at  the  point  of 
impact,  but  occasionally  at  a  distance  from  it ;  under  these  cir- 
cumstances the  tear  is  more  likely  to  be  ragged  and  irregular, 
whilst  if  it  yields  at  the  point  struck,  the  gut  may  be  cleanly  torn 
across.  The  parts  most  frequently  affected  by  this  form  of  injury 
are  the  junction  of  the  moveable  jejunum  with  the  fixed  duodenum, 
and  the  lower  3  feet  of  the  ileum.  The  effect  of  the  accident  on 
the  mesentery  is  also  of  importance,  since  in  the  first  place  it  may 
give  rise  to  considerable  intraperitoneal  haemorrhage,  and  later  on 
may  cause  sloughing  of  the  gut  as  a  result  of  thrombosis. 

The  Effects  of  rupture  of  the  intestine  are  always  extremely 
serious,  if  extravasation  of  the  contents  follows,  since  acute  diffuse 
peritonitis  is  almost  certain  to  be  lighted  up ;  in  a  few  cases  a 
localized  intraperitoneal  abscess  has  been  known  to  result,  but 
such  is  by  no  means  common. 

The  early  Symptoms  consist  of  severe  and  usually  lasting  shock, 
accompanied  by  intense  abdominal  pain.  Owing  to  escape  of  the 
intestinal  contents,  a  virulent  form  of  acute  peritonitis  follows 
immediately,  from  which  the  patient  rapidly  succumbs.  Free 
gas  is  sometimes,  but  not  frequently,  met  with  in  the  peritoneal 
cavity,  as  in  rupture  of  the  stomach,  and  may  be  recognised  by 
the  existence  of  a  resonant  note  on  percussion  in  front  of  the  liver. 
In  a  few  cases  emphysema  of  the  abdominal  walls  has  been  caused, 
and  in  the  absence  of  thoracic  injuries  or  of  diffuse  cellulitis  is  an 
absolutely  certain  sign  of  rupture  of  the  intestinal  tube.  Vomiting 
occurs,  but  not  to  an  excessive  degree ;  if  blood  is  found  in  the 
vomit,  it  suggests  that  either  the  stomach  or  upper  part  of  the 
intestinal  canal  has  been  injured.  Occasionally  a  blood-stained 
motion  is  passed,  but  only  late  in  the  case. 

The  Diagnosis  of  a  ruptured  intestine  is  always  a  matter  of 
uncertainty  in  the  absence  of  such  symptoms  as  resonance  in 
front  of  the  liver  or  emphysema  of  the  abdominal  walls,  which  are 
very  uncommon.  The  amount  of  shock  is  an  uncertain  guide, 
although,  if  prolonged  and  severe,  it  is  suggestive  ;  whilst  the 
presence  of  an  area  of  deep  fixed  tenderness  and  pain  with,  perhaps, 
a  rigid  abdominal  wall  over  it,  and  the  incidence  of  early  acute 
peritonitis  are  probably  the  only  signs  that  we  can  depend  upon 
with  any  certainty.  The  history  and  nature  of  the  accident  are 
important,  and  should  be  carefully  investigated. 

In  the  non-existence  of  any  distinct  signs  of  rupture,  Treatment 
in  the  early  stages  can  only  be  expectant,  and  directed  towards 
combating  the  shock  and  relieving  the  pain.  A  small  dose  of 
opium  should  be  administered  with  this  object,  and  also  to  check 
peristalsis,  and  hinder  further  extravasation  of  the  intestinal  con- 
tents ;  but  as  little  as  possible  should  be  given,  since  it  tends  to 
mask  symptoms.  If  the  surgeon  has  good  grounds  for  suspect- 
ing that  the  intestine  is  torn,  he  ought  at  once  to  undertake  an 
exploratory  laparotomy,  which  in  careful  hands  will  do  less  harm 


924  A   MANUAL  OF  SURGERY 

to  the  patient  than  waiting  for  the  onset  of  acute  peritonitis  to 
make  the  diagnosis  certain.  If  severe  shock  is  present,  an  injec- 
tion of  hot  saline  solution  into  a  vein  will  sufficiently  restore  the 
patient  in  the  majority  of  cases  to  warrant  such  a  procedure. 
When  a  rupture  is  found,  the  same  rules  of  treatment  should  be 
followed  as  those  which  have  been  enunciated  for  a  ruptured 
stomach. 

In  Punctures  or  Stabs  involving  the  intestine,  the  results  differ 
considerably  according  to  the  amount  of  distension  of  the  bowel,  as 
also  with  the  fluidity  of  the  faeces  and  the  direction  of  the  incision. 
Thus,  a  longitudinal  cut  (running  parallel  to  the  axis  of  the  bowel) 
is  more  likely  to  gape  than  a  transverse  one,  owing  to  the  greater 
power  of  the  circular  muscle  fibres ;  a  small  puncture  may  be 
almost  closed  by  a  protrusion  of  mucous  membrane.  Wounds  of 
the  small  intestine  are  more  likely  to  be  accompanied  by  extrava- 
sation than  when  the  colon  is  involved,  owing  to  the  contents  of 
the  former  being  in  a  much  more  liquid  state. 

The  Symptoms  are  very  similar  to  those  already  detailed  as 
characteristic  of  rupture  of  the  intestine.  As  far  as  regards  the 
immediate  phenomena,  there  is  nothing  absolutely  typical  unless 
gas  or  faecal  material  is  escaping  either  from  the  abdominal  wound 
or  from  a  prolapsed  portion  of  bowel.  Shock  is  not  necessarily 
so  severe  as  when  the  intestine  is  ruptured  by  violence  without 
penetration  ;  abdominal  pain  is  always  present,  and  the  pheno- 
mena of  acute  peritonitis  quickly  follow. 

Treatment. — Every  case  of  suspected  penetration  should  be 
carefully  and  thoroughly  explored  ;  a  probe  is  first  passed,  and 
then  the  abdominal  parietes  divided  on  either  side  of  the  probe, 
so  as  to  enable  the  extent  of  the  mischief  to  be  ascertained.  If 
the  peritoneum  is  not  opened,  no  harm  has  been  done,  since  after 
purification  the  different  layers  of  the  wall  are  sutured  together. 
If  the  peritoneum  has  been  involved,  the  opening  in  it  should 
be  enlarged,  so  as  to  explore  the  viscera  and  determine  with 
certainty  whether  or  not  the  gut  has  been  wounded.  If  a  small 
punctured  or  incised  wound  of  the  intestine  is  present,  it  is  closed 
by  a  purse-string  stitch  or  by  a  row  of  Lembert  or  Czerny- 
Lembert  sutures.  If  a  more  extensive  lesion  exists,  excision  of 
the  damaged  portion  may  be  necessary  ;  but  if  the  patient  is  deeply 
collapsed  from  the  supervention  of  peritonitis,  it  may  be  wiser  to 
bring  the  divided  ends  to  the  abdominal  wall,  and  form  a  tem- 
porary artificial  anus,  which  is  subsequently  dealt  with  when  the 
patient's  general  condition  has  improved.  As  to  the  treatment  of 
the  resulting  peritonitis,  we  must  refer  to  what  has  been  written 
concerning  rupture  of  the  stomach  (p.  902). 

For  Gunshot  Wounds  and  their  treatment,  see  pp.  203  and  205. 


ABDOMINAL  SURGERY  925 

Perforation  of  the  Intestine  arises  from  many  different  causes, 
such  as  the  impaction  of  a  foreign  body,  or  the  yielding  of  an 
intestinal  ulcer,  as  occurs  in  tuberculous  disease  or  typhoid  fever, 
or  from  that  form  of  enteritis  which  follows  strangulated  hernia. 
We  have  already  discussed  the  phenomena  resulting  from  the 
perforation  of  an  ulcer  of  the  stomach  or  duodenum  (pp.  905  and 
921),  and  another  variety  caused  by  perforation  of  the  appendix 
will  be  alluded  to  subsequently  (p.  947). 

When  the  jejunum  or  upper  portion  of  the  ileum  is  involved, 
perforation  is  usually  due  to  the  impaction  of  a  foreign  body, 
such  as  a  fish-bone,  or  to  yielding  of  a  tuberculous  ulcer.  In  acute 
cases,  general  peritonitis  is  almost  certain  to  follow,  and  what  we 
have  written  as  to  the  results  and  treatment  of  such  a  lesion  in 
the  stomach  applies  here  with  equal  force.  Occasionally  the 
lesion  is  of  a  more  chronic  type,  especially  when  due  to  tubercle, 
and  then  adhesions  may  form,  allowing  an  intraperitoneal  abscess 
to  develop,  and  should  it  open  externally,  a  faecal  fistula  follows. 
In  not  a  few  cases  the  process  of  cicatrization  may  lead  to  a  spon- 
taneous closure  of  the  fistula,  and  no  operation  should  be  under- 
taken until  sufficient  time  has  elapsed  to  determine  whether  or 
not  this  will  occur.  A  similar  condition  sometimes  results  from 
tuberculous  peritonitis,  the  umbilicus  being  a  common  site  for 
such  a  fistula  to  develop.  In  other  cases  several  coils  of  intes- 
tine may  be  matted  together  by  adhesions,  amongst  which  an 
abscess  forms,  and  this  by  opening  into  the  bowel  in  two  or  more 
places  gives  rise  to  a  fistulous  communication,  known  as  a  fistula 
bimucosa. 

In  the  lower  portion  of  the  ileum,  typhoid  fever  is  the  most  usual 
cause  of  perforation.  It  generally  occurs  about  the  end  of  the 
second  or  in  the  third  week  of  the  disease,  and  rarely  more  than 
one  perforation  is  present.  It  is  most  commonly  seen  in  bad 
cases  associated  with  meteorism  and  haemorrhage,  but  is  not 
limited  to  such.  The  symptoms  are  usually  those  of  sudden 
collapse,  as  indicated  by  a  falling  temperature  and  a  quick  and 
feeble  pulse,  whilst  severe  and  persistent  abdominal  pain  followed 
by  distension  indicates  the  development  of  general  peritonitis. 
Even  when  the  patient  is  already  collapsed  by  the  disease,  some 
slight  fall  of  temperature  with  acceleration  of  the  pulse  may  occur, 
followed  by  abdominal  pain  and  meteorism.  Early  rigidity  of  the 
belly  wrall  is  an  important  diagnostic  sign,  whilst  there  may  be 
some  irritability  of  the  bladder.  The  only  treatment  which  holds 
out  any  prospect  of  saving  the  patient  is  operation,  but  owing  to 
his  depressed  condition  the  outlook  is  not  particularly  bright. 
Obviously,  when  he  is  moribund,  it  is  useless  to  interfere  ;  but  the 
fact  that  at  least  seven  cases  of  recovery  have  been  reported,  out 
of  rather  more  than  forty  that  have  been  subjected  to  operation, 
shows  that  in  suitable  circumstances  a  certain  percentage  of 
success  may  be  anticipated.     The  abdomen  should  be  opened  in 


926  A   MANUAL  OF  SURGERY 


the  middle  line  below  the  umbilicus,  and  if  the  lesion  is  not  at 
once  obvious,  the  ileum  is  sought  for  at  its  junction  with  the 
caecum,  and  the  bowel  brought  up  and  carefully  examined  inch  by 
inch  till  the  perforation  is  found  ;  it  may  then  either  be  closed  by 
sutures,  or  stitched  to  the  margins  of  the  wound  so  as  to  create 
a  temporary  artificial  anus.  The  peritoneum  is  cleansed  and 
drained  in  the  usual  way. 

In  the  large  intestine  the  most  common  cause  of  perforation  is 
ulceration  due  to  chronic  obstruction.  Masses  of  faeces  accumu- 
late within  the  bowel,  and  by  their  pressure  give  rise  to  inflam- 
mation of  the  walls,  which  runs  on  either  to  ulceration  or  to 
actual  necrosis.  Most  usually  the  peritoneum  is  by  this  means 
laid  open,  and  acute  perforative  peritonitis  follows.  In  malignant 
disease  of  the  colon,  perforation  also  occurs  in  some  instances, 
giving  rise  to  a  localized  abscess,  and  subsequently  to  a  faecal 
fistula. 

Stenosis  of  the  Intestine. 

This  arises  from  two  main  causes,  viz.,  the  contraction  of 
cicatrices,  and  the  development  of  malignant  growths. 

Cicatricial  Stricture  usually  results  from  the  healing  of  ulcers 
which  have  extended  more  or  less  circularly  around  the  bowel. 
After  typhoid  fever  they  are  therefore  rare,  since  the  ulcers  are 
rather  longitudinal  than  transverse,  and,  indeed,  there  is  only  one 
certain  case  of  stricture  arising  from  this  source  on  record.  In 
the  small  intestine  tuberculous  ulceration  is  one  of  the  commonest 
causes,  since  it  always  tends  to  travel  round  the  gut  along  the 
line  of  the  vessels ;  it  is  usually  found  in  the  neighbourhood  of 
the  ileum,  and  may  involve  an  extensive  portion  of  the  bowel,  or 
be  multiple.  It  also  arises  from  syphilitic  disease,  or  as  a  sequela 
of  strangulated  hernia,  injury,  or  the  separation  of  an  intussus- 
ception. In  the  large  intestine  dysentery  is  perhaps  the  most 
important  cause  of  stricture,  whilst  syphilis  or  pelvic  cellulitis 
may  determine  its  occurrence  in  or  near  the  rectum. 

Owing  to  the  contents  of  the  small  intestine  being  of  a  some- 
what liquid  nature,  a  stricture  in  this  situation  often  exists  for 
some  time  before  symptoms  of  any  urgency  arise.  The  patient 
may  complain  of  a  certain  amount  of  indigestion  and  discomfort, 
but  sooner  or  later  the  narrowed  aperture  of  the  gut  becomes 
blocked  either  by  a  fold  of  mucous  membrane  or  by  a  portion  of 
undigested  food,  and  thus  an  attack  of  obstruction  is  induced. 
In  the  early  stages  of  the  disease  this  can  be  overcome  and 
remedied  by  purgatives,  but  each  recurrence  is  likely  to  increase 
in  severity,  until  finally  an  acute  attack  supervenes,  which  kills 
the  patient,  unless  relieved  by  prompt  surgical  interference. 

In  the  large  intestine  very  similar  phenomena  appear,  but  the 
attacks  of  obstruction  are  of  a  somewhat  different  character,  since 
there  is  less  pain  and  vomiting  ;  and    aperients,  instead  of  re- 


ABDOMINAL  SURGERY  927 

lieving  the  patient,  as  they  often  do  in  the  earlier  attacks  in  the 
small  gut,  always  aggravate  the  symptoms ;  there  is  also  much 
greater  distension  of  the  abdomen.  The  diagnosis  of  stricture, 
though  strongly  suggested  by  the  symptoms,  can  only  be  abso- 
lutely confirmed  by  an  exploratory  operation,  except  when  the 
lower  part  of  the  rectum  is  involved. 

The  Treatment  in  the  earlier  stages  consists  of  suitable  dieting, 
and  the  administration  of  purgatives,  or  of  large  enemata,  and 
for  a  time  such  will  be  successful.  Sooner  or  later,  however,  a 
more  than  usually  serious  attack  of  obstruction  will  call  for 
something  more  radical,  and  we  must  refer  readers  to  the  chapter 
on  obstruction  for  details  of  the  treatment  to  be  adopted.  If  on 
operating  the  stricture  is  found  and  recognised,  enteroplasty  or 
enterectomy  should  be  undertaken,  if  the  small  gut  is  involved. 
For  stricture  of  the  caecum  or  ascending  colon,  some  short- 
circuiting  method,  whereby  the  ileum  is  implanted  into  the  colon 
below  the  stricture  (ileo-colostomy),  is  perhaps  the  best  plan  to 
adopt ;  in  the  transverse  colon  excision  is  possible,  as  also  in  the 
sigmoid  flexure,  whilst  in  the  descending  colon  enteroplasty  may 
be  undertaken.  Failing  any  of  these  radical  measures,  the 
establishment  of  an  artificial  anus  in  the  bowel  above  the  stenosis 
suffices  to  give  relief.  It  must  be  remembered,  however,  that  no 
permanent  opening  can  be  made  more  than  a  foot  above  the  ileo- 
cecal valve,  since  the  absorption  of  nutrition  is  thereby  so  inter- 
fered with  that  death  from  asthenia  is  certain  to  follow  in  a  very 
short  time.  The  intestinal  contents,  too,  are  fluid  and  very  acid 
at  this  level,  and  give  rise  to  much  irritation  of  the  skin. 

Cancer  of  the  Bowel  is  almost  always  primary  in  nature,  and 
is  then  usually  a  columnar  carcinoma,  to  which  colloid  degenera- 
tion is  sometimes  added.  Secondary  growths  are  occasionally 
met  with,  and  are  necessarily  of  the  same  nature  as  the  original 
tumour.  The  disease  may  occur  as  a  localized  plaque  imbedded 
in  the  mucous  membrane,  and  undergoing  the  usual  ulcerative 
changes ;  but  more  frequently  it  appears  as  a  circular  infiltration 
of  the  bowel.  Secondary  deposits  arise  after  a  time  in  the  mesen- 
teric glands,  the  liver,  or  even  in  distant  parts  ;  the  general  history 
of  these  growths  suggests,  however,  that  they  are  not  so  malignant 
in  type  as  cancer  elsewhere.  At  first  they  merely  give  rise  to 
dyspeptic  Symptoms  of  varying  character,  according  to  the  size 
and  situation  of  the  mass,  and  then  to  these  may  be  superadded 
intermittent  attacks  of  chronic  or  subacute  obstruction,  which 
originally  come  under  the  care  of  the  physician,  but  at  length  the 
surgeon's  assistance  is  needed  to  relieve  or  deal  with  an  acute 
attack.  Two  other  manifestations  of  the  disease  may  determine 
surgical  action,  viz.  :  (1)  The  existence  of  a  tumour,  which, 
though  at  first  readily  moveable,  soon  becomes  fixed  owing  to 
the  formation  of  adhesions  to  surrounding  tissues ;  and  (2)  the 
development  of  an  abscess  due  to  an  invasion  of  the  growth  by 


928  A   MANUAL  OF  SURGERY 

the  Bac.  coli,  which  finds  its  way  through  the  ulcerated  surface  of 
the  tumour.  This  complication  is  most  likely  to  occur  when  the 
colon  is  affected,  and  all  the  manifestations  of  an  acute  or  sub- 
acute intraperitoneal  abscess  supervene.  In  favourable  cases  it 
bursts  externally,  or  is  opened,  giving  exit  to  exceedingly  offensive 
pus,  and  for  a  while  the  patient's  symptoms  are  relieved ;  a  fiscal 
fistula  follows,  and  the  disease  runs  a  rapid  course  to  its  inevitably 
fatal  issue. 

Treatment. — Whenever  a  diagnosis  of  malignant  disease  of  the 
bowel  has  been  made  or  is  suspected,  an  exploratory  laparotomy 
is  justifiable  in  order  to  confirm  or  disprove  the  fact.  Unfor- 
tunately, physicians  are  only  too  liable  to  leave  the  case  until 
the  progress  of  the  disease  has  settled  the  question,  and  then 
palliative  treatment  may  alone  be  possible.  If  found  early 
enough,  the  growth,  together  with  a  good  margin  of  healthy  tissue 
on  either  side,  should  be  removed,  and  the  intestinal  canal  re- 
stored by  enterorrhaphy.  A  V-shaped  portion  of  the  mesentery 
is  included  in  the  part  excised,  so  as  to  remove  if  possible  any 
affected  lymphatic  glands.  Should  this  be  impracticable  owing  to 
the  extent  or  fixity  of  the  growth,  the  following  plans  of  treatment 
may  be  considered,  and  that  which  best  suits  the  requirements  of 
the  particular  case  undertaken  : 

i.  The  growth  may  be  short-circuited  by  uniting  portions  of  gut 
above  and  below  it.  This  is  usually  accomplished  by  one  of  the 
forms  of  lateral  anastomosis  described  hereafter ;  thus,  the  caecum 
may  be  attached  to  the  sigmoid  flexure  in  a  case  of  cancer  of  the 
transverse  colon. 

2.  The  bowel  may  be  entirely  divided  above  the  tumour,  and 
the  upper  end  implanted  into  the  gut  below  it,  the  lower  end  of 
the  divided  bowel  being  sutured.  This  lateral  implantation  is  the 
best  plan  of  treatment  to  employ  for  cancer  of  the  caecum  which 
cannot  be  extirpated ;  the  ileum  is  divided  above  the  valve,  and 
its  open  end  implanted  into  the  ascending  colon  well  above  the 
growth  (ileo-colostomy),  whilst  the  lower  end  is  totally  closed. 

3.  The  affected  coil  of  gut  has  been  excluded  from  the  intes- 
tinal tube  by  dividing  the  bowel  above  and  below,  and  uniting 
the  divided  ends,  whilst  the  open  ends  of  the  diseased  coil  are 
either  entirely  closed  by  sutures,  or  one  end  is  closed  and  the 
other  is  brought  to  the  surface,  and  fixed  there  so  as  to  establish 
a  fistulous  track.  The  latter  practice  is  probably  the  safer  to 
adopt,  since  there  is  always  a  certain  amount  of  discharge  from 
the  cancerous  growth,  and,  at  any  rate,  in  the  small  intestine  the 
mucous  membrane  itself  secretes,  so  that  total  closure  would  be 
accompanied  by  danger. 

4.  Finally,  if  none  of  these  measures  are  applicable,  or  if  the 
patient's  condition  is  such  as  to  make  it  unwise  to  attempt  them, 
and  if  the  growth  is  situated  in  the  colon,  an  artificial  anus  may 
be  established. 


ABDOMINAL  SURGERY 


929 


Operations  on  the  Intestines. 

Before  describing  in  detail  the  actual  operations  which  are 
undertaken  upon  the  small  or  large  intestine,  it  is  essential  that 
the  various  Sutures  employed  in  such  work  should  be  discussed. 
The  interior  of  the  bowel  is  occupied  by  material  which,  as  long 
as  it  remains  in  its  proper  place,  is  innocuous  enough  ;  but  let 
it  once  find  its  way  into  the  peritoneal  cavity,  an  acute  and 
often  fatal  peritonitis  is  almost  certain  to  follow.  Hence, 
every  union  made  by  the  surgeon  must  be  air-  and  water-tight, 
and  capable  of  accommodating  itself  to  varying  degrees  of  intra- 
intestinal  pressure.  For  this  reason  a  continuous  stitch  must 
never  be  employed  except  in  the  long  axis  of  the  bowel,  or 
unless  there  is  some  button  or  bobbin  within  it.  Again,  it  is 
essential  that  on  its  peritoneal  aspect  the  line  of  union  should 
present  nothing  but  serous  membrane,  as  otherwise  adhesions  are 
certain  to  form,  and  the  comfortable  action  of  the  bowel  will  be 


Fig.  328. — Lembert's  Suture  as  applied  for 
a  Longitudinal  Wound  of  the  Bowel. 

The  stitches  are  carried  well  beyond  the  ex- 
tremities of  the  incision,  so  as  to  obliterate 
the  groove  always  caused  by  this  method  of 
suturing. 


Fig.  329. — L  emberi's 
Suture  seen  in  Section, 
to  show  Character  of 
Approximation. 

I.,  Suture ;  a,  serosa ;  b, 
muscularis  ;  c ,  mucosa. 


subsequently  impaired.     Hence,  special  forms  of  stitches  have  to 
be  adopted,  the  more  important  of  which  are  described  below. 

Laiiberfs  Suture,  originally  proposed  at  the  end  of  last  cen- 
tury, has  for  its  object  the  bringing  of  surfaces  of  peritoneum 
together  without  encroaching  on  the  mucous  membrane ;  any 
stitch  which  involves  the  whole  thickness  of  the  wall  is  liable  to 
be  followed  by  leakage  of  the  intestinal  contents,  and  possibly 
peritonitis.  The  needle  is  passed  at  right  angles  to  the  axis  of 
the  wound  through  a  small  fold  of  the  serous  and  muscular  coats, 
going  down  to  the  submucosa  ;  each  fold  is  placed  about  one- 
twelfth  of  an  inch  from  the  margins  of  the  incision  (Fig.  328). 
On  drawing  up  and  tightening  the  stitch,  the  margins  of  the  wound 
are  tucked  in  (Fig.  329),  and  only  the  serous  coats  brought  into 
apposition.  A  series  of  similar  stitches  are  inserted  along  the 
whole  extent  of  the  wound,  numbering  about  ten  or  twelve  to 
the  inch.  In  closing  a  longitudinal  incision  in  this  way,  a  groove 
will  be  formed  at  either  end  which  must  be  obliterated  by  two  or 

59 


93° 


A  MANUAL  OF  SURGERY 


three  extra  sutures.  For  a  small  puncture  the  same  type  of  stitch 
is  utilized,  but  it  may  be  introduced  circularly  around  the  opening 
like  a  purse-string,  and  by  tightening  it  the  margins  of  the 
aperture  are  turned  in  and  buried. 

The  Czerny-Lembert  Suture  is  very  similar  in  its  nature,  but 
consists  of  two  rows :  the  first  has  for  its  object  the  closure  of 
the  wound  in  the  mucous  membrane  (Fig.  330,    I.),  and  in  a 

h       c 


Fig.  330. — Czerny-Lembert  Suture. 

I.,  Stitch  securing  divided  mucous 
membrane;  II.,  ordinary  Lembert 
suture,  for  the  serous  coats ;  a,  serosa; 
b,  muscularis  ;  c,  mucosa. 


Fig.  331. — Halsted's  Mattress 
Suture. 


longitudinal  wound  this  may  be  of  the  continuous  type ;  the 
second  row  consists  of  the  ordinary  Lembert  stitches,  con- 
tinued or  interrupted  according  to  the  requirements  of  the  case 
(Fig.  330,  II.).  By  this  means  the  knots  of  the  first  series  of 
sutures  are  covered  over  and  buried  by  the  second  row. 

Halsted's   Mattress    Suture    (Fig.  331)    is    a   very  valuable  one, 


Fig.  332. — Wolfler's  Suture. 

,  Stitch  through  serous  and  muscular  coats 
applied  and  tied  from  within  ;  II.,  stitch 
uniting  divided  mucous  membrane  over 
the  former,  so  as  to  cover  it  in  ;  a,  serosa  ; 
b,  muscularis  ;  c ,  mucosa. 


Fig.  333. — Paul's  Tubes 
(Glass),  Large  and  Small 
Sizes. 


and  constantly  utilized.  It  consists  practically  of  a  double 
Lembert,  a  loop  being  thus  formed  at  one  end,  whilst  the  knot 
is  tied  at  the  other.  It  is  introduced  with  exactly  the  same  pre- 
cautions as  the  original  Lembert. 

Occasionally  it  happens  that  two  segments  of  bowel  have  to  be 
stitched  together,  although  the  surgeon  cannot  reach  the  outer 
coats  owing  to  this  portion  being  fixed.  Thus,  in  dealing  with 
the  posterior  segments  of  the  walls  of  the  bowel,  either  in 
pylorectomy  or  gastroenterostomy,  it  is  found  that  one  can  only 
work  from  the  front,  and  the  stitches  must  then  be  inserted  by 


ABDOMINAL  SURGERY  931 

what  is  known  as  Wolfiey's  Method  (Fig.  332).  The  sutures  are 
first  passed  through  the  serous  and  muscular  coats  on  either 
side  (I.),  the  knots  being  tied  on  the  inner  aspect — i.e.,  towards 
the  lumen  of  the  open  gut.  The  mucous  membrane  is  then 
secured  by  a  second  row  of  stitches  (II.),  so  as  to  cover  over  the 
first  series  of  knots.  Of  course,  only  a  portion  of  the  circum- 
ference of  the  bowel  has  to  be  dealt  with  in  this  way ;  as  soon  as 
possible,  one  changes  to  the  Czerny-Lembert  method. 

Passing  on  now  to  the  actual  operations,  the  following  have  to 
be  described  : 

1.  Enterotomy  is  a  term  which  is  only  correctly  applied  to  an 
incision  made  into  the  intestine  either  for  the  removal  of  a  foreign 
body  or  for  the  examination  of  its  interior.  The  wound  should 
always  be  placed  in  the  longitudinal  axis  of  the  gut,  and  along  its 
anti-mesenteric  border ;  it  is  closed  by  a  row  of  Lembert,  Czerny- 
Lembert,  or  Halsted  stitches. 

2.  Enterostomy,  or  the  formation  of  an  artificial  opening  into 
the  bowel,  is  an  operation  sometimes  undertaken  for  the  relief  of 
intestinal  obstruction  when  the  patient  is  almost  moribund,  and 
one  is  unable  to  make  an  exact  diagnosis  of  the  cause.  It  is 
especially  useful  when  the  obstruction  is  probably  due  to  some 
lesion  located  in  the  caecum  or  ascending  colon.  An  incision 
is  made,  either  in  the  middle  line  or  in  the  iliac  region  on  the 
right  side,  somewhat  similar  to  that  employed  for  removal  of 
the  appendix  ;  the  first  distended  coil  which  presents  is  drawn 
well  out,  and  opened  after  carefully  protecting  the  peritoneal 
cavity  from  faecal  infection.  A  large  trocar  and  cannula  are  first 
introduced,  so  as  to  allow  the  flatus  and  fluid  contents  of  the  gut 
to  escape ;  the  opening  is  then  enlarged  and  a  Paul's  (glass)  tube 
tied  in  (Fig.  333),  so  as  to  carry  away  the  intestinal  contents  clear 
from  the  wound,  to  the  margins  of  which  the  bowel  is  fixed.  This 
proceeding  is  sometimes  known  as  Nelaton's  operation,  and  is  at 
the  best  merely  a  temporary  expedient. 

3.  Enteroplasty  is  a  plan  of  treatment  which  has  been  devised 
for  dealing  with  cicatricial  strictures  of  the  intestine,  and  is  based 
on  the  same  idea  as  the  operation  of  pyloroplasty  for  fibrous 
stenosis  of  the  pylorus  (p.  917).  A  longitudinal  incision  is  made 
through  the  stenosed  gut  along  the  anti-mesenteric  border  ;  this 
is  opened  out,  and  converted  into  a  transverse  cleft,  which  is  care- 
fully sutured,  the  lumen  of  the  bowel  being  thereby  considerably 
increased. 

4.  Enterectomy,  or  excision  of  a  portion  of  the  bowel,  is  required 
in  the  following  conditions  :  (a)  For  the  removal  of  gangrenous 
gut  after  strangulation,  whether  internal  or  external ;  {b)  in  the 
treatment  of  multiple  penetrating  wounds,  as  after  a  stab  or  gun- 
shot injury;  (c)  in  dealing  with  an  artificial  anus  or  faecal  fistula; 
(d)  for  the  removal  of  simple  or  malignant  strictures  ;  and  (e)  in 
some  cases  of  intussusception.     Not  long  ago  the  operation  was 

59—2 


932  A  MANUAL  OF  SURGERY 

but  rarely  undertaken,  and  the  results  were  most  unsatisfactory; 
but  at  the  present  time  a  very  considerable  degree  of  success  may 
be  expected,  and  enterectomy  is  frequently  practised.  Naturally, 
the  results  vary  largely  with  the  condition  for  which  it  is  per- 
formed, and  with  the  experience  and  skill  of  the  operator  ;  a 
much  higher  rate  of  mortality  follows  when  the  excision  is  done 
for  malignant  disease,  for  gangrene  following  strangulation,  or  for 
intussusception,  than  when  performed  for  other  causes. 

Whenever  practicable,  the  bowel  should  be  thoroughly  emptied 
prior  to  operation,  and  rendered  as  sterile  as  possible  by  the  use 
of  such  drugs  as  calomel  (gr.  i.  daily),  salol,  /i-naphthol,  naphtha- 
lene, bismuth  subnitrate,  etc.,  for  a  few  days  previously.  The 
abdomen  is  opened  by  any  suitable  incision,  and  the  portion  to  be 
removed  clearly  defined,  the  general  peritoneal  cavity  being  pro- 
tected by  a  careful  packing  with  sponges  or  gauze. 

The  bowel  must  then  be  clamped  on  either  side  of  the  seat  of 
operation,  so  as  to  prevent  the  escape  of  intestinal  secretions  or 
faeces.  Any  of  the  forms  of  clamps  figured  in  surgical  instrument 
catalogues  will  effect  this  purpose,  and  amongst  the  best  are 
Makins'  or  Lane's ;  but  perhaps  it  is  wiser  to  do  without  them, 
the  same  result  being  obtained  by  passing  a  piece  of  drainage- 
tube  through  the  mesenteric  attachment,  and  tying  or  clamping 
it  around  the  gut. 

The  affected  portion  is  now  removed  by  scissors,  cutting  through 
the  bowel  and  taking  away  a  V-shaped  portion  of  the  mesentery, 
after  securing  as  far  back  as  possible  the  main  nutrient  vessels  to 
the  diseased  area,  according  to  Murphy's  recommendation.  It 
must  be  remembered  that  the  terminal  vessels  run  circularly  round 
the  gut,  and  have  but  little  lateral  anastomosis,  and  therefore  it  is 
desirable  that  the  incisions  should  slightly  diverge  from  the  mesen- 
teric attachment,  otherwise  the  projecting  edge  of  the  anti-mesen- 
teric  border  is  certain  to  slough,  and  septic  peritonitis  will  result. 
Some  operators  recommend  that  the  mesentery  should  not  be  cut 
into,  but  that  the  gut  should  be  detached  from  the  mesenteric 
junction  ;  such  practice  will  suffice  when  merely  a  small  segment 
of  bowel  is  to  be  removed  ;  but  if  a  large  portion  needs  resection, 
it  would  take  a  much  longer  time  to  secure  all  the  bleeding  spots. 
The  wound  in  the  mesentery  is  subsequently  secured  by  sutures, 
and  the  divided  ends  of  the  bowel  united  by  one  of  the  many  forms 
of  enterorrhaphy  described  below. 

5.  Enterorrhaphy  is  required  for  any  condition  in  which  there  is 
a  solution  of  continuity  of  the  canal,  and  necessarily  the  methods 
employed  must  vary  according  to  the  character  and  situation  of 
the  lesion.  We  have  already  alluded  to  the  plans  that  are 
utilized  in  dealing  with  longitudinal  wounds  of  the  gut.  The 
two  chief  methods  that  remain  to  be  discussed  are  the  end-to-end 
union  of  a  totally  divided  segment  of  the  bowel,  and  the  means 
whereby  lateral  approximation  or  union  is  secured. 


A BDOMINA L  SURGERY 


933 


For  end-to-end  union  the  following  are  the  chief  plans  that 
have  been  adopted  : 

A.  Enterorrhaphy  by  simple  suturing.  In  this  the  surgeon 
utilizes  no  special  apparatus,  but  trusts  to  the  deftness  of  his 
fingers  and  the  accuracy  of  his  stitches.  The  gut  is  united  by 
a  series  of  interrupted  Lembert  or  Czerny-Lembert  sutures,  in- 
serted around  the  circumference  at  distances  of  about  one-twelfth 
of  an  inch.  The  greatest  care  must  be  employed  in  dealing  with 
the  mesenteric  attachment,  where  the  peritoneal  layers  separate 
in  order  to  enclose  the  bowel,  and  where  there  is  a  consider- 
able likelihood  of  the  muscular  coat  being  missed  ;  if  this  happens, 
leakage  is  almost  certain  to  ensue.  This  method  in  skilled  hands 
is  very  satisfactory  in  its  results,  but  there  is  one  great  objection 
to  it,  viz.,  the  time  taken  in  its  performance. 


Fig      334. —  Maunsell's    Operation       I 
for    uniting     divided    segments 
of  Gut  Fig.  335- — Maunsell's  Operation. 

The    mesenteric    and    anti-mesenteric      Taction  stitches  carried  through  the 
traction    stitches    have    been    intro-  ?u°e.  and  out  of  the  lateral  0Pen" 

duced,  and  A  shows  the  situation  of  inS- 

the  lateral  incision,  and  its  forma- 
tion by  transfixion. 

B.  Maunsell's  opevation,  in  which  a  temporary  invagination 
enables  the  coats  of  the  gut  to  be  accurately  sutured  together,  is 
a  most  valuable  proceeding.  It  may  be  described  in  stages  as 
follows :  (a)  Two  long  horsehair  sutures  are  passed  through  the 
whole  thickness  of  the  mesenteric  and  anti-mesenteric  borders  of 
each  end  of  the  divided  intestine,  and  tied  together  with  the  knots 
on  the  inner  aspect  of  the  bowel  (Fig.  334).  (b)  A  longitudinal 
incision  about  three-quarters  of  an  inch  in  length  (Fig.  334,  A)  is 
then  made  through  the  anti-mesenteric  border  of  the  bowel,  about 
an  inch  from  the  end  of  the  upper  or  lower  segment,  according  to 
convenience,  (c)  The  horsehair  sutures  (Fig.  335,  D)  are  now 
passed  within  the  intestine,  and  drawn  out  of  the  lateral  opening. 
Traction  upon  these,  assisted  by  a  little  careful  manipulation, 
enables  the  surgeon  to  produce  an  artificial  intussusception 
(Fig.  336).  Difficulty  may  be  experienced  in  this  if  the  lateral 
opening  has  been  placed  too  far  from  the  section,  or  if  the 
mesentery  is   loaded  with  fat  or  very  oedematous.     The  divided 


A  MANUAL  OF  SURGERY 


934 

ends  of  the  bowel  now  present  through  the  lateral  aperture  as 
two  tubes  one  within  the  other  (Fig.  337),  their  serous  coats 
being  in  contact,  and  the  mucous  coats  lining  both  the  inner 
and  outer  aspects  of  the  protrusion.  (d)  A  sharp  straight 
needle  (Fig.  337,  A)  carrying  after  it  a  thread  of  fine  silk  or  cat- 
gut, is  passed  through  one  of  the  diameters  of  the  protrusion, 
transfixing  the  serous,  muscular,  and  mucous  coats.  The 
central  portion  of  the  suture,  as  it  passes  across  the  inner  tube, 
is  drawn  out  and  divided,  and  the  two  halves  are  tied  on 
either  side.  Similar  sutures  are  passed  in  other  diameters,  until 
some  sixteen  or  more  are  present.  By  this  means  the  two  tubes 
are  securely  united  together,  (e)  All  the  sutures  are  cut  short, 
and    the   intussusception    reduced.      The   bowel    will    be    found 


Fig.  336.  —  Maunsell's  Operation, 
showing  Position  of  Intestine  after 
Invagination  has  been  accom- 
plished. 

The  dotted  lines  indicate  the  mucous 
membrane  ;  the  continuous  lines,  the 
serous. 


Fig.  337. — Method  of  insert- 
ing Stitches  in  Intestine  in 
Maunsell's  Operation. 

A  shows  the  needle  passed  through 
both  sides  of  the  bowel,  and 
through  all  the  intestinal  coats, 
so  that  one  passage  of  the 
needle  places  two  sutures. 


accurately  sutured  (Fig.  338,  A),  the  knots  of  all  the  stitches  being 
placed  within  the  lumen  of  the  gut.  (/)  The  lateral  opening  in  the 
bowel  (Fig.  338,  B)  is  closed  by  a  continuous  row  of  Lembert's 
sutures,  and  if  need  be  a  row  of  the  same  is  inserted  around  the 
circular  junction,  as  an  additional  safeguard  in  order  to  bury  the 
penetrating  stitches,  and  so  prevent  leakage.  The  operation  can 
be  rapidly  performed,  and  gives  excellent  results. 

Should  it  be  necessary  to  unite  unequal  portions  of  intestine,  the 
larger  segment  is  first  reduced  in  size  by  the  insertion  of  a  row  of 
Lembert's  or  Czerny-Lembert's  sutures,  so  as  to  make  the  opening 
correspond  in  size  to  that  of  the  smaller  ;  invagination  may  then 
be  accomplished  through  a  lateral  opening  in  the  larger  portion, 
and  the  operation  completed  as  before. 

A  modification  of  this  method  has  been  recently  suggested  and 
practised  with  success  by  Ullman.  After  the  invagination  through 
the  lateral  incision  has  been  accomplished,  a  hollow  bobbin  made 
of  decalcified  bone  or  carrot,  and  with  a  circular  groove  around  its 


ABDOMINAL  SURGERY 


935 


middle,  is  inserted  into  the  inner  canal,  lined  by  mucous  mem- 
brane (Fig.  339).  Around  this  the  two  tubes  of  gut  are  firmly  tied 
by  a  single  silk  thread.  The  intussusception  is  now  reduced,  the 
bobbin  being  drawn  into  the  bowel,  and  the  operation  is  completed 
by  closing  the  lateral  opening.     The  bobbin  retains  its  shape  and 


Fig.  338. — Maunsell's  Opera- 
tion COMPLETED  AFTER  THE  IN- 
VAGINATION  HAS   BEEN    REDUCED. 

A  shows  line  of  union  with  serous 
coats  turned  well  in,  so  that  none 
of  the  sutures  appear  outside ; 
B,  longitudinal  incision  stitched 
up. 


Fig.    339. — Ullman's    Modification 
of  Maunsell's  Operation. 

A  bobbin  is  seen  in  place  in  the  centre 
of  theinvaginated  canal,  and  a  single 
suture,  S,  secures  it  in  position. 


texture  sufficiently  long  to  enable  the  segments  of  the  intestine  to 
become  firmly  united  by  plastic  lymph.  If  further  use  confirms 
Ullman's  experiences,  we  shall  have  in  this  method  a  most 
valuable  addition  to  our  means  of  obtaining  rapid  and  secure 
end-to-end  union. 


Full  Scze 


A,  Male  half;  B 
by  c,   spring 


A        P"  B 

Fig.  340. — Murphy's  Button. 

female  half  ;   P,  inner  cup  or  flange  of  male  half,  governed 
;  S,  spring  catches  working  along  a  screw  thread  on  the 


inner  aspect  of  the  central  stem  of  the  female  half. 


C.  Enterorrhaphy  by  the  use  of  special  apparatus.  Under  this 
heading  various  bobbins  and  Murphy's  button  must  be  included. 

Murphy  s  Button  is  represented  in  Fig.  340.  It  consists  of  two 
portions,  a  male  and  a  female,  which  can  be  easily  insinuated  one 
into  the  other  and  closed,  but  which  can  only  be  separated  by  un- 
twisting, the  spring  catches  (S)  seen  in  the  side  of  the  stem  of  the 


936 


A  MANUAL  OF  SURGERY 


male  working  along  a  screw  thread  in  the  interior  of  the  female. 

Each  half  consists  of  a  central  stem,  which  is  hollow  for  the  passage 
of  faeces,  to  the  outer  end  of  which  is  attached 
a  cup-shaped  expansion.  In  the  male  half 
there  is  an  additional  inner  cup  or  flange  (P), 
separated  from  the  former  by  a  spring  (c),  so 
that  when  the  two  halves  are  approximated, 
the  inner  cup  is  kept  constantly  pressed 
against  the  female  half,  and  thus  pressure- 
atrophy  of  the  tissues  grasped  between  the 
two  segments  results,  ultimately  setting  the 
button  free.  In  the  meantime,  however,  a 
sufficient  formation  of  lymph  will  have  oc- 
curred along  the  line  of  junction  of  the  two 
to  prevent  extravasation  and  to  secure  union. 
In  performing  end-to-end  anastomosis,  a 
running  thread  is  inserted  through  each  end 
of  the  divided  intestine  in  the  manner  shown 
in  Fig.  341.  It  commences  at  the  anti- 
mesenteric  border  (b),  and  traverses  the 
whole  thickness  of  the  gut  two  or  three  times 
until  it  reaches  the  mesentery  (a),  when  a 
return  overstitch  is  introduced  so  as  to  gather 
without  fail  the  two  layers  of  the  mesentery 
into  the  grasp  of  the  button.  The  same 
stitch  is  continued  along  the  opposite  side  of 
the  tube,  and  brought  out  again  at  the  anti- 
mesenteric  border.  A  half-button  is  now 
and  two  ends  of  introduced  into  each  end  of  the  divided  gut, 
suture;  c,  mesenteric  and  preferably  the  heavier  male  end  into 
attachment.  ftie  lower  segment ;  the  stitch  is  then  drawn 

tight    and    tied,    so    as    to    gather    up    the 

gut  wall  round  the  central  stem  of  the  button    (Fig.  342).     The 

two  halves  are  now  pressed  together  (Fig.  344),  sufficient  force 


Fig.  341. — Method  of 
inserting  Suture 
for  End-to-End 
Anastomosis  with 
Murphy's  Button. 


a,  Overstitch 

mesenteric 


b,  anti- 
border 


DOWN         BROS      LONDON 


Fig.  342. 


-Appearance  of  Intestinal  Segments  with  Murphy's 
Button  Tied  in.     (Down  Brothers.) 


being  employed  to  bring  the  walls  of  the  gut  into  accurate  apposi- 
tion, but  without  exercising  injurious  pressure. 

The  button  is  generally  set  free  about  the  seventh   day,  and 


ABDOMINAL  SURGERY 


937 


should  pass  downwards,  and  be  expelled  with  the  faeces  any  time 
from  the  fourteenth  to  the  twenty-first  day.  Occasionally  there 
are  difficulties  in  the  onward  passage  of  the  button,  which  may 
either  be  retained  entirely,  or  may  become  impacted  ;  under  these 
circumstances  it  has  been  known  to  ulcerate  through  the  walls  of 
the  gut,  and  cause  fatal  peritonitis.  The  results  of  the  operations 
undertaken  by  means  of  the  button  are  very  satisfactory,  as  com- 
pared with  ancient  statistics  ;  but  it  is  doubtful  whether  they  are 
any  better  than  those  obtained  by  many  of  the  methods  intro- 
duced more  recently.  The  one  great  advantage  of  this  appliance 
is  the  rapidity  with  which  the  anastomosis  is  completed.  There 
are,  however,  several  very  grave  objections  to  its  employment  as 
a  routine  measure  ;  the  fact  of  its  being  made 
of  metal  is  of  itself  a  drawback,  and  fatal 
issues  have  certainly  occurred  from  slough- 
ing, from  want  of  union  due  to  the  use  of  too 
large  a  button,  or  of  one  badly  constructed, 
and  even  from  subsequent  obstruction  and 
perforation  when  it  has  passed  lower  down. 
On  the  whole,  one  would  be  inclined  to  use 
it  when  time  is  of  value,  and  the  patient's 
general  condition  such  as  necessitates  the 
utmost  speed  in  operating ;  under  other 
circumstances  one  would  prefer  some  other 
method. 

Many  other  useful  contrivances,  such  as 
Mayo  Robson's  bobbin  (Fig.  343),  Allingham's 

bobbin,  Chaput's  button,  etc.,  have  been  introduced  of  late,  and 
with  most  of  them  good  results  can  be  obtained.  The  majority 
consist  of  a  hollow  tube  of  decalcified  bone  made  of  different  sizes 
to  fit  the  varying  lumen  of  the  gut.  The  object  is  not  so  much 
to  bring  about  apposition  of  the  divided  ends  of  the  bowel  as  to 
act  as  an  internal  splint,  steadying  the  part  during  and  after  the 
operation,  facilitating  thereby  the  introduction  of  the  stitches,  and 
shielding  the  line  of  union  from  the  irritation  of  faeces  for  some 
days.  Mr.  Robson  recommends  that  two  continuous  sutures 
should  be  employed,  one  to  unite  the  divided  ends  of  the  mucous 
membrane,  and  the  other  to  approximate  the  serous  and  muscular 
coats.  It  will  be  found  advantageous  to  have  a  curved  needle  at 
each  end  of  these.  The  sero-serous  suture  is  first  introduced  for 
the  posterior  half  of  the  incision,  each  stitch  taking  a  firm  grip  of 
the  sero-muscular  coats  up  to  about  a  centimetre  from  the  margin. 
The  muco-mucous  suture  is  then  put  in  for  the  same  extent.  The 
bobbin  is  now  placed  in  position  ;  the  muco-mucous  suture  is  first 
finished  and  tied,  and  finally  the  anterior  half  of  the  sero-serous 
suture  is  similarly  completed.  Each  of  these  sutures  must  be 
firmly  tied  around  the  bobbin,  so  that  no  slipping  is  possible.  The 
material  of  which  it  is  composed  (decalcified  bone)  is  such  as  to 


Fi  g.  343.  —  Mayo 
Robson's  Bobbin. 
(Down  Brothers.) 


938  A   MANUAL  OF  SURGERY 

do  no  subsequent  harm  to  the  mucous  membrane,  since  it  becomes 
soft  and  pulpy  in  the  course  of  a  few  days. 

6.  Lateral  Anastomosis  of  the  intestine  is  usually  undertaken  in 
order  to  effect  the  short-circuiting  of  some  malignant  growth,  or 
of  a  stricture  which  cannot  otherwise  be  dealt  with.  It  is  some- 
times employed  instead  of  end-to-end  anastomosis  to  unite  divided 
segments  of  intestine.  The  open  ends  are  first  entirely  closed  by 
Lembert  or  Czerny-Lembert  stitches,  and  the  portions  of  bowel 
made  to  overlap.  Corresponding  lateral  incisions  are  then  made 
into  each. 

The  anastomosis  may  be  effected  in  the  following  ways  : 

(a)  By  Simple  Suturing,  or,  as  it  is  sometimes  called,  by  Wolfler's 
operation.  This  has  been  already  described  under  gastroenteros- 
tomy at  p.  920.  The  longitudinal  openings  in  the  two  portions 
of  bowel  lying  exactly  opposite  each  other  are  secured  by  sutures, 
inserted  in  the  posterior  half  of  Wolfler's  plan,  and  in  the  rest  of 
the  opening  by  the  Czerny-Lembert  method.  In  order  to  prevent 
subsequent  contraction,  it  is  absolutely  essential  that  the  mucous 
membrane  be  continuous  all  round  the  aperture. 

(b)  Murphy's  Button  is  probably  the  quickest,  and  certainly  the 
most  satisfactory,  of  all  the  plans  that  have  yet  been  suggested. 
The  details  of  its  insertion  differ  slightly  from  those  employed  in 
effecting  an  end-to-end  anastomosis.  Incisions  are  made  in  the 
two  sections  of  bowel  to  be  united,  each  incision  being  two-thirds 
of  the  diameter  of  the  button  to  be  used.  The  wounds  at  first 
only  involve  the  serous  and  muscular  coats.  A  purse-string 
suture  is  inserted  round  the  incision,  traversing  the  whole  thick- 
ness of  the  intestinal  walls ;  the  mucosa  is  then  incised,  and  the 
half-button  introduced.  By  drawing  the  stitch  tight  and  tying  it 
around  the  stem  of  the  button,  the  wall  of  the  gut  is  gathered 
into  the  hollow  of  the  cup.  This  is  accomplished  on  each  side, 
and  then  the  halves  of  the  button  are  pressed  together  in  the  way 
shown  in  Fig.  344.  Murphy  recommends  that  after  the  operation 
the  bowels  should  not  be  confined,  but  should  be  kept  loose,  so  as 
to  prevent  any  solid  mass  of  faeces  blocking  the  channel  through 
the  button. 

(c)  A  Robson's  Bobbin  may  be  employed,  the  sutures  being 
applied  in  exactly  the  same  way  as  for  end-to-end  anastomosis. 

7.  The  establishment  of  an  Artificial  Anus  has  frequently  to  be 
undertaken  in  cases  of  intestinal  obstruction,  where  the  onward 
passage  of  faeces  is  prevented  by  some  irremoveable  barrier. 
It  is  sometimes  required  in  the  treatment  of  intussusception, 
and  for  rupture  or  penetrating  wounds  of  the  gut.  When  the 
small  intestine  is  involved,  enterostomy  may  be  undertaken 
as  described  above  (p.  931);  but  it  must  be  noted  that  life 
is  impossible  for  any  length  of  time  with  an  artificial  anus 
situated  more  than  a  foot  above  the  ileo-caecal  valve,  on  account 
of  the  interference  with  nutrition  owing  to  cutting  off  such  a  large 


ABDOMINAL  SURGERY 


939 


extent  of  absorbent  mucous  membrane.  Some  form  of  short- 
circuiting  operation,  or  some  means  whereby  the  continuity  of 
the  bowel  is  restored,  must  therefore  be  subsequently  undertaken. 
Things  are,  however,  different  in  the  large  intestine  ;  colotomy  is 
frequently  employed  in  dealing  with  diseases  of  the  lower  bowel, 
and  is  an  extremely  successful  proceeding. 

The  character  of  the  artificial  anus  varies  considerably  accord- 
ing to  whether  or  not  it  is  intended  to  be  a  permanent  condition. 
If  merely  a  temporary  opening  is  required,  the  smaller  the  portion 
of  bowel  secured  to  the  parietes  the  better,  since  the  subsequent 
operation  for  its  closure  is  so    much   simpler   (Fig.  345).     But 


Fig    3^ . — Method   of   closing   Murphy's   Button   in  Lateral  Anasto 

MOSIS    BETWEEN    GaLL-BlADDER    AND    DUODENUM         (DOWN    BROTHERS.) 

where  a  permanent  aperture  has  to  be  established,  the  surgeon's 
aim  should  be  to  totally  deflect  the  course  of  the  faeces  ;  and 
hence  it  is  desirable  to  entirely  withdraw  a  portion  of  the  gut 
from  the  abdominal  cavity,  and  to  cut  away  a  complete  segment, 
including  also,  if  possible,  a  portion  of  the  mesentery.  By  this 
means  the  upper  and  lower  openings  are  brought  to  the  surface  of 
the  skin,  and  separated  from  one  another  by  an  area  of  cicatricial 
tissue  representing  the  section  of  the  mesentery  (Fig.  346). 

Colotomy,  or,  as  it  should  be  correctly  termed,  '  colostomy,'  is 
an  operation  for  the  establishment  of  an  artificial  anus  in  some 
portion  of  the  large  intestine.  Any  part  of  the  colon  may  be  thus 
dealt  with  through  a  median  laparotomy  ;  but  one  usually  prefers 


940  A  MANUAL  OF  SURGERY 

to  open  the  termination  of  the  descending  colon  through  the  peri- 
toneum in  the  left  iliac  region.  Formerly  the  favourite  method 
was  to  open  the  descending  colon  in  the  left  loin  behind  the  peri- 
toneum (left  lumbar  colotomy  or  Amussat's  operation).  Callisen's 
name  has  also  been  associated  with  this  proceeding,  but  he  merely 
proposed  to  do  it  through  a  vertical  incision  ;  Amussat  was  the 
first  to  perform  the  operation,  utilising  a  transverse  incision,  and 
extending  its  applicability  to  both  sides  of  the  body. 

Uses  of  Colotomy. — The  operation  is  required  under  the  following 
conditions:  (i)  For  congenital  absence  of  the  rectum,  when  a 
perineal  incision  has  failed  to  discover  it  ;  (2)  for  chronic  obstruc- 
tion of  the  large  intestine,  which  cannot  be  relieved  by  enemata 


'"'-'-'  :-.   "\ 

:■'"'    ({  X"' 

>  )■   I 

•  «ESfju  .. 

'\«W      \ 

,&: 

\ 

*A^ 

Fig.  345. — Diagram  of  Temporary  Fig.  346. — Diagram  of  Temporary 

Colotomy,  showing  the  Single  Colotomy,     showing     the     Two 

Opening   on   a   level  with   the  Openings    separated    one    from 

Skin,  the  passage  to  the  Lower  the  other  by  a  section   of  the 

Bowel  being  merely  blocked  by  Mesentery. 

A    SPUR    OF    MUCOUS    MEMBRANE.  ^      ^^       ^^      indicates      the 

amount  of  Bowel  cut  away  ;  but,  of 
course,  such  an  extensive  resection 
is  only  practicable  when  there  is  a 
very  long  mesentery,  which  is  un- 
usual . 

or  medical  means,  such  as  that  arising  from  simple  or  malignant 
stricture,  or  from  the  pressure  of  pelvic  tumours  ;  (3)  for  carcinoma 
of  the  rectum  or  sigmoid  flexure,  whether  obstruction  is  present 
or  not,  if  a  radical  operation  is  impracticable,  or  as  a  preliminary 
to  excision  ;  (4)  for  some  cases  of  syphilitic  and  other  forms  of 
ulceration  of  the  large  bowel,  which  cannot  heal  as  long  as  they 
are  irritated  by  the  passage  of  faeces  ;  (5)  for  irremediable  cases 
of  recto-vesical  and  recto-vaginal  fistula,  whatever  their  origin  ; 
(6)  for  volvulus  of  the  sigmoid  flexure,  the  inguinal  operation 
being  needed,  not  only  to  relieve  the  obstruction,  but  also  to 
prevent  recurrence. 


ABDOMINAL  SURGERY  941 

The  ascending  colon  is  occasionally  opened  in  cases  of  mem- 
branous or  ulcerative  colitis  in  order  to  prevent  the  irritation 
caused  by  the  passage  of  faeces  over  the  inflamed  tissues.  The 
result,  however,  is  somewhat  unpleasant,  in  that  the  contents  of 
the  bowel  at  that  level  are  usually  fluid  and  very  acid,  giving  rise 
to  much  local  irritation. 

Lumbar  Colotomy. — We  shall  here  merely  describe  the  operation 
as  performed  on  the  left  side  of  the  body.  The  patient  lies  on 
the  right  side,  with  a  sandbag  beneath  the  loin,  so  as  to  increase 
the  space  between  the  last  rib  and  the  crest  of  the  ilium. 

The  position  of  the  colon  is  indicated  by  a  vertical  line  drawn 
upwards  from  a  point  half  an  inch  behind  the  centre  of  another 
line,  passing  from  the  anterior  to  the  posterior  superior  iliac  spine. 

The  centre  of  the  incision  should  correspond  to  this  line  mid- 
way between  the  last  rib  and  the  crest  of  the  ilium.  It  should 
be  made  parallel  to  the  last  rib,  and  for  practical  purposes 
may  commence  at  the  outer  border  of  the  erector  spinas,  and 
pass  outwards  for  about  4  or  5  inches  (Fig.  375,  A,  p.  1068). 
This  incision  is  carried  through  the  layers  of  the  abdominal 
muscles,  dividing  the  latissimus  dorsi  and  a  small  portion  of  the 
external  oblique,  and  beneath  this  the  posterior  attachments  of 
the  internal  oblique  and  transversalis  muscles,  constituting  the 
fascia  lumborum.  This  should  be  cleanly  divided  along  the  whole 
length  of  the  incision,  the  last  dorsal  nerve  and  first  lumbar  artery 
being  usually  included.  The  sheath  of  the  quadratus  lumborum 
is  opened,  and  the  outer  fibres  of  the  muscle  notched,  if  necessary. 
The  deeper  portions  of  the  wound  are  now  held  apart  by  spatulas, 
and  the  loose  fatty  subperitoneal  tissue  gently  torn  through  with 
the  fingers  and  forceps  ;  it  varies  considerably  in  amount  and  con- 
sistency. The  gut  must  then  be  looked  for,  and  may  be  readily  re- 
cognised, if  distended  ;  but  if  collapsed,  a  good  deal  of  difficulty  is 
often  experienced,  though  the  hand  of  an  assistant  pressing  back  the 
anterior  abdominal  wall  may  bring  it  into  view.  It  is  well  to  define 
the  lower  edge  of  the  kidney  by  the  fore-finger,  and  the  portion  of 
gut  lying  immediately  in  front  of  it  is  usually  the  colon.  In  other 
cases  it  may  be  made  evideni  by  inflating  the  rectum  with  air. 

In  about  20  to  30  per  cent,  of  individuals  a  true  peritoneal 
ascending  or  descending  meso-colon  exists,  and  under  such  cir- 
cumstances it  is  necessary  to  open  the  general  peritoneal  cavity 
in  order  to  bring  the  required  portion  of  gut  into  view  ;  the  opera- 
tion is  then  completed  in  the  same  way  as  for  iliac  colotomy,  the 
bowel  not  being  opened  for  some  days  if  possible. 

When,  however,  the  gut  has  only  a  partial  serous  investment, 
the  peritoneal  reflections  are  carefully  defined,  and  the  uncovered 
portion  drawn  upwards  between  the  fingers  into  the  wound.  The 
highest  attainable  segment  of  gut  should  be  selected,  so  that  no 
loose  or  slack  part  may  remain  above  the  wound,  to  give  rise 
later  on  to  prolapse.     If  possible,  the  bowel  should  be  left  for  a 


942  A   MANUAL  OF  SURGERY 


day  or  two  before  being  opened,  and  is  secured  to  the  skin  by 
sutures  which  merely  pass  through  the  muscular  coat.  The  horns 
of  the  incision  are  then  closed,  and  the  gut  incised  at  a  later  date. 

If,  however,  the  patient  is  suffering  from  obstruction,  and  an 
immediate  opening  of  the  bowel  is  desirable,  the  best  plan  to 
adopt  is  to  pull  the  gut  well  out  of  the  wound,  which  is  then 
carefully  guarded  by  an  antiseptic  compress,  and  to  tap  it  with 
trocar  and  cannula,  subsequently  making  a  small  incision  into  it, 
in  which  a  Paul's  tube  is  at  once  tied,  so  as  to  allow  the  intestinal 
contents  to  escape  without  soiling  the  wound.  A  few  fixation 
stitches  are  then  introduced  into  the  walls  of  the  bowel,  so  as  to 
prevent  it  from  retracting.  The  tube  is  probably  set  free  about 
the  fourth  day,  but  by  this  time  the  wound  will  be  in  such  a  state 
that  no  great  harm  will  come  from  the  escape  of  faeces  in  the 
neighbourhood.  If  a  Paul's  tube  is  not  to  hand,  the  patient  is 
rolled  over  on  to  his  back,  and  a  large  trocar  and  cannula  inserted, 
so  that  the  first  gush  of  flatus  and  fluid  faeces  may  be  clear  of  the 
wound.  On  removing  the  cannula  the  mucous  membrane  of  the 
gut  is  stitched  to  the  margin  of  the  skin,  whilst  the  anterior 
portion  of  the  incision  is  sutured,  and  the  small  cavity  behind  the 
gut  packed  with  gauze.  By  fixing  the  bowel  as  far  back  as 
possible,  this  cavity  will  be  diminished  in  size.  An  antiseptic 
dressing  is  then  applied  over  a  piece  of  protective  to  the  anterior 
portion  of  the  incision,  and  a  pad  of  tenax  is  placed  behind  to 
receive  the  faecal  discharge. 

Lumbar  colotomy  is  not  much  in  favour  at  the  present  day. 
It  is  always  a  difficult  proceeding  if  the  bowel  is  not  distended  ; 
and  if  an  immediate  opening  is  necessary,  there  is  a  considerable 
risk  of  suppuration  of  the  wound  and  cellulitis.  It  has  been 
almost  entirely  replaced  by  the  iliac  operation. 

Iliac  Colotomy,  or  Littre's  Operation,  consists  in  opening  the 
lower  portion  of  the  colon  or  sigmoid  flexure  through  the  anterior 
abdominal  wall.  An  incision  2  to  3  inches  in  length  is  made  at 
right  angles  to  a  line  extending  from  the  anterior  superior  spine 
to  the  umbilicus,  the  centre  of  the  incision  corresponding  to  the 
junction  of  the  outer  and  middle  thirds  (Fig.  319,  C).  The 
abdominal  parietes  are  divided,  and  the  peritoneum  opened.  Two 
fingers  are  then  inserted,  and  the  sigmoid  flexure  sought  for  ;  it 
is  recognised  by  the  presence  of  the  appendices  epiploicae  and  the 
longitudinal  bands  of  muscle  fibres.  It  is  carefully  examined, 
and  the  upper  part  of  it  selected  for  fixation  in  the  wound,  so  as 
to  diminish  the  risk  of  subsequent  prolapse.  It  is  desirable  to 
withdraw  a  coil  about  4  or  6  inches  in  length,  together  with  its 
mesentery.  Many  different  plans  of  fixing  it  are  in  vogue,  but 
the  method  we  prefer  is  to  pass  a  strong  silk  thread  through  the 
parietes  and  parietal  peritoneum  on  either  side  of  the  wound,  the 
stitch  traversing  the  mesentery  en  route.  It  is  then  made  to 
traverse  the  same  structures  once  more  in  exactly  the  same  way, 


ABDOMINAL  SURGERY 


943 


but  at  a  distance  of  about  half  an  inch  from  the  former  (see  Fig.  347). 
The  loose  ends  are  then  tied  together,  so  as  to  bring  the  parietal 
peritoneum  and  sigmoid  meso-colon  into  close  apposition.  A  few 
additional  stitches  should  be  inserted,  uniting  the  skin  to  the  longi- 
tudinal muscular  bands  at  each  end  of  the  incision,  so  as  to  prevent 
any  subsequent  retraction  of  the  exposed  bowel  or  escape  of  small 
intestine.  Some  surgeons  simply  secure  the  parietal  peritoneum 
to  the  gut  by  a  row  of  carefully  inserted  sutures  ;  others  pass  a 
glass  rod  through  the  mesentery  and  stitch  the  peritoneum  to  the 
skin,  whilst  it  has  also  been  suggested  to  make  a  hole  through  the 
mesentery  and  suture  the  two  edges  of  the  incision  through  it, 
i.e.,  beneath  the  bowel.  The  projecting  portion  of  gut  is  then 
covered  with  purified  protective,  and  an  antiseptic  dressing 
applied.  At  the  end  of  two  or  three  days  the  bowel  is  opened,  no 
anaesthetic  being  generally  necessary  for  this  proceeding.  About 
the  eighth  day  a  portion  of  the  whole  lumen  of  the  gut  should  be 


Fig.  347.— Iliac  Colotomy  to  show  Fixation   Stitch   passing   through 
Mesentery  and  Abdominal  Parietes. 

removed,  down  to  and  even  including  the  mesentery,  so  as  to 
completely  separate  the  upper  from  the  lower  end,  and  thus 
establish  an  efficient  spur.  The  deep  stitch  is  removed  about  the 
twelfth  day.  Should  it  be  necessary  to  open  the  bowel  at  the 
time  of  operation,  the  distended  coil  is  first  withdrawn  and  the 
deep  trans-mesenteric  stitch  passed  and  tied.  The  margins  of 
the  wound  are  then  carefully  protected  by  antiseptic  compresses, 
and  the  bowel  is  tapped  with  a  trocar  and  cannula.  When  the 
first  gush  of  flatus  and  faeces  has  escaped,  the  opening  is  enlarged 
and  a  large-sized  Paul's  tube  tied  in.  The  skin  is  then  carefully 
sutured  all  round  to  the  bowel  and  mesentery,  and  a  collar-like 
pad  of  gauze  protects  the  junction. 

When  cicatrization  of  the  wound  is  complete,  a  protective 
apparatus  is  required  in  order  to  keep  the  patient  clean.  This 
should  consist  of  a  hollow  oval  cup,  made  of  plated  metal,  vulcanite 
or  celluloid,  with  a  rolled  edge,  and  kept  in  position  either  by 
a  truss  spring  or  an  abdominal  belt.  This  hollow  cup  should  be 
large  enough  to  include  a  2-inch  margin  of  skin  all  round  the 
opening,  and  in  the  concavity  a  small  portion  of  antiseptic  dressing 


944  A  MANUAL  OF  SURGERY 


is  placed.  Such  an  apparatus  enables  the  patient  to  go  about  in 
comparative  comfort ;  the  bowels  are  encouraged  to  act  thoroughly 
every  morning  by  means  of  an  enema,  so  that  no  further  disturb- 
ance need  occur  during  the  day. 

Comparison  of  the  Two  Operations. — As  we  have  already  stated, 
the  iliac  operation  has  almost  entirely  superseded  the  lumbar  pro- 
ceeding, and  the  reasons  for  this  change  of  attitude  are  as  follows  : 
(i)  The  operator  is  not  hampered  by  lack  of  space,  as  so 
frequently  happens  in  opening  the  loin.  (2)  A  clean  incision 
can  be  made  without  tearing  or  bruising  the  subperitoneal  fat. 
(3)  The  sigmoid  flexure  is  readily  identified,  and  no  other  viscus 
is  likely  to  be  opened  for  it  by  mistake ;  if  the  colon  takes  an 
abnormal  course  in  the  loin,  or  is  provided  with  a  complete  meso- 
colon, the  peritoneum  has  usually,  if  not  always,  to  be  opened, 
and  thus  the  one  advantage  which  can  be  claimed  for  the  lumbar 
proceeding  is  lost.  (4)  An  artificial  anus  situated  in  the  iliac 
region  can  be  attended  to  by  the  patient  himself  without  assist- 
ance, and  is  more  easily  cleansed  and  protected.  (5)  It  is  occa- 
sionally possible  for  a  certain  amount  of  sphincteric  control  to  be 
developed  after  the  abdominal  operation,  owing  to  the  muscles 
of  the  abdominal  parietes  becoming  adherent  to  the  coats  of  the 
gut.  Of  course,  this  can  only  be  attained  when  these  structures 
are  brought  into  accurate  apposition,  as  by  the  fixation  stitch 
described  above.  (6)  A  more  complete  diversion  of  the  faeces  can 
be  effected  by  the  iliac  operation  than  by  the  lumbar.  In  the 
latter  it  is  impracticable  to  withdraw  the  whole  lumen  of  the  gut 
unless  the  peritoneum  is  opened ;  an  opening  is  merely  made  on 
one  side,  and  one  has  to  trust  to  the  formation  of  a  valve  or  spur 
of  mucous  membrane  for  the  blocking  of  the  lower  aperture ;  in  the 
former  the  two  segments  of  the  bowel  can  be  entirely  separated. 

The  objections  urged  against  the  iliac  operation  consist  in  the 
following  facts:  (1)  That  it  involves  the  opening  of  the  peri- 
toneum ;  (2)  that  immediate  relief  to  obstruction  is  more  risky 
than  in  the  lumbar  method ;  and  (3)  that  there  is  a  somewhat 
greater  tendency  to  prolapse.  The  first  of  these  objections  must 
now  be  entirely  waived.  The  second  is  certainly  valid,  but  by 
a  careful  use  of  Paul's  tube  and  by  fixing  the  gut  firmly  to  the 
skin  by  additional  sutures  the  danger  is  minimized.  Certainly  the 
lumbar  operation  is  not  devoid  of  risk  when  an  immediate  opening 
of  the  gut  is  required.  Lastly,  if  the  surgeon  is  careful  to  see 
that  no  slack  portion  of  gut  exists  above  that  which  he  fixes  in 
the  wound,  i.e.,  if  he  opens  the  lower  end  of  the  descending 
colon,  there  will  be  but  little  likelihood  of  any  subsequent  pro- 
trusion. 


ABDOMINAL  SURGERY  945 


Appendicitis  (Syn. :  Perityphlitis,  Epityphlitis,  etc.). 

Appendicitis  is  an  affection  which  may  appear  at  any  time  of 
life,  but  is  most  common  in  the  young.  The  male  sex  is  more 
frequently  attacked  than  the  female  in  the  proportion  of  4  to  1 . 
The  disease  is  of  a  most  protean  type,  being  sometimes  of  but 
slight  significance,  but  occasionally  running  such  a  virulent  course 
as  to  destroy  life  in  a  few  hours.  Its  importance  necessarily  lies 
in  the  fact  that  the  peritoneal  envelope  is  always  involved,  and 
hence  a  certain  degree  of  peritonitis  is  almost  necessarily  a  con- 
sequence. 

^Etiology. — Many  different  conditions  contribute  either  directly 
or  indirectly  in  determining  an  attack  of  appendicitis.  (1)  The 
appendix  is  to  be  looked  on,  not  as  an  actively  functional  structure, 
but  as  a  degenerated  relic  or  remnant,  which  is  apparently  of 
little  value  or  importance.  Hence,  as  in  other  similar  structures, 
it  often  has  but  a  poor  blood-supply,  derived  from  the  posterior 
ileo-caecal  branch  of  the  ileo-colic  artery.  The  main  nutrient 
vessels  traverse  in  the  meso-appendix,  but  a  second  twig  often  runs 
down  the  base  of  the  mesentery,  and  is  more  or  less  independent 
of  the  others.  In  the  female  it  is  said  to  have  an  additional  twig 
from  the  right  ovarian  trunk,  and  this  may  explain  why  the  disease 
is  less  common  in  females  than  in  males.  (2)  A  large  amount  of 
lymphoid  tissue  is  present  in  its  walls,  so  much,  in  fact,  that  the 
title  of  '  abdominal  tonsil '  has  been  applied  to  it.  Inflammatory 
processes  are  thus  readily  set  up  within  its  walls  as  a  result  of  the 
absorption  of  toxins  or  organisms,  which  are  almost  constantly 
present  within  it.  (3)  Its  length  and  direction  vary  considerably 
in  different  individuals.  In  length  it  may  measure  anything 
between  1^  and  11  or  12  inches,  but  is  usually  3  to  4  inches  long, 
whilst,  as  to  direction,  it  may  lie  in  any  axis  ;  perhaps  most  fre- 
quently it  is  to  be  found  behind  the  caecum,  and  pointing  down 
towards  the  pelvis.  The  facility  with  which  the  intestinal  con- 
tents find  their  way  into  its  lumen  thus  varies  in  different  indi- 
viduals, and  it  seems  probable  that  appendicitis  is  more  commonly 
met  with  where  it  is  so  placed  as  to  readily  admit  material  which 
is  with  difficulty  expelled,  i.e.,  when  it  is  transverse  or  directed 
downwards.  A  long  appendix  is  also  more  liable  to  become 
twisted  on  itself.  (4)  The  extent  to  which  the  meso-appendix  is 
attached  is  also  an  important  element,  since  the  portion  which 
projects  beyond  its  free  border  is  less  well  supplied  with  blood. 
As  a  matter  of  fact  the  mesentery  rarely  extends  beyond  the  junc- 
tion of  the  middle  with  the  distal  third,  and  perforation  often 
occurs  about  this  spot.  (5)  The  communication  with  the  caecum 
is  usually  a  small  one,  and  is  guarded  by  an  insignificant  fold  of 
mucous  membrane,  known  as  the  valve  of  Gerlach.  Sometimes 
this  aperture  becomes  blocked,  or  the  orifice  stenosed,  so  that  an 

60 


946  A  MANUAL  OF  SURGERY 


accumulation  of  mucus  occurs  within  the  appendix.  (6)  Faecal 
concretions  or  foreign  bodies,  such  as  pips,  pins,  etc.,  are  also 
met  with  within  it,  and  by  their  presence  and  irritation  may 
determine  an  attack  of  inflammation.  Foreign  bodies  are  much 
less  common  than  was  formerly  imagined  (present  in  less  than 
4  per  cent,  of  cases),  occurring  most  frequently  in  children  and 
young  people.  Faecal  concretions  (present  in  15  to  20  per  cent, 
of  cases)  are  oval  bodies,  rarely  more  than  half  an  inch  in  length  ; 
on  section  they  are  found  to  be  laminated,  and  consist  of  dried 
faecal  material  mixed  with  myriads  of  bacteria.  They  are  not 
very  hard,  and  can  easily  be  cut  with  a  knife.  They  are  usually 
the  result  of  chronic  constipation,  which  is  always  to  be  looked  on 
as  a  predisposing  cause  of  appendicitis. 

Other  causes  of  appendicitis  are  occasionally  described,  such  as 
rheumatism,  and  in  chronic  cases  tubercle  or  actinomycosis  ; 
typhoid  ulceration  is  rarely  met  with  in  the  appendix.  Dysentery 
is  sometimes  associated  with  appendicitis,  though  more  commonly 
it  leads  to  a  true  ulcerative  typhlitis,  involving  the  caecum. 

Injury  in  the  shape  of  a  strain  or  sudden  twist  is  not  unfre- 
quently  mentioned  as  the  cause  of  an  outbreak,  and  probably  acts 
by  displacing  a  long  appendix  in  such  a  way  as  to  lead  to  its 
kinking  and  possibly  to  obstruction  of  the  nutrient  vessels. 

Whatever  the  assigned  cause  may  be,  it  must  ever  be  kept  in 
mind  that  appendicitis  is  an  infective  malady,  due  to  invasion  of 
the  walls  of  the  appendix  by  organisms,  especially  by  the  Bac.  coli, 
though  ordinary  pyogenic  cocci,  especially  the  Streptococcus  pyo- 
genes, are  often  present  in  addition. 

Pathological  Anatomy. — Bacteria  find  an  entrance  into  the  wall 
of  the  appendix  either  through  an  eroded  area  of  the  mucous 
membrane  due  to  the  impaction  of  a  foreign  body  or  of  a  faecal 
concretion,  or  else  they  are  absorbed  into  the  lymphoid  tissue 
so  abundantly  present,  and  at  once  commence  to  develop  and 
multiply.  As  a  result  of  this  the  mucosa  becomes  greatly 
swollen  and  thickened,  and  as  it  is  surrounded  by  fairly  strong 
muscular  walls,  constriction  of  the  vessels  follows,  preventing 
recuperative  processes  from  being  undertaken,  and  hence  the 
bacteria  are  enabled  to  continue  their  destructive  work.  In  con- 
sequence, ulceration  of  the  mucous  lining  supervenes,  or  inter- 
stitial suppuration  in  the  wall.  Sometimes  the  small  terminal 
artery  of  the  appendix  becomes  thrombosed,  or  undergoes  an 
obliterative  endarteritis,  leading  to  sloughing  of  one  or  more 
portions  of  the  walls,  generally  at  the  apex.  The  veins  also 
are  liable  to  become  thrombosed,  and  bacteria  may  find  their 
way  into  the  thrombus,  causing  its  disintegration,  and  if  emboli 
are  detached,  pylephlebitis  or  portal-vein-pyaemia,  with  possibly 
hepatic  abscess,  may  result.  The  most  important  changes,  how- 
ever, are  those  occurring  in  the  peritoneum,  which  is  always 
inflamed,  and,  indeed,  upon  the  condition  of  this  structure  depends 


ABDOMINAL  SURGERY  947 


to  a  large  extent  the  prognosis  of  the  case.  It  may  merely  be 
thickened  by  a  deposit  of  lymph,  giving  rise  to  adhesions  which 
bind  it  down  to  neighbouring  parts,  or  a  localized  suppurative 
affection  may  ensue ;  or,  again,  an  acute  diffuse  and  usually  fatal 
peritonitis  follows,  either  as  a  result  of  rupture  of  the  appendix, 
or  as  an  outcome  of  sloughing  or  perforation  of  its  walls. 
The  localized  abscess  is  in  reality  intraperitoneal,  but  its  ex- 
tension is  limited  by  the  formation  of  adhesions  between  neigh- 
bouring coils  of  gut.  When  an  attack  of  appendicitis  has 
passed  off,  some  stenosis  of  the  lumen  of  the  tube  is  a  common 
sequence,  and  as  a  result  of  this  the  terminal  portion  may  become 
distended  with  retained  secretion,  and  the  patient  may  suffer  from 
intermittent  attacks  of  colicky  pain  due  to  the  efforts  of  the  ap- 
pendix to  relieve  itself ;  it  will  also  predispose  the  individual  to 
recurrent  inflammation. 

Hence,  from  a  clinical  standpoint,  the  following  varieties  of 
appendicitis  may  be  recognised  : 

1.  Simple  or  catarrhal  appendicitis,  associated  with  a  plastic 
peritonitis. 

2.  Ulcerative  or  gangrenous  appendicitis,  accompanied  by  a 
localized  intraperitoneal  abscess. 

3.  Gangrenous  or  perforative  appendicitis,  resulting  in  an  acute 
diffuse  sero-purulent  peritonitis.  Such  a  condition  is  frequently 
fatal,  and  constituted  one  of  the  commonest  causes  of  the  so-called 
'  idiopathic  peritonitis  '  of  the  old  days. 

4.  Relapsing  appendicitis,  in  which  attack  follows  attack,  some- 
times with  very  little  interval. 

Clinical  History. — (i.)  The  mild  variety  of  the  disease,  known 
as  a  simple  catarrhal  appendicitis,  to  which  is  added  merely  a 
localized  plastic  peritonitis,  usually  commences  somewhat  sud- 
denly, the  patient  being  seized  with  pain  in  the  right  iliac  fossa, 
and  accompanied  by  nausea,  vomiting,  more  or  less  complete 
constipation,  and  slight  fever  (1010  or  1020  F.).  An  examination 
of  the  abdomen  reveals  definite  tenderness  in  the  right  iliac 
region,  most  marked  at  a  spot  corresponding  to  the  base  of  the 
appendix,  i.e.,  i£  inches  inwards  from  the  anterior  superior  iliac 
spine,  along  a  line  drawn  towards  the  umbilicus  (McBurney's 
spot),  whilst  the  right  leg  is  usually  drawn  up  in  order  to  relax 
the  tension  of  the  abdominal  muscles.  A  swelling,  generally  dull 
on  percussion,  may  sometimes  be  detected  by  palpation,  a  little 
below  McBurney's  spot,  and  consists  of  coils  of  intestine  matted 
together  over  and  around  the  inflamed  appendix.  Such  symptoms 
usually  last  three  or  four  days,  and  then,  if  properly  treated, 
resolve  satisfactorily  without  any  abscess  formation. 

This  simple  form  of  the  disease  is  exceedingly  common,  and  the 
prognosis  is,  on  the  whole,  favourable.  Tofft,  of  Copenhagen, 
found  adhesions  in  the  neighbourhood  of  the  appendix  in  35  per 
cent,  of  all  bodies  subjected  to  post-mortem  examination. 

60 — 2 


948  A  MANUAL  OF  SURGERY 


(ii.)  The  more  serious  variety,  commonly  resulting  in  a  localized 
abscess,   may  commence  in  a  similar  way,  but  with  more  acute 
symptoms.     There  may  be  an  initial  rigor,  and  the  temperature 
soon  runs  up,  even  to  1040  F.     Some  general  abdominal  tender- 
ness and   distension  follow  ;  constipation  is  often   absolute,   and 
fa?cal  vomiting  may  occur.     The  muscles  on  the  right  side  of  the 
abdominal  walls  are   held  tense   and    rigid,  and  a  well-marked 
swelling  can    usually  be    detected  in  the  iliac  fossa.     Under  a 
careful  regime  this  may  disappear,  and  the  symptoms  gradually 
abate  in  their  severity,  the  temperature  and  the  pulse  falling  con- 
currently ;   but  it  is  very  common  for  suppuration  to  ensue,  and 
such   is  indicated  by   the  temperature   persisting  at   its  original 
high  level,  or  by  the  pulse-rate  increasing  in  rapidity,  whilst  the 
temperature  falls.     Fluctuation  is  rarely  to  be  detected  in  the 
early  stages,  and,  indeed,  it  is  bad  practice  to  wait  for  it  before 
interfering,  since   there   is   a   considerable   probability  that    the 
tension  within  the  abscess  may  be  sufficient  to  break  down  the 
wall  of  newly  formed  and  not  too  strong  adhesions,  and  the  general 
peritoneal   cavity  may  be  thus  infected.     The  abscess  develops 
at  first  around  the  appendix,  and  is,  of  course,  primarily  intra- 
peritoneal.    Not  unfrequently  it  bursts  into  the  bowel,  and  there- 
by  relief  is   gained    without    the   assistance   of   surgery ;    some 
authorities,    indeed,   maintain   that   this   occurs  in   every  case  of 
the  more  severe  type  which  resolves.     In  other  instances  it  may 
point    externally,   either   through    the   anterior   abdominal  wall, 
which  becomes  congested  and  oedematous  as  the  pus  approaches 
the  surface,  or  through   the    loin,   the  pus    having    invaded    the 
retroperitoneal  cellular  tissue.     In  the  latter  case,  it  is  sometimes 
found  that  the  abscess  burrows  widely  up  and  down  the  back  of 
the  abdomen,  and  may  even  extend  behind  and  above  the  liver, 
constituting   a  subphrenic  abscess.     Not  unfrequently  it  tracks 
up  along  the  inner  or  outer  side  of  the  ascending  colon,  and  then 
may  get  into  relation  with   the  under  surface  of  the  liver.     In 
other  patients,  and  especially  when  the  tip  of  the  appendix  lies 
over  the  brim  of  the  pelvis,  the  pus  travels  downwards  and  forms 
a  collection   behind  the  rectum  ;  the  surgeon   must  never  omit 
a  rectal  examination  in  appendicitis,  where  the  temperature  is  of 
such  a  nature  as  to  suggest  the  existence  of  an  abscess,  and  yet 
no  evidence  of  one  can  be  found.     Should  it  burst  into  the  peri- 
toneal cavity,  all  the  phenomena  of  perforative  peritonitis  super- 
vene, probably  indicated  by  a  sudden  fall   of  temperature,  and 
followed  by  increased  abdominal  pain  and  distension.     A  faecal 
fistula    may    follow    the    bursting    or    opening    of    any    of   these 
abscesses. 

In  not  a  few  cases  the  patient's  general  symptoms  improve 
after  the  first  outbreak  ;  the  temperature  may  become  normal, 
the  pain  decrease,  and  the  vomiting  cease.  It  is  often  difficult  to 
be  certain  whether  this  improvement  is  merely  temporary,  or  is 


ABDOMINAL  SURGERY  949 


the  commencement  of  a  true  convalescence.  Under  the  former 
circumstances  i.e.,  if  it  is  merely  an  interval  of  quiescence),  careful 
examination  will  probably  reveal  some  disturbing  factor  ;  either 
the  abdominal  distension  persists,  or  perhaps  hiccough  is  present, 
or  a  well-marked,  though  localized,  tenderness  continues,  perhaps 
only  to  be  detected  per  rectum,  or  the  pulse.rate  may  remain 
unduly  high.  After  a  few  days-  the  temperature  begins  to  rise 
once  more,  the  focal  symptoms  become  more  urgent,  and  a 
subacute  or  chronic  abscess  forms. 

A  complication  likely  to  occur  in  the  more  severe  types  of  the 
disease  is  pylephlebitis,  or  infective  thrombosis  of  the  branches  of 
the  portal  vein  in  the  liver.  Such  would  be  indicated  by  recurrent 
rigors,  and  possibly  by  pain  and  tenderness  in  the  hepatic  area. 
Necessarily  it  is  almost  invariably  fatal. 

(iii.)  Diffuse  septic  peritonitis  results  either  from  the  rupture 
of  a  localized  intraperitoneal  abscess,  and  will  then  be  preceded 
by  the  symptoms  outlined  above,  or  is  present  from  the  outset, 
being  then  due  to  primary  perforation  or  gangrene  of  the  appendix 
itself.  The  ordinary  signs  of  acute  peritonitis  are  developed  (see 
p.  895),  but  possibly  there  may  be  obtainable  some  history  of  pain 
starting  in  the  right  iliac  fossa,  which  will  give  a  clue  to  the 
diagnosis. 

(iv.)  Relapsing  appendicitis  is  characterized  by  recurrent  attacks 
of  varying  gravity  in  an  individual  who  has  been  once  the  subject 
of  the  disease.  They  may  occur  only  at  prolonged  intervals,  or 
be  so  frequent  as  to  entirely  incapacitate  the  patient,  and  are 
mainly  due  to  the  presence  of  some  abnormal  adhesion  or  con- 
striction of  the  appendix.  It  is  not  uncommon  for  the  appendix 
to  become  fixed  to  the  sheath  of  the  psoas  muscle,  and  then  any 
excessive  movements  of  the  limb  may  light  up  an  attack.  Where 
stenosis  exists,  secretions  containing  bacteria  may  be  pent  up 
behind  the  constriction,  and  from  time  to  time  the  patient  suffers 
from  severe  pain  of  a  colicky  nature  without  fever,  supposed  to  be 
due  to  an  attempt  to  get  rid  of  the  excess  of  mucus.  Such  attacks 
have  been  named  '  appendicular  colic'  In  a  few  cases  the  ap- 
pendix becomes  totally  obliterated  after  a  time  and  incorporated 
in  a  mass  of  adhesions,  a  natural  cure  being  thus  established  ; 
but  more  frequently,  if  these  recurrences  are  allowed  to  continue, 
the  patient  finally  succumbs  from  diffuse  peritonitis. 

The  Diagnosis  of  appendicitis  ought  not  to  be  a  matter  of 
great  difficulty  if  the  practitioner  bears  in  mind  the  cardinal 
symptoms,  viz.,  pain  and  tenderness  in  the  right  iliac  fossa, 
together  with  fever,  vomiting,  and  constipation.  If  to  these  are 
superadded  the  existence  of  a  localized  swelling  beneath  the  tense 
and  rigid  abdominal  muscles,  but  little  doubt  can  remain  as  to  the 
nature  of  the  case. 

The  Prognosis,  on  the  other  hand,  is  never  absolutely  certain, 
for,  as  has  been  well  pointed  out  by  many  acute  observers,  the 


95o  A   MANUAL  OF  SURGERY 


initial  symptoms  are  frequently  alike  in  all  the  varieties,  and  hence 
one  can  never  know  what  course  the  case  is  going  to  take  ;  as 
R.  Morris,  of  New  York,  says,  '  The  infected  appendix  is  a  cap 
which  sometimes  snaps,  sometimes  flashes,  and  sometimes  causes 
an  explosion,  and  none  of  us  can  tell  in  advance  just  what  is  going 
to  happen.'  As  particularly  bad  signs  may  be  mentioned  a  con- 
tinued high  temperature,  in  spite  of  rest  and  careful  dietetic 
measures,  or  a  fall  of  temperature  with  increased  rate  of  the 
pulse.  Persistent  hiccough  is  also  a  bad  sign.  The  existence  of 
a  swelling  in  the  iliac  fossa  is  not  a  bad  sign,  but  rather  the 
reverse.  Absence  of  a  localized  swelling  is  due  either  to  a 
defective  formation  of  protective  adhesions,  and  hence  is  likely  to 
be  noted  in  the  most  acute  cases,  or  to  the  appendix  being  placed 
behind  the  caecum  in  a  position  less  favourable  to  operative 
measures. 

Treatment. — So  much  has  been  written  on  this  subject  during 
the  last  ten  years,  that  it  is  extremely  difficult  to  compress  even 
a  brief  summary  of  the  many  facts  observed  into  a  necessarily 
limited  space.  Formerly  typhlitis  was  the  exclusive  property  of 
the  physician  ;  but  the  last  decade  has  brought  about  a  great 
change,  and  many  authorities  consider  that  appendicitis  is  more 
justly  within  the  realm  of  the  surgeon,  or,  at  any  rate,  that  a 
surgeon  should  always  share  the  responsibility  of  treatment  with 
the  physician.  At  any  moment  complications  may  develop  even 
in  what  appear  to  be  simple  cases,  in  which  surgical  assistance 
will  alone  hold  out  any  hopes  of  saving  the  patient.  In  America 
surgery  is  the  recognised  treatment  for  almost  every  case  of  the 
disease  ;  in  this  country  more  conservative  ideas  still  persist,  but 
we  are  glad  to  note  that  a  more  healthy  opinion  is  gradually 
gaining  ground,  and  that  surgical  interference  is  becoming 
recognised  as  the  most  appropriate  means  of  treatment  in  many 
cases. 

In  the  milder  form  of  appendicitis,  where  the  temperature  does 
not  run  above  ioi°  and  the  symptoms  are  not  severe,  all  that  is 
required  in  the  majority  of  instances  is  to  put  the  patient  to  bed, 
and  apply  fomentations  locally  ;  the  lower  bowel  should  be  emptied 
by  an  enema,  and  if  it  seems  likely  that  there  is  an  accumulation 
of  irritating  fasces  within  the  intestine,  a  dose  of  castor-oil  or  of 
calomel  may  be  administered.  A  fluid,  unstimulating  diet  is  all 
that  is  permitted,  and  should  there  be  much  vomiting,  rectal 
alimentation  may  be  resorted  to.  Possibly  a  little  morphia  may 
be  given  with  advantage  to  quiet  the  patient  and  check  peristalsis; 
but  the  less  the  better,  since  it  tends  to  mask  symptoms. 

In  the  graver  cases  the  same  general  treatment  may  be  insti- 
tuted to  start  with,  but  the  question  as  to  the  advisability  of 
operation  will  soon  have  to  be  faced.  There  are  certain  conditions 
in  which  all  surgeons  are  agreed  as  to  operation  being  essential,  viz., 
where  general  peritonitis  is  present,  or  when  an  abscess  is  pointing. 


ABDOMINAL  SURGERY  951 

In  the  former  case  the  only  hope  that  exists,  and  even  that  is  of 
the  slenderest  description,  lies  in  opening  the  abdomen  (usually  in 
the  middle  line),  flushing  it  out  with  some  weak  antiseptic  lotion, 
or  perhaps  better  with  sterilized  salt  solution  at  a  temperature 
of  about  108°  F.,  and  searching  for  the  appendix.  If  found,  it 
should  be  removed,  and  drainage,  either  by  Keith's  tubes  or  by 
gauze  wicks,  must  be  arranged  for.  In  the  great  majority  of 
cases  death  will  ensue  in  spite  of  all  our  precautions,  but  the 
more  recent  reports  certainly  show  better  results. 

When  an  abscess  is  evidently  present,  being  indicated  either  by 
fluctuation  or  by  a  commencing  oedema  of  the  abdominal  wall, 
there  should  be  no  hesitation  in  cutting  down.  An  incision  is 
made  over  the  cedematous  spot,  and  deepened  carefully,  since  the 
tissues  are  probably  matted  together,  and  cut  like  bacon  or  brawn. 
The  knife  or  index-finger  will  suddenly  sink  into  the  abscess 
cavity,  and  a  gush  of  fcetid  pus  follows.  The  cavity  is  gently 
explored,  so  as  to  ascertain  whether  or  not  the  appendix  can  be 
felt ;  no  undue  force  should  be  used,  for  fear  of  breaking  down 
adhesions  and  thus  opening  the  general  peritoneal  sac.  If  the 
appendix  cannot  be  readily  found,  it  is  best  left  alone  ;  the  abscess 
is  thoroughly  irrigated,  drainage  is  provided  for,  and  the  incision 
partly  closed.  Probably  the  case  will  go  on  well,  the  discharge 
losing  its  smell  about  the  third  day,  and  the  remaining  sinus  will 
gradually  heal  by  granulation.  Should  the  appendix,  however, 
present  itself,  it  should  be  removed. 

It  is,  however,  in  those  cases  where  neither  of  the  above  condi- 
tions are  manifest,  and  yet  the  symptoms,  both  local  and  general, 
point  to  the  fact  that  a  lesion  of  considerable  gravity  is  present, 
that  the  greatest  difference  of  opinion  exists.  We  are  quite  ready 
to  admit  that  in  many  instances  conservative  or  medical  treat- 
ment will  suffice  to  bring  about  a  satisfactory  result  ;  but  this  can 
never  be  depended  on,  and,  unfortunately,  only  too  many  lives 
have  been  sacrificed  through  an  unwillingness  to  call  in  a  surgeon, 
except  at  the  last  moment.  Under  these  circumstances,  even  if 
acute  peritonitis  has  not  occurred,  the  patient  is  profoundly  toxsemic 
or  exhausted  by  preceding  suffering  ;  hence  any  operative  measures 
are  likely  to  fail  through  the  asthenic  condition  of  the  individual, 
even  if  the  local  phenomena  are  such  as  can  be  efficiently  dealt 
with.  Personally,  w^e  are  distinctly  in  favour  of  early  operation, 
and  the  general  rule  (to  which,  of  course,  there  are  exceptions) 
which  we  should  suggest  as  justifiable,  is  that,  if  in  spite  of  suitable 
rest  and  medical  treatment  the  symptoms,  both  general  and  local,  are  not 
commencing  to  abate  at  the  end  of  forty-eight  hours,  operation  should 
be  undertaken.  The  great  advantages  we  would  claim  for  this  pro- 
cedure are  :  (1)  That  the  patient  is  not  in  a  state  of  collapse  from 
toxaemia,  and  hence  can  stand  the  shock  of  an  intraperitoneal 
exploration  without  much  risk ;  (2)  that  the  appendix  itself  is  not 
so  likely  to  be  tied  down  by  a  mass  of  firm  adhesions,  and  can 


952  A   MANUAL  OF  SURGERY 


thus  be  found,  isolated,  and  removed  ;  (3)  that  such  removal  is 
most  desirable  in  order  to  secure  the  patient  against  the  danger  of 
recurrence ;  and  (4)  that  a  much  smaller  incision  will  be  needed 
under  these  circumstances,  and  therefore  there  is  less  chance  of  a 
ventral  hernia  subsequently  forming.  The  following  conditions 
may  also  be  mentioned  as  specially  indicating  operation  :  per- 
sistent distension  of  the  abdomen,  hiccough,  or  a  continued  high 
pulse-rate  in  spite  of  a  falling  temperature. 

Operation. — Probably  the  best  incision  is  an  oblique  one,  crossing 
McBurney's  spot,  or  a  little  below  it,  and  parallel  with  the  outer 
end  of  Poupart's  ligament,  somewhat  similar  to  that  for  ligaturing 
the  external  iliac  artery  (Fig.  319,  D).  The  whole  thickness  of 
the  abdominal  wall  is  freely  divided,  and  the  peritoneum,  if  need 
be,  opened,  so  as  to  expose  the  caecum.  The  appendix  is  then 
carefully  sought  for,  after  protecting  the  general  cavity  by  sponges  ; 
it  may  be  necessary  to  lift  the  caecum  from  its  bed  in  order  to  find 
it,  or  to  separate  agglutinated  coils  of  intestine.  In  cases  of  diffi- 
culty, the  longitudinal  bands  of  muscle  on  the  ascending  colon 
should  be  traced  downwards  to  the  appendix,  where  the  three  sets 
of  fibres  converge.  An  abscess  usually  containing  extremely 
offensive  pus  may  be  opened  in  this  way  ;  but  if  the  operation  is 
an  early  one,  there  is  often  no  pus  around  the  appendix,  although 
its  walls  may  be  yellow  from  purulent  infiltration.  Whenever 
possible,  the  appendix  should  be  removed  ;  it  is  first  freed  from 
adhesions,  and  the  meso-appendix  ligatured.  If  sufficiently 
healthy,  a  formal  amputation,  as  in  the  chronic  cases,  should  be 
undertaken,  but  such  a  procedure  is  often  impracticable.  A  silk 
thread  is  then  tied  around  the  base  about  half  an  inch  from  the 
caecum,  and  the  appendix  cut  off;  the  stump  is,  if  practicable, 
buried  by  the  insertion  of  two  or  three  sutures  into  the  serous 
membrane  covering  the  caecum.  Not  unfrequently,  however,  the 
tissues  are  too  much  infiltrated  and  matted  together  to  admit  of 
such  proceedings ;  all  that  can  be  done  is  to  stuff  the  wound  with 
long  strips  of  gauze,  and  allow  it  to  heal  by  granulation.  In  the 
earlier  more  favourable  cases,  where  actual  suppuration  has  not 
occurred,  the  cavity  is  washed  out  after  removal  of  the  appendix, 
a  drainage-tube  inserted,  and  the  abdominal  wall  partly  closed. 
After  the  operation  the  patient  should  be  fed  mainly  per  rectum 
for  a  few  days,  stomach-feeding  being  gradually  commenced  about 
the  third  day.  A  small  amount  of  opium  may  be  needed,  and,  if 
all  is  going  well,  the  bowels  may  be  opened  by  the  use  of  enemata 
in  about  five  days  if  they  have  not  already  acted. 

For  relapsing  appendicitis,  radical  treatment  must  be  instituted  if 
the  attacks  are  at  all  frequent,  and  possibly  it  would  be  justifiable 
to  lay  down  the  rule  that  operation  should  be  undertaken  in  the 
quiescent  period  after  the  second  attack.  If  left  till  many  attacks 
have  occurred,  the  task  may  prove  very  difficult,  owing  to  the 
number   and   density  of   the   adhesions  which   are  then   present. 


ABDOMINAL  SURGERY  953 

They  are  dealt  with  in  the  best  way  practicable,  and  the  appendix 
thus  freed  is  amputated.  This  is  accomplished  by  dividing  the 
serous  coat  by  a  circular  incision,  and  retracting  a  cuff  of  serous 
and  muscular  tissues  sufficiently  to  enable  the  mucous  membrane 
to  be  ligatured,  divided,  and  then  covered  over  and  buried  by 
stitching  or  ligaturing  the  cuff  of  serous  membrane  over  the  end. 

A  plan  of  dividing  the  abdominal  wall  suggested  by  McBurney 
may  be  employed  in  cases  which  promise  to  be  of  a  simple  nature 
and  not  complicated  by  many  adhesions.  The  incision  is  as  above  ; 
each  of  the  three  flat  muscles  is  divided  in  the  course  of  its  fibres, 
and  held  aside  by  retractors.  The  peritoneum  is  divided  trans- 
versely. After  the  appendix  has  been  removed,  each  layer  is 
sutured  separately.  This  method  minimizes  the  risk  of  hernia, 
but  it  is  not  suited  to  cases  where  many  adhesions  are  likely  to  be 
present,  since  an  enlargement  of  the  incision  downwards,  such  as 
is  almost  necessarily  required,  involves  a  crucial  division  of  one  or 
more  of  the  muscles. 

Sequelae. — A  Facal  Fistula  may  result  from  a  perforative  ap- 
pendicitis when  the  abscess  has  been  merely  opened,  and  no 
radical  treatment  undertaken  at  the  same  time,  or  it  may  follow 
an  amputation  of  the  appendix  from  sloughing  or  yielding  of  the 
stump.  It  is  usually  small  in  size,  and  sinuous  in  its  course,  and 
may  in  many  cases  close  of  itself.  Occasionally  it  is  necessary  to 
deal  with  it  by  laying  bare  the  caecum  in  the  iliac  fossa,  and  re- 
moving the  appendix  or  suturing  the  opening.  Failing  that,  it 
may  be  necessary  to  short-circuit  the  caecum. 

A  Ventral  Hernia  sometimes  follows  from  the  yielding  of  the 
cicatrix  in  the  abdominal  wall  after  an  abscess  has  been  opened 
and  drained.  Both  omentum  and  bowel,  perhaps  matted  together 
and  adherent  to  the  cicatrix,  are  found  in  the  protrusion.  In 
some  cases  it  may  suffice  to  cover  it  with  the  concave  pad  of  a 
truss,  but  in  others  operation  is  required  ;  adhesions  must  be 
divided  or  broken  down,  and  often  the  opportunity  can  be  taken 
of  removing  the  appendix,  if  this  has  not  already  been  accom- 
plished. The  margins  of  the  divided  muscles  are  then  sought  for, 
and  united  by  a  row  of  buried  sutures  in  the  ordinary  way. 

Affections  of  the  Liver. 

Rupture  of  the  Liver  is  produced  by  injuries  to  the  abdominal 
walls,  such  as  blows,  kicks,  or  crutches,  or  it  may  be  torn  by  the 
broken  end  of  a  rib.  Penetrating  injuries  also  occur,  as  from 
sword  or  dagger  thrusts,  and  the  organ  may  be  involved  in  a  gun- 
shot wound.  The  resulting  lesion  varies  considerably  ;  the  gland 
may  be  merely  torn  or  contused  from  a  non -penetrating  blow,  or 
freely  incised  by  a  sharp  cutting  implement,  in  which  case  some 
of  the  larger  venous  trunks  are  likely  to  be  divided  ;  a  bullet  some- 
times  produces  almost  total    disorganization.       The    amount    of 


954  A  MANUAL  OF  SURGERY 

injury  depends,  to  some  extent,  on  the  condition  of  the  organ  ;  if 
it  is  firm  and  sclerosed,  it  may  receive  little  damage  from  a  blow 
which  would  otherwise  do  it  considerable  harm,  whilst  if  it  is 
enlarged  and  fatty,  it  is  readily  torn. 

The  chief  Symptoms  are  shock,  which  is  often  not  very  exces- 
sive, pain  and  tenderness  in  the  right  hypochondrium,  and  the 
evidences  of  loss  of  blood.  The  last  is,  perhaps,  the  most  im- 
portant, as  upon  its  severity  depends  to  a  large  extent  the  result. 
Sometimes  the  capsule  remains  intact,  and  then,  although  there  is 
considerable  intraglandular  ecchymosis  and  laceration,  no  free  blood 
escapes  into  the  peritoneal  cavity.  Such  a  lesion  is  not  unlikely 
to  be  followed  by  an  abscess  of  the  liver.  When  the  capsule  is 
torn,  intraperitoneal  haemorrhage  is  sure  to  ensue  ;  if  slight,  the 
patient,  though  suffering  from  all  the  phenomena  characteristic  of 
loss  of  blood,  may  recover,  the  blood  being  absorbed,  and  the 
wound  in  the  liver  cicatrizing.  This  process  is  usually  attended 
by  a  certain  amount  of  jaundice  and  some  vomiting,  whilst  the 
urine  is  also  tinged  with  bile  pigment.  In  other  cases,  the  blood 
collects  at  first  in  the  upper  part  of  the  abdomen,  but  gradually 
extends  downwards ;  if  the  bowel  is  uninjured,  recovery  may 
ensue,  but  not  uncommonly  there  is  some  associated  contusion  of 
the  gut  wall,  through  which  intestinal  bacteria  find  their  way, 
giving  rise  to  a  localized  or  general  peritonitis.  Of  course,  in  the 
more  severe  lesions  where  perhaps  the  left  lobe  is  entirely  torn 
off  or  a  portion  hopelessly  contused,  death  from  haemorrhage  is 
almost  certain  to  ensue  in  a  very  short  time. 

The  Diagnosis  of  hepatic  rupture  turns  mainly  on  the  history  of 
the  accident,  the  situation  of  the  blow,  and  the  resulting  symptoms. 
Evidences  of  intraperitoneal  bleeding,  associated  with  pain  in  the 
right  side,  are  extremely  suggestive.  It  must  not,  however,  be 
forgotten  that  the  passage  of  a  hansom  cab  or  other  vehicle  over 
the  body  may  give  rise  to  much  shock,  and  to  considerable  local 
pain  and  tenderness,  and  yet  no  serious  mischief  need  have 
happened  to  the  liver. 

The  Treatment  in  the  more  simple  cases  consists  merely  in 
careful  expectancy,  the  surgeon  holding  himself  in  readiness  to 
interfere  should  any  untoward  symptoms  supervene.  The  patient 
is  kept  quietly  in  bed  ;  ice  may,  if  necessary,  be  applied  to  the 
side,  the  diet  is  limited  to  fluids,  and  the  bowels  emptied  by 
enemata.  In  the  more  serious  cases,  where  the  diagnosis  of 
ruptured  liver  is  tolerably  certain,  an  exploratory  laparotomy 
should  be  undertaken,  and  an  attempt  made  to  deal  with  the 
wound.  Possibly  a  median  incision  is  as  good  as  any,  since  the 
left  half  of  the  liver  often  bears  the  brunt  of  the  injury.  Out- 
lying ragged  portions  of  the  gland  may  be  totally  removed,  prefer- 
ably by  the  cautery,  though  one  usually  has  to  depend  upon 
plugging  the  wound  with  gauze  in  order  to  effect  haemostasis. 
Clean  linear  cuts  may  be  sutured  with  silk,  but  there    is    con- 


ABDOMINAL  SURGERY  955 


siderable  difficulty  in  preventing  the  stitches  from  tearing  out  of 
the  friable  hepatic  tissue ;  it  is  wise  to  insert  all  the  stitches  first, 
taking  up  a  good  margin  of  the  gland  substance  before  attempting 
to  tie  any.  The  wound  is  then  carefully  closed  by  the  fingers,  and 
the  sutures  slowly  and  gently  tightened.  Very  shallow  wounds 
which  it  is  impossible  to  stitch  or  plug  satisfactorily  may  be 
seared  with  the  cautery  so  as  to  stop  bleeding,  and  then  a  gauze- 
wick  drain  is  placed  over  them,  and  brought  out  of  the  external 
wound. 

Abscess  of  the  Liver  is  due  to  a  variety  of  causes. 

1 .  Multiple  A  bscesses  develop  in  cases  of  pyaemia,  whether  the 
emboli  are  carried  by  the  hepatic  artery  or  by  the  portal  vein. 
In  the  former  case,  the  condition  arises  as  a  complication  of 
general  pyaemia  of  systemic  origin  ;  in  the  latter,  the  originating 
focus  of  mischief  is  located  in  the  area  of  distribution  of  the  portal 
vein — i.e.,  in  the  intestinal  canal.  Thus,  pylephlebitis,  as  it  is 
termed,  is  not  uncommonly  met  with  in  appendicitis,  and  some- 
times in  typhoid  fever,  whilst  suppurating  piles  may  also  lead  to  it. 

2.  Suppurative  Cholangitis  is  another  cause  of  multiple  abscess  of 
the  liver.  It  consists  of  an  inflammatory  affection  of  the  biliary 
ducts  and  passages,  and  is  due  to  the  spread  of  organisms  from 
the  intestine,  or  occasionally  from  the  gall-bladder  after  an 
operation.  The  biliary  ducts  in  the  liver  become  enormously 
dilated,  and  filled  with  a  mixture  of  bile  and  pus  which  looks 
very  like  yellow  ochre.  It  is  accompanied  by  pain  over  the 
gland  and  the  general  phenomena  of  pyrexia,  but  rigors  are  not 
present.  The  patient  is  not  usually  jaundiced,  but  bile  may  be 
found  in  the  urine.  Treatment  is  of  little  avail,  but  if  a  diagnosis 
can  be  made,  and  the  gall-bladder  has  not  been  already  incised,  it 
may  relieve  tension  to  open  and  drain  it. 

3.  Hydatid  cysts  may  suppurate,  and  require  treatment  as  for 
an  abscess  of  the  liver. 

4.  The  more  important  abscesses,  from  a  surgical  standpoint, 
are  those  which,  from  their  size,  demand  operative  treatment. 
They  may  result  from  traumatism  in  the  way  stated  above,  or 
may  arise  in  connection  with  hydatid  cysts,  but  more  commonly 
are  of  the  type  known  as  tropical  abscess:  The  latter  usually  occurs 
in  individuals  who  have  travelled  in  the  tropics,  and  75  per  cent, 
of  the  cases  are  attributed  to  dysentery.  The  exact  mode  of 
causation  has  not  yet  been  fully  worked  out,  but  it  seems  probable 
that  they  are  primarily  of  embolic  origin.  They  are  most  fre- 
quently situated  at  the  back  of  the  right  lobe,  but,  of  course, 
any  part  of  the  viscus  may  be  involved.  Though  often  single,  the 
cavity  is  frequently  loculated,  indicating  that  several  original 
foci  of  suppuration  have  united  together.  Any  of  the  ordinary 
pyogenic  organisms  may  be  found  within  them,  and  not  unfre- 
quently  the  Bac.  coli  is  present.     In  a  few  cases  the  Amoeba  coli,  an 


956  A  MANUAL  OF  SURGERY 

organism  which  is  found  in  the  bowel  in  some  forms  of  dysentery, 
has  been  discovered.  Occasionally  the  pus  is  sterile,  the  causative 
organisms  having  probably  been  disposed  of,  possibly  as  a  result 
of  the  chronicity  of  the  process.  The  abscess  wall  consists  of 
disintegrating  hepatic  tissue  in  acute  cases,  but  may  have  a 
fibro-cicatricial  wall  in  the  more  chronic  forms,  and  in  an  old- 
standing  abscess  the  limiting  membrane  may  be  as  tough  as 
leather.  The  pus  is  sometimes  of  the  ordinary  type,  but  not 
uncommonly  reddish-brown  in  colour,  somewhat  like  chocolate, 
and  of  a  most  nauseating  odour. 

The  Symptoms  are  in  some  instances  extremely  slight,  the 
patient  perhaps  dying  of  peritonitis  due  to  its  rupture  without 
its  presence  having  ever  been  suspected.  The  individual  usually 
complains  of  a  sense  of  weight  and  fulness  in  the  right  hypo- 
chondriurn,  and  in  the  more  acute  cases  this  may  be  accompanied 
by  severe  pain  and  localized  tenderness  over  the  whole  hepatic 
region,  the  pain  being  also  referred  to  the  right  shoulder.  A 
certain  amount  of  febrile  disturbance  occurs,  the  degree  of  which 
depends  on  the  rapidity  of  formation  of  the  abscess  ;  in  the  more 
acute  forms  the  temperature  is  high  and  rigors  may  be  present. 
The  pyrexial  phenomena  are  associated  with  loss  of  appetite, 
rapid  and  well-marked  emaciation,  and  perhaps  a  certain  amount  of 
icterus,  though  the  latter  is  not  usually  a  prominent  phenomenon. 
On  physical  examination  a  more  or  less  evident  enlargement  of 
the  liver  will  be  detected,  with,  perhaps,  a  feeling  of  elasticity,  or 
even  of  fluctuation  at  some  spot.  The  dulness  often  extends  up 
towards  the  thorax  rather  than  downwards,  though  when  the 
abscess  is  situated  not  far  from  the  free  margin  of  the  liver,  this 
is  not  the  case.  A  doubtful  diagnosis  can  sometimes  be  con- 
firmed by  the  aspirator  or  hypodermic  needle,  but  this  should 
not  be  utilized  unless  one  is  fully  prepared  for  immediate  opera- 
tion in  the  case  of  pus  being  found.  Manson  directs  that  the 
aspirator  needle  should  be  introduced  in  the  following  situations  : 
(i)  In  the  right  axillary  line  through  the  seventh  or  eighth  costal 
interspace ;  (2)  just  below  the  ribs  in  the  right  nipple  line ; 
(3)  immediately  below  the  lung  in  the  line  drawn  downwards 
from  the  angle  of  the  right  scapula. 

Left  to  itself,  several  distinct  courses  are  open  for  the  abscess 
to  follow  :  it  may  become  adherent  to  the  anterior  abdominal  wall 
and  point  in  the  epigastrium,  its  onward  passage  being  indicated 
by  congestion  and  oedema  of  the  parietes ;  it  may  open  into  the 
peritoneal  cavity,  or  into  one  of  the  hollow  viscera,  such  as  the 
colon  or  duodenum  ;  or,  again,  it  may  travel  upwards,  burrowing 
through  the  diaphragm,  and  either  bursting  into  the  lung,  its 
contents  being  expectorated,  or  into  the  pleural  cavity,  leading  to  an 
empyema.  Occasionally  it  remains  passive  as  a  chronic  encysted 
abscess,  and  then  the  walls  become  very  thick.  One  of  us  recently 
opened  an  hepatic  abscess  which  had  been  diagnosed  by  a  hypo- 


ABDOMINAL  SURGERY  957 


dermic  needle  twelve  years  previously,  and  left  alone.  It  con- 
tained about  two  pints  of  pus,  and  the  walls  were  fully  |  inch 
thick.  The  patient  came  under  observation  because  the  swelling 
was  becoming  more  prominent,  as  the  result  of  increased  intra- 
abdominal pressure,  due  to  pregnancy. 

Treatment. — Aspiration,  repeated  once  or  twice,  has  been  fre- 
quently employed,  but  is  of  little  value,  and  not  a  few  cases 
are  on  record  in  which  septic  peritonitis  or  pleurisy  has  followed 
the  introduction  of  the  needle  from  the  front  or  side  respectively. 
Experience  proves  that  the  usual  law  of  treating  suppuration 
ought  to  be  strictly  obeyed,  viz.,  that  the  abscess  should  be 
opened  and  drained.  If  pointing  in  front  and  adherent  to  the 
parietes,  there  is  no  difficulty  or  danger  in  making  an  incision 
over  the  most  prominent  spot  and  laying  the  cavity  open  ;  it  is 
then  well  flushed  out  and  a  drainage-tube  inserted.  If  on  dividing 
the  abdominal  parietes  it  is  found  that  the  liver  is  not  yet  adherent, 
it  is  perhaps  best  to  plug  the  wound  with  sterilized  or  antiseptic 
gauze  so  as  to  determine  the  formation  of  adhesions  to  such  an 
extent  as  to  cut  off  the  general  peritoneal  cavity ;  in  a  few 
days  the  abscess  can  then  be  opened  with  safety.  If  there  is  no 
great  thickness  of  hepatic  tissue  between  the  surface  and  the  pus, 
a  knife  may  be  employed  for  this  purpose ;  but  if  the  abscess  lies 
deeply,  it  has  been  suggested  that  the  thermo-cautery  should  be 
employed  so  as  to  prevent  bleeding  by  sealing  the  mouths  of  the 
hepatic  veins.  When  it  is  urgently  necessary  to  open  the  abscess 
at  once,  even  though  no  adhesions  are  present,  the  general  serous 
cavity  must  be  carefully  protected  by  sponges  or  pledgets  of  gauze 
before  letting  out  the  pus,  and  the  assistant  must  keep  the  parietes 
in  close  contact  with  the  hepatic  tissue.  It  may  be  possible  to 
insert  a  few  stitches  through  the  liver  substance,  securing  it  thus 
to  the  parietal  peritoneum  ;  otherwise  one  must  trust  to  a  careful 
packing  of  the  wound.  After  opening  the  abscess,  it  is  usually 
advisable  to  wash  it  out,  and  this  may  with  advantage  be  repeated 
subsequently. 

When  the  abscess  is  in  its  most  common  situation,  viz.,  the 
back  of  the  right  lobe,  it  is  often  most  satisfactory  to  open  it 
from  the  side ;  a  similar  proceeding  is  sometimes  needed  when 
an  abscess  has  been  opened  from  the  front,  and  does  not  drain 
properly.  An  incision  is  made  a  little  behind  the  mid-axillary 
line  through  the  ninth  or  tenth  intercostal  space,  and  a  portion  of 
one  of  the  adjacent  ribs  removed.  The  pleural  cavity  is  opened, 
and  the  costal  pleura  stitched  carefully  to  that  portion  which 
covers  the  diaphragm  ;  it  will  be  found  that  this  structure 
lies  nearly  vertical  in  this  position,  and  but  little  difficulty  is 
experienced  in  shutting  off  the  general  pleural  cavity.  The 
diaphragm  is  then  divided,  and  not  unfrequently  the  peritoneal 
cavity  is  opened  ;  if  so,  it  may  be  stuffed  temporarily,  so  as  to 
determine  adhesions,  and  then    the  liver  incised  ;  less  commonly 


958  A  MANUAL  OF  SURGERY 

adhesions  may  have  already  formed,  or  a  bare  area  of  the  liver 
may  he  found,  through  which  the  pus  can  be  withdrawn  and  the 
abscess  opened. 

Hydatid  Cysts  occur  in  the  liver  more  frequently  than  in  any 
other  part  of  the  body.  For  general  details  as  to  the  life-history 
of  the  Tania  ccliinococcus  and  the  structure  of  hydatid  cysts,  see 
p.  187.  They  produce  a  localized  painless  enlargement  of  the 
liver,  the  cysts  varying  in  size  from  a  small  marble  to  a  child's 
head  ;  the  outline  is  well  defined  if  superficial,  but  not  so  if  placed 
deeply  ;  the  cavity  is  usually  filled  with  fluid  and  daughter-cells. 
Fluctuation  may  be  distinguished,  and  a  hydatid  fremitus  or  thrill 
(arising  from  the  concussion  of  the  contained  daughter-cysts) 
may,  it  is  said,  be  elicited  on  palpation.  The  diagnosis  is  easily 
made  if  the  cyst  projects  from  the  lower  border,  but  when  deeply 
embedded  in  the  organ  it  may  be  exceedingly  difficult,  and  the 
tumour  can  only  be  distinguished  with  certainty  from  carcinoma 
or  syphilis  by  the  use  of  the  aspirator,  or  preferably  by  an  open 
exploration.  The  character  of  the  fluid  withdrawn  from  a 
hydatid  cyst  is  at  once  conclusive,  as  it  is  of  low  specific  gravity, 
viz.,  1007  to  1009,  slightly  opalescent,  with  no  albumen,  and  a 
trace  of  salt ;  the  presence  of  scolices  or  hooklets  is  the  pathogno- 
monic feature. 

Terminations. — The  cyst  may  remain  latent  and  innocuous,  or 
may  actually  dry  up  and  form  a  mass  somewhat  like  wet  mortar, 
owing  to  the  death  of  the  organism  ;  or  it  may  burst  and  be 
evacuated  in  different  directions,  with  or  without  suppuration. 
Thus,  it  may  open  externally  through  the  abdominal  parietes,  or 
into  the  peritoneal  cavity,  causing  fatal  shock  and  in  many  cases 
peritonitis  ;  or  into  the  stomach  or  intestines,  spontaneous  cure 
usually  resulting  ;  or  it  may  penetrate  the  diaphragm,  and  the 
contents  be  expectorated,  or  set  free  in  the  pleural  cavity,  causing 
a  rapidly  fatal  pleurisy.  It  has  been  known  to  open  into  the 
pericardium,  or  even  into  the  hepatic  veins,  the  contents  then 
being  impacted  in  the  right  auricle  ;  in  both  cases  immediate 
death  resulted. 

Treatment. — The  ideal  plan  of  dealing  with  a  hydatid  cyst 
would  be  to  dissect  it  entirely  away,  and  such  is  not  altogether  im- 
practicable in  cases  where  the  growth  is  superficial,  since  its  con- 
nections with  surrounding  parts  are  not  very  intimate.  The  great 
danger  to  be  dreaded  is  haemorrhage,  and  owing  to  the  vascularity 
of  the  liver  and  the  difficulty  of  controlling  bleeding  from  it,  this 
is  an  objection  of  the  gravest  importance.  However,  if  the  tumour 
is  small  and  superficial,  there  need  be  no  fear  in  attempting  it, 
the  cavity  being  firmly  plugged  with  gauze  for  a  few  days. 

The  surgeon,  however,  usually  has  to  content  himself  with 
incision  of  the  cyst,  turning  out  the  scolices  or  daughter-cysts,  and 
inserting   a    large   drainage-tube.     If  adhesions   to   the  anterior 


ABDOMINAL  SURGERY  959 


abdominal  wall  are  present,  this  can  be  accomplished  at  one 
sitting  ;  but  if,  as  more  commonly  happens,  none  have  been 
developed,  it  is  wiser  to  undertake  the  operation  in  two  stages,  as 
for  hepatic  abscess,  so  as  to  make  certain  that  the  general  peri- 
toneal cavity  is  firmly  shut  off.  Another  advantage  which  follows 
the  division  of  the  operation  into  two  parts  is  that  the  latter  pro- 
ceeding, viz.,  the  incision  of  the  liver  and  cyst,  can  be  undertaken 
without  an  anaesthetic,  and  the  patient  is  enabled  to  help  in  the 
removal  of  the  cysts  by  coughing  when  required. 

Formerly  aspiration  and  electrolysis  were  largely  employed  in  the 
treatment  of  this  affection.  It  has  been  found,  however,  that 
although  a  considerable  percentage  of  cases  could  be  cured  in 
this  way  (more  than  a  half),  yet  that  it  was  not  unaccompanied 
by  risk  of  peritonitis,  and  that  recurrence  was  often  observed. 
Moreover,  some  of  the  fluid  not  unfrequently  leaked  into  the 
peritoneal  cavity,  and  probably  from  the  absorption  of  some  toxic 
product  present  led  to  urticaria,  and  sometimes  to  even  graver 
phenomena  of  poisoning.  Electrolysis  merely  acts  by  producing 
a  puncture  of  the  cyst  wall  and  consequent  leakage.  Both  of 
these  methods  should  be  entirely  discontinued. 

A  suppurating  hydatid  cyst  is  dealt  with  according  to  the  same 
rules  of  treatment  as  hold  good  for  abscess  of  the  liver. 

Tumours  of  the  Liver  are  rarely  primary.  Secondary  sarcoma 
and  carcinoma  are  by  no  means  uncommon,  but  of  course  nothing 
can  be  done  for  them.  A  few  cases  are  on  record  of  removal  of 
a  tumour  or  gumma  together  with  a  portion  of  the  tissue  of  the 
organ,  but  such  must  necessarily  be  a  matter  of  such  rarity  that 
we  cannot  spare  space  to  discuss  it. 

Affections  of  the  Gail-Bladder  and  Biliary  Passages. 

Rupture  of  the  Gail-Bladder  results  from  such  injuries  as  blows, 
crushes,  kicks,  etc.,  whilst  it  may  also  be  produced  by  penetrating 
wounds  or  bullets ;  occasionally  it  may  follow  ulceration  from 
within,  as  from  a  large  impacted  gallstone.  It  is  probable  that 
in  health  the  gall-bladder  is  occupied  not  by  bile,  but  by  mucus, 
and  its  function  is  apparently  not  to  act  as  a  bile  reservoir, 
but  as  a  pressure  gauge  regulating  the  flow  of  bile  into  the 
intestine.  Whenever  the  biliary  passages  are  stenosed  or  blocked, 
bile  regurgitates,  as  also  after  death,  and  necessarily  if  the  bladder 
is  ruptured,  bile  will  find  it  easier  to  escape  in  this  direction  than 
down  the  long  and  sinuous  bile-ducts,  and  therefore  extravasation 
into  the  peritoneal  cavity  always  follows.  Pure  bile  is  sterile, 
but  if  any  inflammation  of  the  biliary  passages  has  been  present, 
organisms  are  sure  to  have  found  their  way  into  the  gall-bladder, 
and  thus  complications  may  readily  ensue.  If  a  considerable 
quantity  of  bile  escapes  suddenly  into  the  peritoneal  sac,  acute 
peritonitis   is   certain   to   follow,  whether  organisms   are   present 


96o  A   MANUAL  OF  SURGERY 


or  not,  owing  to  the  irritating  nature  of  the  fluid  ;  jaundice  is 
also  developed  from  absorption  of  bile  by  the  peritoneum,  and  it 
may  also  be  found  in  the  urine.  A  more  gradual  escape  of  the 
secretion  will  probably  lead  to  the  formation  of  a  localized  intra- 
peritoneal abscess  or  collection  of  fluid,  associated  with  jaundice 
and  probably  clay-coloured  stools.  In  a  penetrating  wound  bile 
and  blood  will  escape  on  the  surface,  and  septic  peritonitis  is 
almost  sure  to  follow. 

The  immediate  Symptoms  are  those  of  shock  and  severe 
hypochondriac  pain,  and  this  will  be  succeeded  by  either  acute 
peritonitis  or  by  the  formation  of  a  localized  intraperitoneal 
swelling,  together  with  jaundice.  When  the  existence  of  such  a 
lesion  is  suspected,  Treatment  always  consists  in  an  exploratory 
laparotomy.  The  fluid  within  the  abdomen  is  carefully  removed 
with  swabs  or  washed  away,  and  the  gall-bladder  carefully 
examined.  Should  only  a  small  injury  be  found,  it  is  perfectly 
feasible  to  close  it  by  sutures  ;  a  gauze  wick  should,  however,  be 
passed  down  to  the  lesion  for  a  few  days  so  as  to  provide  a  means 
of  drainage  should  leakage  occur.  A  more  serious  rupture  will 
necessitate  removal. of  the  gall-bladder,  or  else  the  margins  of  the 
wound  may  be  stitched  to  the  abdominal  parietes,  and  a  biliary 
fistula  thus  produced.  Should  the  common  bile-duct  be  entirely 
divided,  the  ends  should  be  closed  by  sutures  and  a  cholecysten- 
terostomy  undertaken  ;  a  small  wound  in  the  duct  may  be  sutured. 

Cholelithiasis  is  the  term  applied  to  the  presence  in  the 
gall-bladder  of  Gallstones.  These  consist  mainly  of  crystals  of 
cholesterine,  held  together  by  mucus  and  coloured  by  the  bile 
pigment ;  they  are  soluble  in  chloroform.  When  first  passed  and 
moist,  their  specific  gravity  is  a  little  higher  than  that  of  water, 
and  hence  when  immersed  in  it  they  sink  ;  after  drying,  however, 
they  are  found  to  float.  The  number  present  varies  immensely  ; 
sometimes  a  single  large  one  exists,  which  is  more  or  less  barrel- 
shaped  ;  more  frequently  they  are  multiple,  scores  or  hundreds 
being  present,  and  are  then  usually  faceted,  and  with  a  satin-like 
yellowish  lustre. 

The  Origin  of  gallstones  is  not  yet  fully  understood,  but  there 
seems  no  doubt  that  they  are  primarily  due  to  an  inflammatory 
condition  of  the  wall  of  the  gall- bladder  or  biliary  passages;  they 
occur  most  commonly  in  women  who  have  suffered  long  from 
dyspepsia  and  constipation,  and  may  be  associated  with  cancer, 
either  as  cause  or  effect.  In  a  case  dealt  with  by  one  of  us,  the 
origin  of  the  trouble  seems  to  have  been  the  swallowing  of  a  pin 
many  years  previously,  which  worked  its  way  into  the  gall- 
bladder, set  up  an  inflammation  which  resulted  in  the  formation 
of  calculi,  and  only  appeared  again  after  a  successful  operation, 
when  sixty-six  stones  had  been  removed. 

The  Symptoms  produced  are  extremely  variable.     Their  occur- 


ABDOMINAL  SURGERY  961 

rence  is  usually  preceded  by  dyspeptic  phenomena,  which  have 
perhaps  lasted  for  years,  and  by  constipation.  Some  pain  is  com- 
plained of  in  the  right  hypochondrium,  but  possibly  nothing  very 
serious  is  noted,  until  a  physical  examination  reveals  the  distended 
gall-bladder,  which  forms  a  tumour  projecting  from  under  cover 
of  the  ribs,  usually  the  8th  or  9th,  and  tending  to  enlarge  down- 
wards towards  the  umbilicus ;  it  is  usually  firm,  elastic,  and 
perhaps  fluctuating ;  it  moves  with  the  liver  during  respiration, 
and  there  is  never  intestine  in  front  of  it.  Such  a  condition  often 
yields  to  medical  treatment ;  the  diet  has  to  be  carefully  regulated, 
and  a  sufficient  amount  of  exercise  ordered.  Alkaline  purgative 
medicines  are  usually  employed,  and  a  well-to-do  patient  may  be 
sent  to  Carlsbad  to  drink  the  waters.  Possibly  massage  may  be 
utilised  to  assist  in  the  extrusion  of  the  calculi,  and  drinking  con- 
siderable quantities  of  olive-oil  is  said  to  be  beneficial  in  effecting 
the  same  object. 

There  are  several  complications,  however,  which  may  call  for 
surgical  treatment. 

1.  Inflammatory  phenomena  connected  with  the  gall-bladder 
(cholecystitis)  may  assume  considerable  proportions.  Acute  in- 
flammation is  usually  due  'to  infection  with  the  Bac.  coli,  which 
travels  up  the  biliary  passages  from  the  intestine.  It  is  evidenced 
by  acute  pain  and  tenderness  in  the  right  hypochondrium,  together 
with  vomiting,  constipation,  and  fever.  The  constipation  may 
be  of  such  a  marked  character  as  almost  to  amount  to  obstruction, 
and  arises  mainly  from  paralysis  of  the  neighbouring  coils  of  gut, 
e.g.,  the  duodenum  and  transverse  colon.  Suppuration  may 
follow,  the  abscess  either  bursting  externally  or  into  the  peritoneal 
cavity,  or  possibly  into  one  of  the  hollow  viscera.  In  other  cases 
the  inflammation  subsides  after  a  time,  but  results  in  a  consider- 
able development  of  adhesions  Avhich  interfere  with  operative 
proceedings,  and  may  also  determine  an  attack  of  intestinal 
obstruction.  Should  the  inflammatory  mischief  extend  up  the 
hepatic  duct  into  the  liver  substance,  diffuse  suppurative  cholangitis 
will  result,  and  may  lead  to  a  fatal  issue.  A  condition  of  chronic 
peritonitis  is  likely  to  follow  whenever  calculi  remain  lodged  in 
the  gall-bladder  for  some  time. 

2.  Biliary  colic  is  another  most  distressing  complication,  due  to 
the  onward  passage  of  gallstones  along  the  ducts.  The  pain  is 
of  a  most  acute  character,  doubling  the  patient  up,  and  causing 
considerable  shock  ;  it  radiates  from  the  right  side,  shooting  over 
the  scapular  region  and  into  the  back ;  it  commences  abruptly, 
and  continues  in  paroxysms  accompanied  by  vomiting  until  the 
stone  is  either  discharged  into  the  intestine  or  slips  back  into  the 
gall-bladder,  leading  to  a  sudden  cessation  of  the  pain  ;  a  sense 
of  tenderness  and  discomfort  may,  however,  persist  for  some  time, 
and  possibly  a  little  jaundice,  owing  to  the  swelling  of  the  mucous 
membrane  obstructing  the  passage  of  bile.     These  attacks  some- 

61 


962  A   MANUAL  OF  SURGERY 


times  come  on  at  more  or  less  regular  intervals,  and  may  be  so 
frequent  as  to  produce  great  exhaustion.  At  the  time,  they  should 
be  treated  by  the  application  of  fomentations  to  the  side,  and  the 
administration  of  opium  ;  sometimes  a  large  dose  of  olive-oil  by 
the  mouth  may  assist  in  the  passage  of  the  stone.  If  they  recur 
at  all  frequently,  cholecystotomy  must  be  undertaken. 

3.  A  gallstone  does  not  always  escape  into  the  bowel ;  it  may 
become  impacted,  and  then  gives  rise  to  a  train  of  tolerably  charac- 
teristic symptoms,  which  vary  somewhat  with  the  site  of  obstruc- 
tion. If  the  cystic  duct  is  blocked,  there  is  severe  pain  in  the 
side,  and  perhaps  distension  of  the  gall-bladder  with  mucus,  con- 
stituting a  tumour  which  can  be  felt,  but  there  is  no  jaundice.  If 
the  calculus  is  lodged  at  the  junction  of  the  common  and  hepatic 
ducts,  there  will  be  intense  icterus,  but  the  gall-bladder  is  not 
necessarily  distended  ;  the  liver,  however,  is  likely  to  be  enlarged 
from  engorgement  with  bile.  When  the  stone  is  impacted  in  the 
common  bile-duct,  the  jaundice  is  intense,  but  the  gall-bladder  is 
usually  small.  Sometimes  the  stone  lodges  close  to  the  intestinal 
end  of  the  duct  in  what  is  known  as  the  ampulla  of  Vater ;  it  may 
then  ulcerate  through  into  the  bowel  without  much  difficulty. 
If  impacted  higher  up,  it  may  work  through  into  the  duodenum 
or  colon  by  a  process  of  ulceration,  or  may  escape  into  the  retro- 
peritoneal cellular  tissue,  leading  to  an  abscess ;  or,  again,  it  may 
open  the  peritoneal  cavity,  and  thus  cause  acute  peritonitis. 

Operative  Treatment  of  Cholelithiasis. — The  conditions  which 
may  call  for  operation  in  the  course  of  a  case  of  gallstones  are  as 
follows  :  (a)  For  recurrent  attacks  of  biliary  colic,  which  cannot 
be  prevented  by  medical  treatment ;  (b)  for  persistent  jaundice ; 

(c)  when  the  gall-bladder  can  be  felt  enlarged  and  tender  ;  and 

(d)  for  acute  cholecystitis. 

Cholecystotomy  consists  in  opening  the  gall-bladder  for  the 
removal  of  calculi,  or  for  purposes  of  drainage.  It  is  best  per- 
formed through  an  incision  which  runs  parallel  to  the  costal 
margin  on  the  right  side,  and  about  an  inch  and  a  half  from  it, 
extending  upwards  as  far  as  the  middle  line  (Fig.  319,  B).  The 
peritoneum  is  opened,  and  the  gall-bladder  sought  for,  any 
adhesions  present  being  carefully  divided ;  it  will  sometimes 
happen  that  these  are  so  abundant  as  to  prevent  the  surgeon 
from  continuing  the  operation,  the  risk  of  opening  the  bowel 
by  mistake  being  too  great.  The  liver  is  drawn  up,  and  the 
intestines  are  pressed  downwards  out  of  the  field  of  operation 
by  means  of  sponges  or  cloths  held  in  position  by  a  broad  re- 
tractor. The  general  peritoneal  cavity  is  thus  carefully  guarded 
from  infection.  If  the  gall-bladder  is  much  distended,  it  is  ad- 
visable to  tap  it  with  a  trocar  and  cannula,  and  withdraw  the 
chief  portion  of  its  contents ;  the  opening  is  then  enlarged  suffi- 
ciently to  allow  of  the  introduction  of  a  scoop,  or  even  of  the 
finger,  and  by  this  means  the  calculi  are  removed.     The  bile- 


ABDOMINAL  SURGERY  963 

ducts  are  carefully  examined  both  by  the  finger  passed  inside 
as  far  as  possible,  and  outside  along  their  whole  length,  and  by 
means  of  a  long  probe  passed  down  the  duct.  If  the  interior 
is  tolerably  healthy,  it  may  be  advisable  to  suture  up  the  wound 
in  the  bladder,  the  threads  not  being  allowed,  however,  to  en- 
croach on  the  mucous  membrane.  A  gauze  wick  should  be 
inserted  down  to  the  incision  before  stitching  up  the  abdominal 
parietes,  so  as  to  provide  for  drainage  should  there  be  any  leakage 
of  bile.  More  usually  temporary  drainage  of  the  biliary  passages 
is  desirable  in  order  to  relieve  the  liver,  and  then  a  full-sized 
drainage-tube  without  any  lateral  openings  is  introduced  into  the 
gall-bladder  and  stitched  to  its  walls,  whilst  the  margins  of  the 
wound  in  the  gall-bladder  are  united  to  the  parietal  peritoneum 
and  transversalis  aponeurosis.  A  biliary  fistula  is  thus  produced 
which  discharges  for  a  time ;  but  as  soon  as  the  obstruction  to 
the  onward  passage  of  bile  into  the  gut  is  overcome,  the  fistula 
closes.  Occasionally  this  does  not  occur,  and  then  the  discharge 
of  bile  continues,  necessitating  further  treatment.  If  there  is 
sufficient  evidence  of  the  existence  of  bile  in  the  motions  to  indi- 
cate that  the  passages  are  clear,  a  plastic  operation  for  the  closure 
of  the  fistula  may  be  undertaken ;  but  if  complete  and  permanent 
obstruction  to  the  passage  of  bile  is  suspected,  an  artificial  com- 
munication with  the  intestine  (cholecystenterostomy)  should,  if 
possible,  be  established. 

It  is  often  very  difficult  to  remove  a  stone  impacted  in  the 
cystic  duct.  Possibly  it  may  be  extracted  by  a  lithotomy  scoop,  or 
pushed  on  from  within,  or  squeezed  forwards  or  backwards  by  the 
finger  and  thumb  from  outs'de  ;  or,  again,  it  has  been  broken  up 
from  within  by  means  of  a  needle,  or  crushed  from  without  by 
forceps,  the  blades  of  which  are  guarded  by  indiarubber,  but  these 
are  bad  methods  to  adopt.  In  difficult  cases  of  this  nature  it  is 
better  to  incise  the  duct  and  extract  the  stone,  the  incision  being 
subsequently  secured  by  Lembert's  sutures,  long-handled  palate 
needles  being  employed  for  the  purpose. 

Sometimes  the  calculus  is  lodged  in  the  bile-duct  behind  the 
second  piece  of  the  duodenum  ;  it  is  then  sometimes  possible  to 
push  the  gut  aside  and  get  at  the  duct  behind  it,  or  in  other  cases 
it  may  be  necessary  to  incise  the  duodenum  longitudinally  front 
and  back,  and  after  extracting  the  stone,  to  make  a  fistula  between 
the  duct  and  the  posterior  wall  of  the  intestine.  In  other  cases 
the  stone  is  left  alone,  and  in  the  course  of  a  few  days  it  may 
become  dislodged  by  natural  means,  as  evidenced  by  the  passage 
of  bile  into  the  intestine. 

Cholecystenterostomy,  or  the  formation  of  an  artificial  com- 
munication between  the  gall-bladder  and  the  bowel,  is  required 
in  cases  where  jaundice  persists,  owing  to  absolute  stenosis  of 
the  common  duct.  It  has  also  been  undertaken  for  the  relief 
of  jaundice  due  to  malignant  disease,  either  of  the  head  of  the 

61 — 2 


964  A  MANUAL  OF  SURGERY 

pancreas  or  of  the  intestine,  causing  pressure  on  the  orifice  of  the 
bile-duct  ;  it  is  quite  unjustifiable  under  these  latter  circumstances, 
as  statistics  have  shown  that  the  danger  of  such  a  proceeding  is 
very  great,  seven  out  of  eight  of  Murphy's  cases  dying.  The 
parts  are  exposed  as  described  above,  the  gall-bladder  and 
duodenum  are  brought  into  contact,  and  a  lateral  anastomosis 
made  by  means  of  a  Murphy  button,  or  by  simple  suturing  ;  but 
Murphy's  method  is  undoubtedly  the  better. 

Cholecystectomy,  or  removal  of  the  gall-bladder,  may  be  neces- 
sary for  traumatic  lesions,  and  for  malignant  disease,  whilst  it  is 
sometimes  employed  after  cholecystotomy  in  order  to  prevent  any 
new  formation  of  gallstones.  The  bladder  has  to  be  isolated,  and 
may  then  be  cut  away,  the  divided  end  of  the  duct  being  secured 
by  a  double  row  of  sutures. 

Affections  of  the  Pancreas. 

The  pancreas  is  an  organ  which  rarely  calls  for  the  attention  of  surgeons, 
and  only  a  few  conditions  need  be  mentioned. 

Wounds  of  the  Pancreas  occur,  but  are  so  often  associated  with  damage  to 
neighbouring  important  tissues  that  they  seldom  need  treatment  per  se. 
Prolapse  through  an  abdominal  wound  has  been  recorded  in  a  few  cases,  the 
organ  having  been  almost  entirely  separated  from  its  connections ;  however 
bruised  or  damaged,  its  total  extirpation  must  never  be  resorted  to,  since 
diabetes  is  certain  to  follow  ;  it  should  therefore  be  carefully  purified  and 
replaced. 

Acute  Purulent  Pancreatitis  is  almost  invariably  a  result  of  infection  from 
the  intestine,  or  from  neighbouring  parts.  It  produces  symptoms  of  deep 
suppuration  with  excruciating  pain,  probably  from  implication  of  the  cceliac 
plexus,  and  often  causes  death  from  purulent  peritonitis.  A  pancreatic  abscess 
may  be  opened  from  the  front,  but  the  greatest  precautions  must  be  taken 
against  infecting  the  peritoneal  cavity.  The  stomach  is  drawn  up,  and  the 
surgeon  burrows  through  the  omentum  between  it  and  the  transverse  colon. 
A  counter-opening  for  drainage  can  be  made  by  the  side  of  the  first  lumbar 
vertebra ;  but  it  must  be  remembered  that  both  the  aorta  and  vena  cava,  and 
the  root  of  the  superior  mesenteric  vessels,  lie  behind  the  gland. 

Cysts  of  the  Pancreas  have  been  observed  and  treated  in  so  many  cases 
since  1887  that  their  characters  are  pretty  clearly  known.  Simple  com- 
plete obstruction  to  the  duct  has  been  proved  exparimentally  not  to  be  a 
sufficient  cause  for  the  disease  ;  some  pathological  condition  of  the  epithelium 
must  also  be  present,  preventing  the  re-absorption  of  the  retained  secretion. 
The  fluid  within  is  usually  turbid  and  brownish  from  admixture  with  blood, 
odourless,  and  with  a  fairly  high  specific  gravity  ;  it  is  of  an  alkaline  or  neutral 
reaction,  and  contains  albumen,  but  no  urea  or  bile ;  it  is  capable  of  peptonizing 
albumen,  of  emulsifying  fat,  and  of  converting  starch  into  sugar.  The  cyst  can 
be  felt  as  a  rounded,  tense,  fluctuating  or  elastic  swelling,  placed  deeply  in  the 
abdomen,  immoveable,  and  perhaps  transmitting  the  aortic  pulsation.  The 
stomach  lies  directly  in  front  of  it,  as  can  be  made  evident  by  distending  it 
with  gas.  It  is  usually  a  disease  of  middle  life,  occurring  most  frequently  in 
men ;  emaciation  is  not  marked,  although  a  good  proportion  of  the  fatty  food 
passes  away  in  the  motions ;  the  skin  is  often  dirty,  earthy,  and  unhealthy- 
looking.  Treatment  consists  in  laying  the  cavity  open,  drawing  off  its  contents, 
and  draining  it,  the  surgeon  finding  his  way  to  the  cyst  between  the  stomach 
and  transverse  colon.  A  large  tube  is  inserted,  either  through  the  front,  or 
from  the  back  by  the  side  of  the  vertebrae.  The  skin  around  usually  becomes 
irritated  by  the  discharge,  owing  to  a  process  of  digestion.     The  prognosis 


ABDOMINAL  SURGERY  965 


with  such  treatment  is  very  good,  Treves  having  collected  fifteen  cures  out  of 
sixteen  cases  thus  dealt  with. 

Carcinoma  of  the  Pancreas  is  met  with  either  as  a  primary  growth,  or 
secondary  to  a  similar  disease  of  the  pylorus.  It  is  usually,  but  not  invariably, 
of  a  scirrhous  type,  and  may  lead  to  distension  of  the  stomach  from  pressure 
on  and  constriction  of  the  pylorus,  and  to  jaundice  and  ascites  by  involving 
the  bile  duct  and  portal  vein.  In  one  or  two  cases  removal  has  been  under- 
taken with  success,  although  an  exact  diagnosis  was  not  arrived  at  before  the 
operation.     Sarcomata  and  other  tumours  are  very  rare. 

Affections  of  the  Spleen. 

Rupture  of  the  Spleen  occurs  as  a  result  of  injury,  causing  great  shock,  pain 
in  the  left  hypochondrium,  and  internal  haemorrhage,  usually  to  such  an  extent 
as  to  prove  rapidly  fatal.  In  less  severe  cases  the  blood  collects  in  the  left 
loin,  and  gravitates  towards  the  pelvis,  the  right  loin  being  often  kept  clear  by 
the  position  of  the  mesentery.  Laparotomy  should  be  undertaken  wherever 
practicable,  and,  if  much  damaged,  the  organ  is  removed,  the  splenic  vessels 
being  secured  by  ligature ;  the  results  of  such  treatment  have  been  most  satis- 
factory. In  a  few  cases  it  has  been  possible  to  stop  the  bleeding  by  inserting 
a  gauze  tampon,  which  is  removed  in  a  few  days. 

Abscess  of  the  Spleen  may  develop  in  the  course  of  pyaemia,  or  follow  an 
injury,  especially  if  associated  with  a  lesion  of  a  neighbouring  coil  of  intestine. 
The  symptoms  are  merely  those  of  deep  suppuration  in  the  left  hypochondrium, 
and  the  abscess  either  finds  its  way  externally,  or  bursts  into  the  peritoneal 
cavity.  It  may  be  opened  and  drained  with  the  same  precautions  as  for  any 
other  intraperitoneal  collection  of  matter,  and  the  results  hitherto  obtained 
have  been  encouraging.  In  pyaemia  the  disease  is  often  fatal  before  the  local 
phenomena  are  recognised. 

Floating  Spleen  is  occasionally  congenital,  but  more  commonly  acquired, 
in  consequence  of  tight  lacing,  injuries,  or  the  presence  of  tumours.  It  is 
known  by  the  existence  of  a  moveable  intra-abdominal  swelling,  whose  shape 
is  that  of  the  spleen,  and  having  a  notch  in  its  anterior  border;  its  size 
increases  after  meals.  It  may  be  so  displaced  as  to  lie  in  the  right  iliac  fossa, 
or  even  in  the  pelvis,  and  then  has  a  long  narrow  pedicle  which  has,  in  a  few 
cases,  led  to  its  torsion  and  strangulation.  Splenectomy  was  formerly  the 
only  treatment,  if  the  displaced  organ  caused  discomfort  or  pain  ;  it  has  been 
found  possible,  however,  to  fix  it,  and  several  successful  cases  have  now  been 
recorded.  Splenopexy,  as  the  operation  is  termed,  is  best  undertaken  by  pre- 
paring a  bed  for  the  organ  outside  the  peritoneum  in  the  loose  cellular  tissue 
beneath  the  floating  ribs  on  the  left  side.  The  spleen  is  then  slipped  through 
a  small  hole  specially  made  for  the  purpose  in  the  parietal  peritoneum,  and 
secured  by  stitches,  which  pass  through  its  capsule  and  anchor  it  to  the  under 
surface  of  the  diaphragm. 

Tumours  of  the  Spleen  are  met  with  either  in  the  form  of  a  general  hyper- 
trophy, as  in  lymphadenoma  or  malaria,  or  as  new  growths,  such  as  cysts 
(hydatid  most  frequently),  or  secondary  carcinoma  or  sarcoma.  The  spleen 
also  becomes  enlarged  in  lardaceous  disease,  rickets,  and  many  of  the  general 
fevers.  An  enlarged  spleen  constitutes  a  swelling  which  extends  downwards 
from  the  left  hypochondrium  towards  the  umbilicus,  the  notch  being  felt 
anteriorly.  The  condition  is  recognised  by  the  constant  absence  of  intestine 
in  front  of  it,  by  the  resonant  note  obtained  in  the  flank,  by  its  mobility  with 
respiration,  and  occasionally  by  its  increased  size  after  meals.  The  treatment, 
where  advisable,  consists  either  of  splenectomy,  or,  in  the  case  of  cysts,  of 
incision  and  drainage. 

Splenectomy,  or  extirpation  of  the  spleen,  has  been  undertaken  for  a  variety 
of  conditions,  and  its  value  and  position,  as  a  surgical  procedure,  are  now 
pretty  well  established.  For  traumatic  lesions  it  is  both  safe  and  justifiable. 
For  primary  hypertrophy,  and  for  malarial  enlargement,  it  may  be  performed 


966  A  MANUAL  OF  SURGERY 

if  serious  discomfort  is  being  caused,  and  cannot  otherwise  be  remedied.  If 
drainage  fails  to  cure  cysts,  excision  may  be  performed.  If  malignant  disease 
is  diagnosed  sufficiently  early,  the  organ  may  be  removed.  Splenectomy  for 
leucocythsemia  is  absolutely  unjustifiable,  all  the  cases  operated  on  having 
died.  The  operation  is  performed  through  any  suitable  incision  of  sufficient 
length.  The  peritoneum  having  been  opened,  the  organ  is  carefully  examined, 
and  if  extensive  adhesions  are  present,  the  surgeon  will  be  wise  to  desist,  since 
fatal  haemorrhage  is  very  likely  to  result  from  any  attempt  to  break  them  down. 
If  the  organ  is  freely  moveable,  it  is  carefully  drawn  out  of  the  abdomen,  the 
pedicle  being  isolated,  and  secured  temporarily  by  pressure  forceps.  It  is  then 
cut  away,  and  the  pedicle  tied  after  transfixion  with  silk  ligatures,  the  ends  of 
which  are  cut  short,  and  returned  into  the  abdomen. 

General  Remarks  on  Abdominal  Operations. 

Before  concluding  this  chapter,  it  seems  desirable  to  add  a  few 
remarks  dealing  generally  with  the  subject  of  abdominal  opera- 
tions. Formerly  they  were  of  rare  occurrence,  and  perhaps  this 
was  as  well,  since  septic  peritonitis  frequently  followed.  At  the 
present  time  no  competent  operator  hesitates  to  open  the  abdomen 
whenever  required,  and  the  death-rate  from  preventible  causes 
has  been  steadily  diminishing.  The  peritoneum,  which  formerly 
the  surgeon  dreaded  to  touch,  is  now  one  of  his  best  friends,  if 
properly  treated.  Attention  to  minute  details  is  essential  if  good 
results  are  to  be  obtained,  and  the  following  are  a  few  points 
which  may  prove  of  service  to  those  aspiring  to  success  in  this 
important  branch  of  work. 

The  patient  should  be  carefully  prepared,  when  circumstances 
permit,  by  regulating  the  diet  and  bowels  for  some  days  previously, 
so  that  the  intestinal  canal  may  be  as  free  from  organisms  as 
possible  ;  a  course  of  internal  antiseptics,  such  as  salol,  calomel, 
/3-naphthol,  may  be  advisable.  If  there  seems  a  likelihood  of 
streptococcal  infection,  the  patient  may  be  immunized  to  the 
action  of  such  organisms  by  the  previous  injection  for  a  day  or 
two  of  a  sufficient  dose  of  antistreptococcic  serum,  as  suggested 
by  H.  E.  Durham;  10  c.c.  given  twice  or  thrice  a  day  for  two 
or  three  days  will  suffice  for  this  purpose.  No  food  should  be 
allowed  by  mouth  for  some  hours,  and  immediately  before  being 
placed  on  the  table  the  bladder  should  be  emptied.  If  the  pro- 
ceedings are  likely  to  be  protracted,  it  is  advisable  to  give  a  rectal 
injection  of  warm  saline  solution,  or  of  beef-tea  and  brandy,  half 
an  hour  beforehand,  and  possibly  a  hypodermic  injection  of 
strychnine  (gr.  ^). 

The  patient  should  be  warmly  wrapped  up  and  protected  from 
cold,  no  unnecessary  exposure  being  allowed.  Chloroform  is  the 
best  anaesthetic  to  employ  in  all  abdominal  cases,  and  the  more 
complete  the  anaesthesia,  the  less  the  shock.  Intraperitoneal 
operations  are  not  painless,  as  has  been  often  stated,  for  although 
the  visceral  peritoneum  is  not  acutely  sensitive,  yet  the  parietal 
layer  is,  and  any  handling  of  this  structure  gives  rise  to  pain  and 
necessarily  to  increased  shock,  if  the  patient  is  conscious. 


ABDOMINAL  SURGERY  967 


The  skin  of  the  abdomen,  the  hands  of  the  surgeon,  and  the 
instruments,  are  rendered  aseptic  in  the  usual  way,  special  atten- 
tion being  directed  to  the  umbilical  cicatrix.  As  soon,  however, 
as  the  peritoneum  has  been  opened,  all  strong  antiseptics  must  be 
discarded,  since  they  are  likely  to  irritate  this  delicate  membrane, 
thus  doing  more  harm  than  good.  Warm  sterilized  salt  solution 
is  the  best  fluid  to  employ  for  irrigating  the  serous  cavity,  or  for 
washing  out  sponges,  swabs,  or  cloths.  If  sponges  are  employed, 
they  should  be  counted  both  before  the  operation,  and  again  before 
closing  the  abdomen. 

Parietal  Incision. — Formerly,  whenever  practicable,  the  incision 
was  made  in  the  middle  line  through  the  linea  alba,  in  conse- 
quence of  the  facts  that  there  is  less  bleeding  in  this  situation, 
that  all  parts  of  the  abdomen  are  easily  accessible  from  it,  and 
that  the  wound  is  more  rapidly  closed.  It  has  been  found,  how- 
ever, that  ventral  hernia  is  a  not  uncommon  sequela,  and  hence 
the  general  practice  at  the  present  time  is  to  make  one's  incision 
in  any  suitable  place,  and  preferably  through  vascular  structures 
such  as  muscle,  retaining  the  linea  alba  for  cases  where  drainage 
of  a  septic  focus  has  to  be  maintained.  Even  in  such  operations 
as  ovariotomy,  where  the  middle  line  gives  the  best  access,  it  is 
wise  to  go  through  the  rectus  a  little  to  one  side  of  the  centre 
rather  than  through  the  linea  alba  itself.  The  linea  semilunaris, 
again,  is  a  bad  situation  for  an  incision,  since  the  traction  of  the 
muscles  which  are  inserted  into  its  outer  side  is  so  great  that 
hernia  is  very  likely  to  follow.  On  the  other  hand,  care  must  be 
exercised  not  to  place  the  incisions  too  near  the  bony  margins 
of  the  abdominal  cavity,  or  subsequent  manipulations  may  be 
hampered  by  the  rigidity  of  one  side  of  the  wound. 

The  muscles  should  be  cleanly  divided,  and  it  is  wise  to  see 
that  all  bleeding  is  stopped  before  opening  the  peritoneum. 
Directors  are  best  avoided,  since  they  are  very  likely  to  wound 
the  serous  membrane,  and  are  quite  unnecessary  in  skilled  hands. 
A  small  hole  should  be  first  made  in  the  peritoneum,  through 
which  a  blunt-nosed  pair  of  forceps  is  inserted,  and  by  lifting 
these  up  and  allowing  the  blades  to  separate  slightly,  a  convenient 
and  safe  substitute  for  a  director  is  obtained.  If  a  long  incision  is 
required,  the  left  index  and  middle  fingers  are  passed  through  this 
opening ;  the  intestines  and  omentum  are  thus  kept  out  of  the 
way,  the  peritoneum  being  well  raised  and  divided  by  scissors  to 
the  required  extent. 

The  intestines  must  be  most  carefully  guarded  during  the 
intraperitoneal  portion  of  the  operation,  as  if  they  are  exposed 
to  the  air,  the  endothelial  lining  is  quickly  shed,  and  adhesions 
may  form  from  without,  whilst  bacterial  invasion  may  be  predis- 
posed to  from  within.  A  series  of  cloths  wrung  out  of  warm 
sterilized  salt  solution  must  be  kept  wrapped  round  them  by  the 
assistant,  and  no  unnecessary  handling  should  be  permitted. 


968  A  MANUAL  OF  SURGERY 


Closure  of  the  Wound. — A  careful  toilette  of  the  peritoneum 
must  be  undertaken  before  the  abdomen  is  closed.  All  blood-clot 
is  removed,  sponges  are  counted,  and,  if  there  has  been  any 
extravasation  of  infective  material,  it  is  well  to  wash  the  site  of 
operation  with  sterilized  salt  solution  at  a  temperature  of  about 
io8°  F.,  a  proceeding  which  often  assists  considerably  in  mini- 
mizing shock.  Many  different  methods  of  closing  the  parietal 
incision  have  been  adopted,  but  perhaps  the  best  consists  in 
securing  the  serous  and  muscular  coats  by  one  set  of  deep  inter- 
rupted stitches  either  of  purified  silk  or  of  silkworm  gut,  which 
remain  buried,  and  then  in  dealing  with  the  skin  by  means 
of  a  continuous  suture,  which  is  subsequently  removed.  There 
is  no  advantage  in  taking  up  each  of  the  layers  separately,  and 
the  integrity  of  the  abdominal  cicatrix  is  increased  by  leaving  all 
the  deeper  stitches  in  situ. 

Drainage  is  not  usually  called  for  in  abdominal  operations.  If 
the  surgeon  is  careful  in  his  manipulations,  and  avoids  measures 
which  are  likely  to  lead  to  subsequent  oozing,  the  peritoneum 
may  be  closed  with  safety.  Where  an  inflammatory  focus  has 
been  opened,  or  when  adhesions  likely  to  bleed  have  been  divided, 
or  raw  surfaces  left  such  as  occur  after  enucleating  a  parovarian 
cyst  from  the  broad  ligament,  some  means  should  be  provided 
whereby  any  considerable  effusion  of  fluid  can  escape.  It  is 
found  that  capillary  drainage  along  a  strip  of  gauze  is  the  best 
that  can  be  employed  for  blood  or  serum.  Ordinary  indiarubber 
tubes  are  liable  to  become  blocked  by  portions  of  the  intestine 
protruding  into  the  lateral  openings,  whilst  glass  tubes,  such  as 
Keith's,  are  unyielding,  and  fail  to  accommodate  themselves  to 
the  sinuosities  of  the  regions  needing  drainage.  Strips  of  aseptic 
gauze  are  therefore  inserted  like  lampwicks,  and  along  these,  by 
capillary  action,  the  effusion  finds  its  way  into  the  general  dressing 
placed  over  the  wound.  Of  course  a  certain  amount  of  adhesive 
inflammation  follows,  and  therefore  the  wick  should  be  as  small 
as  possible,  consistent  with  efficiency,  and  is  changed  or  removed 
at  the  end  of  forty-eight  hours.  In  some  cases  it  is  an  advantage 
to  enclose  the  gauze- wick  in  gutta  percha  tissue  which  has  been* 
previously  perforated  here  and  there.  Where,  however,  pus  is  to 
be  removed,  ordinary  drainage-tubes  must  be  employed. 

After-Treatment. — After  the  completion  of  the  operation,  the 
patient  is  replaced  in  bed,  with  the  head  low.  If  restless  and 
irritable,  a  small  dose  of  opium  may  be  administered,  but  the  less 
the  better,  since  it  induces  intestinal  paresis,  and  this  in  turn 
assists  bacterial  invasion  from  the  gut.  No  food  is  allowed  to  enter 
the  stomach  for  twenty-four  hours,  although  the  mouth  may  be 
washed  out  with  warm  water  or  with  still  lemonade,  and  nutrient 
enemata  administered  every  four  or  six  hours.  The  great  essential 
is  to  avoid  vomiting,  and  this  is  best  accomplished  by  a  complete 
temporary  cessation  of  stomach-feeding.     At  the  end  of  twenty- 


ABDOMINAL  SURGERY  969 


four  hours,  if  all  is  going  well,  a  little  fluid  nourishment  may  be 
given,  and  this  is  gradually  increased.  The  bowels  are  left  to 
nature,  and  unless  constipation  persists  for  some  days  no  aperient 
is  necessary. 

If  peritonitis  is  threatening,  the  patient  complains  of  abdominal 
pain  and  distension,  whilst  flatulence  and  vomiting  are  distressing 
symptoms  (peritonism).  Under  these  circumstances  the  adminis- 
tration of  a  saline  purgative  (e.g.,  20  grains  of  sulphate  of  soda 
every  half- hour)  may  stop  the  process  by  re-establishing  peri- 
stalsis, removing  bacteria  and  their  products,  and  lessening  the 
vascular  tension.  Failing  this,  the  outlook  is  grave,  though  in 
some  cases  it  may  be  justifiable  to  reopen  the  abdomen,  wash 
out,  and  drain. 


CHAPTER  XXXIII. 
HERNIA. 

By  the  term  Hernia  is  meant  the  protrusion  of  some  viscus  from 
its  normal  situation  through  an  opening  in  the  walls  of  the  cavity 
within  which  it  is  contained.  This  may  affect  not  only  the 
abdominal  viscera,  but  also  the  brain  and  lungs,  giving  rise  to 
conditions  which  we  have  already  described.  In  this  chapter 
we  merely  deal  with  hernia  as  met  with  in  connection  with  the 
abdomen. 

The  most  common  Situations  at  which  hernia  occurs  are  those 
spots  where  the  parietes  are  weakened  by  the  transmission  of  such 
structures  as  the  spermatic  cord  and  round  ligament  (inguinal 
hernia),  or  at  the  entrance  of  the  crural  canal,  where  the  main 
vessels  of  the  leg  pass  under  Poupart's  ligament  (femoral  hernia), 
or  at  the  umbilicus  (umbilical  hernia).  Viscera  may,  however, 
protrude  through  the  obturator  foramen,  sciatic  notch,  the 
diaphragm,  and  in  various  other  situations. 

^Etiology. — A  great  many  conditions  may  be  associated,  directly 
or  indirectly,  with  the  production  of  a  hernia.  They  may,  how- 
ever, be  described  for  practical  purposes  under  two  main  headings 
— the  congenital  and  the  acquired. 

Congenital  Causes  are  rather  predisposing  than  exciting  in  nature, 
and  must  be  looked  for  amongst  the  many  malformations  and 
conditions  of  imperfect  development  to  which  the  abdominal 
parietes  and  contents  are  liable.  The  following  are  the  most 
important  of  these  :  (a)  The  non-obliteration  of  the  funicular 
process  of  peritoneum,  which  in  the  male  precedes  and  accom- 
panies the  testicle  on  its  progress  downwards  from  the  abdominal 
cavity  to  the  scrotum,  and  in  the  female  passes  along  the  round 
ligament.  The  so-called  congenital  inguinal  hernia  results  from 
this,  although  it  must  be  remembered  that  the  rupture  does  not 
necessarily  show  itself  at  birth,  and,  indeed,  may  not  appear  till 
after  puberty,  the  term  being  therefore  a  misnomer.  In  females 
under  the  age  of  twenty-five,  hernia  into  the  canal  of  Nuck,  as 
this  peritoneal  tube  is  called,  is  the  most  frequent  variety  met 


HERNIA  971 

with,  (b)  The  late  descent  of  the  testis,  whether  it  finds  its  way 
into  the  scrotum  or  not,  is  usually  associated  with  the  formation 
of  an  inguinal  hernia  of  the  congenital  type,  or  of  some  form  of 
interstitial  hernia.  (c)  Inherited  weakness  of  the  abdominal 
muscles  and  parietes,  with  unusual  patency  of  the  rings,  will 
certainly  predispose  to  this  condition,  and,  moreover,  there  is 
no  doubt  as  to  the  tendency  of  hernia  to  run  in  families. 
(d)  Abnormal  length  of  the  mesentery  or  omentum  has  also 
been  looked  on  as  a  causative  factor ;  but,  although  it  may 
have  some  influence  when  other  conditions  are  present,  it  can 
per  se  have  but  little  effect,  (e)  Congenital  phimosis,  by  inducing 
forcible  acts  of  micturition,  acts  as  an  exciting  cause.  (/)  Con- 
genital apertures  occur  in  the  linea  alba  or  linea  semilunaris, 
especially  opposite  one  of  the  muscular  intersections  in  the  rectus, 
and  through  these  one  form  of  ventral  hernia  may  develop. 
(g)  The  umbilicus  is  sometimes  imperfectly  developed  at  birth, 
permitting  the  viscera  to  protrude  into  the  base  of  the  umbilical 
cord  (congenital  umbilical  hernia),  (h)  The  diaphragm  is  also 
occasionally  defective,  allowing  the  stomach  or  other  viscera  to 
find  their  way  into  the  thoracic  cavity. 

Acquired  Causes. — Hernia  may  result  from  any  condition  which 
tends  either  to  weaken  the  abdominal  parietes,  or  to  increase  the 
intra-abdominal  pressure.  Thus,  all  violent  exercise,  especially 
when  of  an  intermittent  nature  and  accompanied  by  excessive 
straining,  as  in  lifting  heavy  weights,  may  determine  its  occur- 
rence, and  the  more  so  if  the  individual  is  forced  to  maintain  the 
upright  position,  or  wears  tight  bands  or  girths  round  the  abdomen. 
Pregnancy  stretches  the  abdominal  walls,  and  parturition,  by 
inducing  violent  muscular  contraction,  may  originate  a  rupture, 
either  through  a  split  in  the  linea  alba  or  through  the  crural 
canal.  Prolonged  and  severe  bronchitis  also  favours  the  occur- 
rence of  a  hernia  by  the  increase  of  intra-abdominal  pressure  due 
to  coughing,  whilst  the  straining  to  pass  water  in  cases  of  enlarged 
prostate  or  stricture  may  act  in  a  similar  manner.  Chronic  con- 
stipation is  a  frequent  factor  in  its  production,  especially  if  the 
patient  makes  use  of  a  closet  with  a  high  seat,  whereby  the 
inguinal  canals  are  left  unprotected  ;  in  uncivilized  races,  where 
defaecation  is  performed  in  the  squatting  posture,  the  lower  part 
of  the  abdomen  is  supported  by  the  flexed  thighs,  and  hernia  is 
very  uncommon.  Patients  with  weak  and  bulging  inguinal 
regions  may  with  advantage  use  a  low  commode.  In  old  and 
weakly  people,  an  additional  cause  may  be  found  in  the  slipping 
downwards  of  the  mesenteric  attachment,  causing  the  intestines 
to  occupy  the  lower  part  of  the  abdomen  rather  than  the  upper, 
so  that  the  former  bulges  out  over  the  pelvic  brim.  This  is 
possibly  due  to  weakening  or  relaxation  of  the  unstriped  mus- 
cular tissue  which  normally  exists  behind  the  peritoneum,  passing 
from  the  posterior  abdominal  wall  to  the  base  of  the  mesentery ; 


972  A   MANUAL  OF  SURGERY 

it  is  sometimes  called  the  muscle  of  Treitz.  Obesity  is  also  a  pre- 
disposing factor  to  hernia,  the  accumulated  fat  being  deposited  in 
the  omentum,  mesentery,  and  subperitoneal  tissue,  thus  increas- 
ing the  intra-abdominal  tension. 

Structure. — A  hernia  consists  of  a  sac  and  its  contents,  the 
sac  being  formed  of  peritoneum,  perhaps  thickened  by  additional 
coverings,  derived  from  the  abdominal  parietes,  and  the  contents 
being  the  protruded  viscera. 

The  sac,  or  peritoneal  investment  of  an  acquired  hernia,  is  in 
the  early  stages  funnel-shaped,  small,  and  thin,  being  derived 
from  that  portion  of  the  serous  membrane  which  normally  lies 
over  the  hernial  aperture.  As  the  rupture  increases  in  size,  the 
sac  becomes  larger,  partly  as  a  result  of  the  stretching  of  that 
portion  of  the  serous  membrane  already  protruded,  and  partly  by 
the  drawing  down  of  fresh  membrane  from  the  neighbourhood ; 
in  the  groin  this  is  derived  rather  from  the  iliac  fossa  than  from 
the  anterior  abdominal  wall.  The  sac  is  described  as  consisting 
of  two  portions — the  neck  and  the  fundus.  The  neck,  sometimes 
large  and  open  at  first,  gradually  becomes  narrowed,  and  is 
generally  thickened  from  the  irritation  to  which  it  has  been  ex- 
posed, either  from  the  wearing  of  a  truss  or  from  the  pressure  of 
the  contained  viscera.  The  body,  or  fundus,  varies  much  in  size 
and  shape,  and  may  undergo  considerable  alterations  in  structure. 

(a)  The  sac,  which  is  at  first  easily  replaced,  soon  becomes 
irreducible  from  adhesions  to  surrounding  parts,  though  it  can  still 
be  readily  emptied  of  its  contents,  (b)  Inflammation  may  occur  as 
a  result  of  injury  or  pressure,  constituting  a  form  of  localized  peri- 
tonitis. If  this  is  of  a  chronic  type,  the  sac  becomes  thickened 
and  opaque,  with  dilated  vessels  coursing  over  it,  as  seen  especially 
in  old  irreducible  umbilical  hernia.  Acute  or  subacute  inflam- 
mation is  also  met  with,  resulting  in  the  formation  of  adhesions 
between  its  inner  wall  and  the  contained  viscera,  or  between  the 
opposite  sides  of  the  sac  if  no  other  structures  interpose.  Natural 
cure  of  a  hernia  may  in  this  way  be  occasionally  produced  by 
adhesions  forming  across  the  neck  of  the  sac,  or  by  an  adherent 
plug  of  omentum,  thus  occluding  the  communication  with  the 
peritoneal  cavity.  The  lower  portion  of  the  sac  may  in  a  similar 
way  be  shut  off  from  the  upper,  either  by  a  band  of  adhesions  or 
by  a  septum  of  adherent  omentum  ;  this  isolated  cavity  is  some- 
times the  seat  of  a  serous  effusion,  known  as  a  hydrocele  of  a  hernial 
sac.  (c)  Haemorrhage  into  the  sac  wall  may  result  from  violence, 
and  will  cause  it  to  become  much  thickened,  and  even  pigmented 
and  leathery  in  appearance. 

The  coverings  of  the  sac  are  indurated  in  old-standing  cases, 
and  matted  together  in  such  a  manner  as  to  render  it  impossible 
to  recognise  the  constituent  parts.  This  is  specially  noticeable  at 
the  neck  of  the  sac,  where  their  union  with  surrounding  structures 
is  often  such  as  to  constitute  an  important  predisposing  element 


HERNIA  973 

in  the  production  of  strangulation.  The  opening  through  which 
the  hernia  protrudes  loses  its  characteristic  features  and  shape, 
being  enlarged,  more  or  less  circular,  and  displaced  so  that  an 
oblique  passage,  such  as  the  inguinal  canal,  becomes  straight,  the 
internal  abdominal  ring  lying  almost  immediately  behind  the 
external. 

Contents. — Any  viscus  in  the  abdomen  may  be  found  in  the  sac 
of  a  hernia,  except,  perhaps,  the  pancreas ;  as  a  rule,  however, 
one  finds  only  small  intestine  or  omentum. 

An  enterocele  is  the  name  given  to  a  hernia  containing  some 
portion  of  the  bowel.  It  is  at  first  reducible ;  but  if  the  gut 
becomes  adherent,  either  to  the  sac  or  to  some  other  contained 
structure,  it  is  rendered  irreducible.  It  may  also  participate  in 
an  inflammatory  condition  of  the  sac ;  whilst,  if  irreducible, 
obstruction  may  ensue  from  impaction  of  its  contents,  and  if  its 
vessels  are  constricted  strangulation  supervenes.  For  a  descrip- 
tion of  these  conditions,  see  p.  945.  The  small  intestine  is  much 
more  frequently  involved  than  the  large  gut.  The  amount  of 
bowel  protruded  varies  from  a  few  inches  to  several  feet. 

If  omentum  is  found  in  a  hernial  sac,  the  condition  is  known  as 
an  epiplocele.  As  long  as  it  remains  reducible,  it  is  likely  to  retain 
its  normal  texture ;  but  when  large  in  amount,  and  especially  if 
irreducible,  it  becomes  ihickened,  brawny,  and  matted  together 
to  such  an  extent  as  almost  to  constitute  a  solid  tumour  ;  it  is 
often  the  seat  of  an  excessive  deposit  of  fat,  and  in  consequence 
of  this  overgrowth  it  may  become  irreducible,  even  when  no 
adhesions  are  present.  Serous  cysts  sometimes  develop  within  it 
as  a  result  of  effusion  between  opposed  surfaces.  In  some  cases 
openings  are  found  in  it  of  sufficient  size  to  allow  the  gut  to  pass 
through  and  become  strangulated.  When  omentum  and  bowel 
are  present  in  the  same  sac,  the  condition  is  known  as  an  entero- 
epiplocele. 

Much  discussion  has  been  caused  by  the  occasional  presence 
of  the  ccecum  in  a  hernial  sac.  It  was  formerly  supposed  that  this 
viscus  was  only  partially  surrounded  with  peritoneum,  and  hence 
it  was  maintained  that  when  found  in  a  hernial  sac  the  peritoneal 
investment  was  incomplete.  It  is  now,  however,  universally 
acknowledged  that  a  caecum  has  generally  a  complete  serous 
covering  and  usually  a  mesentery,  so  that  it  is  freely  moveable  ; 
consequently  it  may  pass  into  a  hernial  sac  in  the  same  way  as 
any  other  moveable  part  of  the  intestine,  and  several  instances  are 
on  record  in  which  it  has  been  found  in  children  to  occupy  the  sac 
of  an  inguinal  hernia  on  the  left  side.  On  the  other  hand,  a  few 
indisputable  cases  have  been  related  in  which  the  serous  envelope 
was  incomplete  in  a  so-called  '  caecocele.' 

The  bladder  may  be  associated  with  a  hernial  sac  in  two  distinct 
ways,  and  usually  in  the  inguinal  region,  (a)  The  fundus  may 
be  dragged  downwards  by  the  traction  of  the  peritoneum,  when 


974  A   MANUAL  OF  SURGERY 


the  hernia  has  attained  a  colossal  size.  There  is  then  only  a 
partial  peritoneal  investment,  the  bladder  lying  outside  the  sac, 
and  being  adherent  to  it.  Considerable  irritability  of  tlK  viscus 
is  induced,  and,  owing  to  stagnation  of  urine  in  the  displaced 
part,  a  phosphatic  concretion  may  form  therein,  and  such  has 
even  been  removed  by  incision  through  the  scrotum,  (b)  Occa- 
sionally a  saccule  of  the  outer  wall  of  the  bladder  becomes  ad- 
herent to  the  peritoneum,  and  is  drawn  down  by  it  into  the 
inguinal  canal ;  its  presence  may  be  suspected  if  a  small  hernia 
is  associated  with  much  vesical  irritability.  Such  a  protrusion 
consists  merely  of  thickened  mucous  membrane  and  submucous 
tissue,  and  is  devoid  of  muscular  fibres  ;  it  is  very  liable  to  be  laid 
open  if  an  operation  for  the  radical  cure  is  undertaken.  If  such 
an  accident  happens,  the  opening  must  be  at  once  closed  by 
sutures,  which  should  not  penetrate  the  mucous  membrane,  other- 
wise phosphatic  concretions  may  form  on  the  portion  of  suture 
exposed,  and  cause  subsequent  trouble. 

Loose  foreign  bodies,  somewhat  resembling  marbles  in  size,  are 
occasionally,  but  very  rarely,  met  with  in  hernial  sacs.  They  are 
derived  from  the  detachment  of  one  or  more  of  the  appendices 
epiploicse,  which  subsequently  become  enlarged  from  a  deposit  of 
fibrin  induced  by  movement  in  the  peritoneal  cavity,  and  may 
even  calcify. 

Signs  and  Symptoms. — -The  characteristic  features  whereby  a 
hernial  protrusion  is  recognised  consist  in  the  presence  of  a  rounded 
or  pyriform  swelling,  in  one  of  the  normal  or  abnormal  situations 
already  mentioned,  which  increases  in  size  when  the  patient 
stands,  coughs,  or  strains,  having,  as  it  is  termed,  '  an  impulse  on 
coughing.'  If  intestine  is  present,  it  may  be  possible  to  obtain 
a  tympanitic  note  on  percussion,  whilst  the  tumour  is  tense  and 
rounded,  and  on  pressure  slips  back  into  the  abdomen  with  a 
distinct  gurgle.  An  enterocele  often  gives  rise  to  dyspeptic 
phenomena,  and  perhaps  to  colicky  pains.  An  omental  hernia 
feels  soft  and  doughy,  has  a  less  distinct  impulse,  or  even  none, 
on  coughing,  and  is  replaced  without  a  gurgle ;  it  is  dull  on  per- 
cussion. When  allowed  to  reappear,  it  does  so  slowly  without 
any  sudden  impulse,  the  omentum  insinuating  itself  gently  down 
the  inguinal  canal,  and  gradually  distending  the  sac. 

The  Treatment  of  hernia,  whether  palliative  by  means  of 
trusses,  or  radical  by  means  of  operation,  differs  so  greatly  in 
the  various  forms,  that  it  will  be  better  to  discuss  each  one 
separately. 

Special  Forms  of  Hernia. 

Inguii.al  Hernia. — The  term  inguinal  hernia  is  limited  to  those 
conditions  in  which  a  protrusion  occurs  into  the  inguinal  canal, 
and,  if  allowed  to  progress,  finally  makes  its  way  through  the 


HERNIA 


975 


external  abdominal  ring.  If  it  extends  into  the  scrotum,  it  is 
termed  complete,  or  scrotal ;  whilst  if  it  does  not  pass  beyond  the 
external  abdominal  ring,  it  is  known  as  a  bubonocele  or  incom- 
plete inguinal  hernia.  The  neck  is  always  in  relation  with  the 
deep  epigastric  artery,  and  the  structures  of  the  cord  are  either 
spread  out  over  the  sac  or  are  in  close  proximity  to  it.  In  the 
early  stages,  the  pubic  spine  can  be  felt  to  the  outer  side  of  the 
neck  of  the  sac ;  but  as  it  increases  in  size  it  lies  over  the  spine, 
which  can  only  be  felt  after  pushing  the  hernia  upwards  and 
inwards. 

Two  main  varieties  of  inguinal  hernia  are  described,  viz.,  the 
oblique  and  the  direct. 

An  Oblique  Inguinal  Hernia  (Fig.  348)  is  one  which  passes  down 


Fig.  348. — Double  Oblique  In- 
guinal Hernia. 


Fig.  349. — Diagram  of  Acquired  In- 
guinal Hernia,  showing  Serous 
Sac  with  Intestine  coming  down 
to  the  Top  of  the  Testis. 


the  whole  length  of  the  inguinal  canal,  entering  at  the  internal 
and  emerging  at  the  external  abdominal  ring ;  the  deep  epigastric 
artery  is  thus  placed  to  the  inner  side  of  the  neck.  During  its 
passage  through  the  canal  every  form  of  oblique  hernia  pushes 
before  it  and  becomes  covered  by  structures  representing  the 
various  layers  of  the  abdominal  parietes.  Hence,  in  cutting  down 
on  such  a  sac,  the  surgeon  will  divide,  in  addition  to  the  skin  and 
subcutaneous  tissues,  (a)  the  intercolumnar  fascia,  derived  from 
the  transverse  fibres  of  the  external  oblique  which  pass  across  the 
external  abdominal  ring ;  (b)  the  cremasteric  muscle  and  fascia, 
representing  and  extending  from  the  internal  oblique  ;  (c)  the 
infundibuliform  fascia  derived  from  the  fascia  transversalis ;  and 
(d)  finally,  a  layer  of  subserous  tissue  varying  in  thickness,  and 
closely  surrounding  the  peritoneal  sac.  In  practice,  the  surgeon 
does  not  attempt  to  recognise  these  different  coverings,  the  oniy 


976 


A  MANUAL  OF  SURGERY 


one  of  importance  being  the  cremasteric,  the  muscular  fibres  of 
which  are  often  evident,  and  serve  as  a  useful  landmark. 

There  are  three  different  forms  of  oblique  inguinal  hernia,  viz., 
the  acquired,  the  congenital,  and  the  infantile  or  encysted. 

i.  An  Acquired  Inguinal  Hernia  (Fig.  349)  is  one  in  which  the 
sac  consists  entirely  of  peritoneum  protruded  from  within  the 
abdomen.  It  gradually  increases  in  size,  and  finds  its  way  along 
the  cord  to  the  scrotum.  The  sac  usually  extends  as  far  as  the 
head  of  the  epididymis,  but  if  of  a  large  size  it  may  overlap 
the  testicle,  which  lies  behind  it.  The  structures  of  the  cord  are 
frequently  spread  out  over  the  sac.  In  old-standing  cases  the 
internal  ring  is  dragged  downwards  and  inwards,  and  often  lies 
behind  the  outer,  and  thus  it  may  be  difficult,  apart  from  operation, 
to  determine  whether  any  particular  hernia  is  direct  or  oblique. 


r.,r/'"^- 


Fig.  350. — Congenital  Inguinal  Hernia. 
A,  Vaginal  variety  ;  B,  funicular  type. 

2.  Congenital  Inguinal  Hernia  (Fig.  350)  is  due  to  non-closure  of 
the  funicular  process  of  peritoneum,  which  passes  down  to  the 
scrotum  with  the  testicle,  and  is  usually  obliterated  completely 
except  below,  where  it  forms  the  tunica  vaginalis.  As  already 
mentioned,  the  hernia  does  not  necessarily  appear  in  infancy,  its 
occurrence  being  often  delayed  until  puberty,  or  when  the  patient 
has  to  undertake  heavy  work.  This  form  of  hernia  is  much  more 
frequently  met  with  on  the  right  side  of  the  body,  owing  to  the 
fact  that  the  right  testicle  descends  into  the  scrotum  at  a  later 
date  than  the  left.  It  is  always  characterized  by  becoming  com- 
plete at  once,  and  its  development  may  be  immediately  followed 
by  acute  strangulation. 

In  the  majority  of  instances  the  patent  funicular  process  is 
continuous  with  the  tunica  vaginalis,  and  the  protruded  viscera 
lie  in  contact  with  the  testis,  and  somewhat  obscure  it ;  this  is 
known  as  a  congenital  vaginal  hernia  (Fig.  350,  A).  Less  fre- 
quently the  funicular  process  is  patent  only  as  far  as  the  head 
of  the  epididymis,  being  shut  off  from  the  tunica  vaginalis.     The 


HERNIA 


977 


hernia  under  such  circumstances  exactly  resembles  the  acquired 
variety,  being  unrecognisable  from  it  except  by  the  fact  that  it 


Fig.  351. — Infantile  Inguinal  Hernia. 

A.,  Prehernial  condition  with  tunica  vaginalis  extending  upwards  to  inguinal 
canal;  B,  hernial  sac  coining  down  behind  tunica;  C,  sac  invaginating 
the  tunica  vaginalis. 

becomes  complete  at  once.     It  is  termed  a.  congenital  funicular  hernia 
(Fig.  350,  B). 

In  every  case  of  congenital  hernia  the  structure*  of  the  cord  are 
spread  out  over  the  sac,  and  more  intimately  adherent  to  it  than 
in  the  acquired  form.  Phimosis  is  usually  associated  with  this 
condition  in  young  boys. 

3.  The  Infantile  or  Encysted  Hernia  is  one  occurring  in  individuals 
in  whom  the  funicular  process,  although  shut  off  from  the  ab- 
dominal cavity  above,  remains  patent  below,  communicating  with 

the  tunica  vaginalis,  which  cavity 
extends,  in  consequence,  as  high 
as  the  inguinal  canal  (Fig.  351, 
A).  The  hernia  has  a  distinct 
sac,  which  passes  down  behind 
the  open  process,  or  invaginates 
it  (Fig.  351,  B  and  C).  It  can- 
not be  recognised  except  on 
operation,  when  the  surgeon  is 
apt  to  open  the  tunica  vaginalis, 
which,  though  reaching  upwards, 
does  not  communicate  with  the 
general  peritoneal  cavity ;  on 
removing  or  displacing  this,  the 
true  sac  of  the  hernia  is  found 
behind  it.  This  is  not  so  likely 
to  occur  at  the  present  day,  when 
the  high  incision  is  made. 
A  Direct  Inguinal  Hernia  (Fig.  352)  is  one  which,  though  passing 

62 


Fig. 


352. — Direct  Inguinal 
Hernia. 


978 


A  MANUAL  OF  SURGERY 


through  the  external  abdominal  ring,  has  only  travelled  through 
a  portion  of  the  inguinal  canal ;  it  is  never  congenital,  and  usually 
smaller  than  the  oblique  type.  The  neck  lies  to  the  inner  side 
of  the  epigastric  artery,  which  is  often  arched  very  distinctly  over  it, 
passing  also  along  its  upper  wall.  The  hernia  traverses  the  space 
known  as  Hesselbach's  triangle,  which  is  bounded  internally  by 
the  outer  border  of  the  rectus  muscle,  by  the  deep  epigastric 
artery  externally,  and  by  Poupart's  ligament  below  (Fig.  353). 
The  obliterated  hypogastric  artery  passes  across  this  space  in  a 


Fig.  353. — Abdominal  Wall  from  Within,  to  show  Hernial 
Apertures. 

A,  V,  Femoral  artery  and  vein  ;  S  V,  spermatic  vessels ;  P  L,  Poupart's  liga 
ment ;  V  D,  vas  deferens;  E,  epigastric  vessels;  R,  rectus  abdominis; 
H,  obliterated  hypogastric  artery  ;  i,  internal  abdominal  ring;  2  and  3, 
sites  of  external  and  internal  direct  hernia  in  Hesselbach's  triangle  ; 
4,  crural  ring  for  femoral  hernia;  5,  obturator  foramen  and  vessels. 

direction  parallel  to  its  outer  border,  dividing  it  into  two  parts, 
and  according  to  whether  the  hernia  protrudes  through  the  inner 
or  outer  segment,  it  is  known  as  an  internal  or  external  direct 
hernia  (Fig.  353,  3  and  2).  The  spermatic  cord  usually  lies  to 
the  outer  side  of  a  direct  hernia,  and  its  constituent  elements  are 
never  spread  out  over  the  sac  as  in  the  oblique  form.  A  direct 
hernia  is  rarely  found  in  young  people,  and  there  is  often  a 
considerable  amount  of  subperitoneal  tissue  covering  the  sac. 

The  External  Direct  Hernia  is  very  similar  in  nature  to  the 
acquired  oblique  form,  except  that  it  is  placed  to  the  inner  side  of 
the  deep  epigastric  artery,  and  pushes  in  front  of  it  the  trans- 
versalis,   instead  of  the  infundibuliform,   fascia.     It  lies   to   the 


HERNIA  979 

outer  side  of  the  conjoined  tendon,  and  has  a  less  complete  cover- 
ing of  the  cremaster  muscle. 

The  Internal  Direct  Hernia  issues  from  the  abdomen  to  the 
inner  side  of  the  obliterated  hypogastric  artery,  rupturing  or 
pushing  before  it  the  conjoined  tendon,  which  in  such  a  case  is 
poorly  developed.  The  coverings  are  the  same  as  for  the  external 
variety. 

Interstitial  Hernia  is  the  name  given  to  an  inguinal  hernia  which 
does  not  follow  its  usual  course,  but  develops  in  some  abnormal 
relation  to  the  abdominal  wall.  Three  varieties  are  described  : 
(a)  Where  a  sac  exists  between  the  transversalis  fascia  and  the 
peritoneum  {intraparietal  form,  or  pro-peritoneal  hernia),  either  with 
or  without  a  hernia  in  the  usual  position  ;  in  the  former  instance 
one  form  of  '  hernia  en  bissac  '  is  produced.  This  abnormal  pocket 
of  the  sac  is  found  either  between  the  symphysis  pubis  and  the 
bladder  (hernia  inguinalis  ante-vesicalis),  or  it  extends  outwards 
towards  the  iliac  fossa  (hernia  inguinalis  intra-iliaca).  As  no  ex- 
ternal swelling  is  caused  by  this  condition,  it  is  usually  impossible 
to  recognise  its  existence  prior  to  operation  ;  occasionally  it  is  the 
cause  of  a  continuation  of  the  symptoms  of  strangulation,  when 
apparently  successful  taxis  has  been  performed,  owing  to  the 
strangled  bowel  being  pushed  backwards  from  the  superficial  into 
the  deeper  portion  of  the  sac.  (b)  An  abnormal  expansion  or 
bulging  of  the  sac  is  situated  between  the  internal  and  external 
oblique  muscles  (interparietal  form).  A  swelling  is  thus  pro 
duced  in  the  region  of  the  inguinal  canal,  covered  by  the  external 
oblique  aponeurosis,  and  tending  to  spread  upwards  and  outwards 
parallel  with  Poupart's  ligament.  The  sac  is  often  shaped  like  an 
hour-glass,  a  more  or  less  complete  septum  existing  at  the  level 
of  the  external  abdominal  ring,  formed  either  by  adhesions  or  by 
a  mass  of  adherent  omentum.  The  usual  downward  course  of 
the  hernial  contents  is  thus  prevented,  and  the  sac  yields  laterally 
above  the  site  of  the  obstruction,  and  passes  between  the  muscles. 
(c )  The  hernia  escapes  as  usual  from  the  external  abdominal  ring, 
but  travels  outward  along  Poupart's  ligament,  somewhat  simu- 
lating a  femoral  hernia  iextraparietal  variety).  This  form  is 
generally  associated  with  late  descent  of  the  testis,  and  a  con- 
tracted state  of  the  scrotum,  so  that  it  is  easier  for  the  hernia, 
which  is  always  of  a  congenital  type,  to  pass  into  the  thigh,  and 
be  guided  by  the  fascia  in  the  direction  indicated ;  in  a  case  of 
this  character  operated  upon  a  few  years  back,  the  testicle  was 
found  lying  close  to  the  anterior  superior  iliac  spine.  There  is  no 
difficulty  in  recognising  such  a  condition. 

The  Signs  of  an  inguinal  hernia  do  not  require  much  special 
notice  here,  as  we  have  already  described  the  general  clinical 
features  of  a  rupture  (p.  974).  In  the  early  stages,  where  merely 
a  bubonocele  exists,  a  fulness  is  noted  in  the  course  of  the 
inguinal  canal,  which  increases  when  the  patient  coughs  ;   it  is 


980  A   MANUAL  OF  SURGERY 

best  detected  by  a  finger  passed  through  the  external  ring  into 
the  canal.  When  it  descends  into  the  scrotum,  the  swelling 
increases  in  size  from  above  downwards,  and  in  the  oblique 
variety  is  continuous  with  the  fulness  in  the  inguinal  canal. 
The  structures  of  the  cord  are  masked  by  the  presence  of  the 
hernia,  but  the  testicle  is  to  be  more  or  less  distinctly  felt  at 
the  lower  and  back  part  of  the  swelling.  When  of  the  direct 
variety,  the  cord  lies  to  the  outer  side,  and  although  the  hernia 
can  be  felt  projecting  from  the  external  ring,  it  passes  directly 
backwards,  and  there  is  no  fulness  along  the  course  of  the  canal. 

Inguinal  hernia  is  usually  met  with  in  the  male  sex,  the  oblique 
variety  being  more  common  in  the  young,  and  the  direct  in  elderly 
patients.  In  the  female  sex  it  is  rare,  except  in  girls  and  young 
nulliparous  women  ;  in  such  cases  it  is  almost  always  congenital, 
passing  into  the  labium  along  the  canal  of  Nuck,  but  rarely 
attaining  any  considerable  size. 

The  Diagnosis  of  an  inguinal  hernia  is  a  tolerably  simple  matter 
if  it  is  uncomplicated  by  any  other  condition  ;  it  may,  however, 
be  difficult,  and  in  old-standing  cases  it  is  practically  impossible 
to  distinguish  the  oblique  variety  from  the  direct.  The  con- 
ditions for  which  it  may  be  mistaken  are  best  considered  in  two 
groups. 

I.  Whilst  the  hernia  is  still  incomplete  and  in  the  bubonocele 
stage,  it  has  to  be  distinguished  from  the  following :  (a)  Encysted 
hydrocele  of  the  cord,  which  is  recognised  by  its  smooth  globular 
outline  and  tense  walls  ;  the  impulse  on  coughing  is  less  distinct, 
and,  although  freely  moveable  in  the  canal,  the  hydrocele  cannot 
always  be  entirely  reduced  into  the  abdomen,  whilst  the  charac- 
teristic gurgle  of  a  hernia  is  absent ;  traction  on  the  testis,  more- 
over, fixes  the  tumour,  and  renders  it  immobile.  The  exact 
limitation  of  the  upper  end  of  the  swelling,  if  it  can  be  reached,  is 
very  characteristic  of  a  hydrocele,  (b)  A  chronic  abscess  originating 
in  the  abdominal  parietes,  or  within  the  abdomen  or  pelvis,  will 
sometimes  point  through  the  external  abdominal  ring.  In  such 
cases,  although  there  is  a  distinct  impulse  on  coughing,  and 
although  the  swelling  is  reducible,  it  has  not  the  definite  outline 
and  characteristic  sensation  of  a  hernia,  being  usually  soft  and 
fluctuating.  Other  evidences  pointing  to  the  existence  of  the 
original  disease  may  also  assist  in  determining  the  nature  of  the 
tumour.  (c)  Enlarged  glands  in  the  groin  which  have  become 
adherent  to  the  external  oblique  are  sometimes  mistaken  for  a 
hernia,  owing  to  the  fact  that  on  coughing  a  distinct  impulse  is 
communicated  to  them  ;  it  is,  however,  merely  heaving  in  nature, 
and  not  expansile,  whilst  on  digital  exploration  of  the  inguinal 
canal  the  absence  of  a  hernia  may  be  readily  ascertained,  (d)  A 
testicle  retained  in  the  inguinal  canal  is  recognised  by  that  side  of  the 
scrotum  being  empty,  and  on  pressing  the  swelling  testicular 
sensation  may  be  elicited.     The  rounded  upper  end  of  the  testes 


HERNIA 


981 


can  often  be  detected,  (e)  Tumours  consisting  of  fat  or  other  tissues 
are  occasionally  seen  in  the  inguinal  canal,  but  are  characterized 
by  the  strict  limitation  of  their  upper  border,  and  usually  by  the 
absence  of  a  distinct  impulse  on  coughing.  On  the  other  hand, 
as  described  elsewhere,  a  mass  of  fat  simulating  a  lipoma  is 
sometimes  present,  resulting  from  a  protrusion  of  the  subperi- 
toneal tissue,  a  hernial  sac  being  found  embedded  in  its  interior. 
(/)  Hematocele  of  the  cord  is  recognised  by  a  history  of  injury, 
the  presence  of  pain  and  ecchymosis,  and  the  absence  of  an 
impulse  on  coughing,  whilst  reduction  is  impracticable. 

2.  When  the  hernia  extends  into  the  scrotum,  less  difficulty  is  ex- 
perienced in  its  diagnosis.  By  examination  of  the  cord  immediately 
outside  the  external  abdominal  ring,  all  purely  scrotal  swellings, 
such  as  hydrocele  or  sarcocele,  are  readily  eliminated,  since  in 
them  the  cord  can,  in  the  early  stages,  be  felt  perfectly  free.  A 
varicocele  can  also  be  similarly  recognised  from  an  omental  hernia 
by  the  condition  of  the  cord  in  its  upper  region  ;  moreover,   if 


Fig..  354. — Inguinal  Truss.     (Down  Brothers.) 

the  patient  is  made  to  assume  the  recumbent  posture,  the  swelling 
disappears  in  each  instance,  but  if  a  finger  is  placed  firmly  over 
the  inguinal  canal  so  as  to  prevent  any  protrusion  of  omentum, 
and  he  is  then  directed  to  stand  up,  the  swelling  immediately 
reappears  if  it  is  venous  in  character.  To  the  practised  finger, 
the  diagnosis  is  never  a  matter  of  difficulty,  since  the  enlarged 
veins  of  a  varicocele  and  omentum  are  not  at  all  alike  to  the 
touch,  the  veins  moving  freely  under  the  finger  '  like  worms  in  a 
bag.'  When  a  hernia  is  associated  with  a  hydrocele  or  sarcocele, 
a  little  more  care  is  necessary  in  order  to  distinguish  between  the 
two  swellings. 

The  Treatment  of  inguinal  hernia  is  either  palliative  by  means 
of  trusses,  or  radical. 

Palliative  Treatment. — Many  different  trusses  have  been  intro- 
duced in  order  to  prevent  the  descent  of  a  hernia.  No  one  form 
is  capable  of  dealing  with  every  case,  but  the  truss  must  be 
applied  with  care,  so  as  to  suit  the  special  needs  of  the  particular 
patient.  It  is  impossible  to  describe  a  tithe  of  the  varieties  which 
have  been  suggested,  and  hence  we  must  refer  our  readers  to 
special  works  on  the  subject.     Suffice  it  to  indicate  the  essentials 


982 


A   MANUAL  OF  SURGERY 


of  a  good  truss.  It  should  consist  of  a  pad  kept  in  position  over  the 
hernial  aperture  by  a  steel  spring  (Fig.  354) ;  it  must  fit  the  patient 
accurately,  resting  behind  on  the  middle  piece  of  the  sacrum,  and 
passing  laterally  midway  between  the  crest  of  the  ilium  and  the 
top  of  the  great  trochanter.  If  the  hernia  is  unilateral,  the  spring 
ends  on  the  sound  side  just  behind  the  anterior  superior  spine,  and 
is  prolonged  anteriorly  into  a  leather  thong  or  cross-strap,  which  is 
secured  to  a  stud  on  the  pad.  To  prevent  it  from  slipping  up,  an 
under-strap  passes  from  the  affected  side  close  behind  the  anterior 
superior  spine  along  the  fold  of  the  nates  to  the  inner  side  of  the 

thigh,  being  fixed  finally  to  a 
second  stud  on  the  pad.  The  pad 
may  be  rounded  or  oval  in  shape, 
and  usually  consists  of  soft  iron 
protected  by  cork,  but  polished 
vulcanite,  wood,  or  an  indiarubber 
cushion  filled  with  air,  water,  or 
glycerine  have  been  employed  in- 
stead ;  it  should  be  well  covered 
with  leather,  and  the  strength  of 
the  spring  must  be  so  adjusted 
as  to  retain  the  hernia  under  all 
conditions  of  strain  to  which  it 
may  be  subjected,  but  without  the 
use  of  undue  force.  In  ordering  a 
truss  from  an  instrument-maker, 
the  only  measurement  required  is 
that  around  the  body,  following  the 
line  taken  by  the  truss,  and  reaching  in  front  to  the  symphysis 
pubis ;  it  is  also  advisable  to  mention  the  size  of  the  hernia,  and 
whether  the  opening  in  the  abdominal  parietes  is  large  or  small. 
In  the  earlier  cases  of  oblique  hernia,  the  pad  should  rest  rather 
over  the  inguinal  canal  than  over  the  external  abdominal  ring, 
the  object  being  to  restore  the  valve-like  action  of  the  canal  by 
approximating  its  sides.  In  a  direct  hernia  the  pad  must  be 
applied  directly  over  the  opening.  If  such  an  apparatus  is 
properly  adjusted  and  continuously  worn,  a  cure  is  sometimes 
established  in  the  course  of  a  year  or  two,  and  in  cases  of  con- 
genital hernia  in  children  a  cure  may  be  confidently  expected  if 
the  mother  or  attendants  of  the  child  conscientiously  carry  out 
the  necessary  details.  If  the  hernia  is  once  allowed  to  slip  down, 
even  after  six  or  twelve  months'  treatment,  all  the  previous  good 
will  have  been  undone. 

In  infants,  an  efficient  support  is  afforded  by  a  skein  of  wool 
(specially  known  as  '  fingering '),  divided  at  one  end,  so  that  when 
placed  round  the  body  the  cut  ends  of  the  skein  can  be  passed 
through  the  loop,  forming  a  knot  over  the  inguinal  canal,  which 
acts  as  the  pad  of  a  truss.  The  cut  ends  are  now  passed  under  the 
perineum,  and  tied  to  the  transverse  portion  behind  (Fig.  355). 


Fig.  355. — Wool  Truss  for 
Treatment  of  Hernia  in 
Children. 


HERNIA 


9S3 


This  apparatus  is  changed  night  and  morning  when  the  child  is 
bathed,  and  also,  if  need  be,  at  shorter  intervals,  the  mother 
being  previously  instructed  as  to  how  to  support  the  hernia  whilst 
the  apparatus  is  being  removed.  In  cases  of  double  rupture  in 
infants  an  indiarubber  band  with  two  pneumatic  air-pads  (Fig.356), 
arranged  so  as  to  fit  over  the  inguinal  canals,  and  with  suitable 
straps  and  studs,  will  often  suffice,  and  is  certainly  more  comfort- 
able than  a  spring  truss.  In  addition  to  such  pressure,  it  is  im- 
portant to  remove  all  causes  of  intra-abdominal  tension,  as  by  cir- 
cumcision, where  phimosis  is  present,  or  by  regulating  the  bowels. 

The  Radical  Cure  of  inguinal  hernia  is  an  operation  to  which 
much  attention  has  been  directed  of  late  years,  since  its  value  was 
brought  prominently  before 
the  profession  by  the  late 
Professor  John  Wood  and 
others.  It  is  very  largely 
employed  at  the  present 
day,  though  there  are  still 
surgeons  who  only  advocate 
its  use  under  exceptional 
circumstances,  appealing  to 
the  frequent  recurrence  after 
operation  as  an  argument 
against  its  adoption.  Whilst 
fully  admitting  that  recur- 
rences are  more  frequent 
than  they  should  be,  we  look 
on  them  as  either  being  due 
to  an  error  of  judgment  in 
the  selection  of  the  cases  for 
operation,  or  as  resulting 
from  imperfect  technique,  or  from  inefficient  after-treatment. 

The  selection  of  cases  for  an  operation  of  this  type,  which  is  not 
an  essential,  but  only  a  desirable  means  of  treatment  (or,  as  it  is 
sometimes  termed,  an  operation  de  complaisance),  is  a  matter  requir- 
ing considerable  judgment  and  discrimination.  In  an  individual 
whose  occupation  does  not  subject  him  to  heavy  strain  or  exer- 
tion, and  who  possesses  a  hernia  which,  under  ordinary  circum- 
stances, is  easily  commanded  by  a  suitably  applied  truss,  no 
operation  is  absolutely  necessary  ;  although  one  is  perfectly 
justified  in  urging  him  to  submit  to  it,  since  he  will  be  thereby 
freed  from  the  irksomeness  of  wearing  a  truss,  and  from  the  risks 
of  possible  strangulation.  If,  however,  the  subject  is  a  labouring 
man,  exposed  to  injury  and  strain,  and  who  may  find  it  difficult 
to  provide  a  suitable  series  of  trusses,  the  operation  should  always 
be  undertaken  unless  distinctly  contra-indicated  (1)  by  a  general 
inherited  weakness  of  the  abdominal  muscles ;  (2)  by  a  relaxed 
and  atonic  condition  of  the  abdominal  parietes,  which  is  so 
commonly  associated  in  elderly  people  with  slipping  downwards 


Fig.  356.  —  Indiarubber  Band  Truss, 
with  Air-pads,  for  Infants. 

The  air-pads  fit  around  the  root  of  the 
penis,  and  are  inflated  through  the 
tube  tied  up  in  front.  The  under- 
straps  fit  round  the  child's  thighs. 


984  A  MANUAL  OF  SURGERY 

of  the  mesenteric  attachment  of  the  intestine  (enteroptosis),  so 
that  the  hypogastrium  obviously  bulges  ;  or  (3)  by  such  con- 
stitutional disease  as  precludes  all  unnecessary  operative  inter- 
ference. (4)  Again,  in  cases  of  extensive  irreducible  hernia,  the 
return  of  large  masses  of  intestine  which  have  lain  for  years  in 
the  hernial  sac  so  increases  the  intra-abdominal  tension  as  fre- 
quently to  determine  recurrence  locally  or  elsewhere,  and  therefore 
operative  interference,  though  very  desirable  owing  to  the  great 
risk  of  strangulation  incurred  by  the  patient,  is  often  followed 
by  very  bad  results,  unless  the  patient  has  previously  been  put 
through  a  course  of  semi-starvation  and  persistent  taxis  in  order 
to  gradually  reduce  the  size  of  the  protrusion. 

As  to  the  best  age  at  which  to  operate,  statistics  definitely 
prove  that  it  is  essentially  an  operation  of  adolescence,  the  results 
gradually  getting  worse  as  the  age  increases.  Young  children 
should  not  be  touched  until  careful  truss  pressure  for  a  year  has 
failed,  or  unless  it  is  impossible  to  keep  up  the  hernia  by  such 
treatment.  In  any  case  it  is  perhaps  wiser  to  delay  it  until  the 
age  of  three,  owing  to  the  risk  of  infection  of  the  wound  from  the 
constant  saturation  of  the  dressings  with  urine. 

Very  many  different  operations  have  been  described  and 
practised  by  various  surgeons ;  in  all  probability  some  of  them 
are  unnecessarily  complicated,  and  can  only  be  briefly  alluded  to. 
The  plan  we  now  employ  in  almost  all  cases  is  known  as  Bassini's 
operation  ;  it  appears  to  us  as  one  of  the  most  scientific  of  all  those 
that  have  been  suggested,  since  it  reproduces  more  accurately  than 
any  other  the  normal  structure  of  the  parts.  The  instruments 
required  are  scalpels,  forcipressure  forceps,  dissecting  forceps,  re- 
tractors, transfixion  needle,  curved  hernia  needles,  and  scissors. 
The  operation  may  be  described  in  the  following  stages:  (1)  The 
pubic  region  having  been  previously  shaved  and  thoroughly 
purified,  an  incision  is  made  in  the  direction  of  the  inguinal  canal 
and  cord,  about  o.\  inches  in  length,  its  centre  being  a  little  above 
the  external  abdominal  ring.  This  is  carried  through  the  skin  and 
subcutaneous  tissues  until  the  structures  of  the  cord  are  reached, 
the  superficial  external  pudic  artery  being  necessarily  divided  en 
route  ;  the  pillars  of  the  ring  are  clearly  defined,  and  the  external 
oblique  aponeurosis  slit  up  for  about  f  inch  beyond  the  apex  of 
the  ring  in  the  direction  of  the  cord.  (2)  The  sac  has  now  to  be 
identified  ;  if  the  hernia  is  one  of  old  standing,  or  contains  adherent 
omentum  or  intestine,  it  is  easily  recognised  ;  but  if  it  is  thin, 
empty,  and  of  recent  formation,  and  especially  in  the  case  of  a 
bubonocele,  its  identification  may  be  a  matter  of  some  difficulty. 
The  structures  of  the  cord  are  lifted  up  out  of  the  wound,  spread 
out  over  the  fingers,  the  coverings  divided,  and  the  white  convex 
border  of  the  fundus  of  the  sac  looked  for.  It  is  sometimes 
necessary  to  induce  vomiting  by  titillation  of  the  fauces,  in  order 
to  cause  the  hernia  to  protrude,  particularly  when  it  is  of  the 
direct  type.     (3)  If  the  sac  is  empty,  it  is  freed  from  its  connection 


HERNIA 


985 


with  the  structures  of  the  cord  without  opening  it,  and  isolated  as 
far  as  or  beyond  the  internal  abdominal  ring,  as  indicated  by  a 
collar  of  fatty  subperitoneal  tissue  surrounding  the  neck.  If  the 
hernia  is  irreducible,  the  sac  is  laid  open,  its  contents  freed  from 
adhesions,  and  the  intestine  returned  into  the  abdomen,  whilst 
omental  tissue  is  removed,  and  the  stump  replaced.  The  greatest 
gentleness  must  be  employed  in  dealing  with  the  intestines  ;  if  a 
considerable  amount  is  present,  it  must  be  surrounded  by  a  cloth 
wrung  out  of  warm  sterilized  salt  solution.  Adhesions  are  care- 
fully divided  either  by  the  finger  or  between  ligatures ;  if  closely 


Fig.  357. — Bassini's  Operation  for  Radical  Cure  of  Hernia. 

A  and  A1,  Spencer  Wells's  forceps,  holding  aside  the  divided  portions  of  external 
oblique  aponeurosis  ;  B,  arched  fibres  of  internal  oblique,  continuous  on 
the  inner  side  with  the  conjoined  tendon  ;  C,  hook  or  retractor  holding 
aside  the  spermatic  cord  ;  D,D,D,D,  deep  silk  stitches  passed  behind  the 
cord  through  the  deepest  fibres  of  Poupart's  ligament  on  the  outer  side, 
and  conjoined  tendon  on  the  inner.  (The  cutaneous  incision  and  the 
incision  through  the  external  oblique  are  here  shown  much  greater  than 
would  actually  be  undertaken,  in  order  to  demonstrate  clearly  the  deeper 
parts.) 

adherent  to  the  sac,  it  may  be  necessary  to  leave  a  small  portion 
of  this  attached  to  the  gut,  which  is  then  returned.  Omentum, 
whether  adherent  or  not,  should  be  removed,  as  the  elongated 
fringes  are  very  liable  to  contract  adhesions  to  the  abdominal 
parietes,  and  subsequently  produce  mischief.  In  removing 
omentum,  it  is  not  advisable  to  encircle  a  large  mass  with  a 
single  ligature,  as  the  vessels  are  less  securely  commanded,  and 
a  pocket  or  pucker  may  be  produced,  possibly  leading  to  internal 
strangulation  at  a  later  date.  Small  portions,  including  one  or 
more  of  the  larger  vessels,  should  be  taken  up  one  after  another, 


986  A  MANUAL  OF  SURGERY 


and  tied  separately  and  with  advantage  at  different  levels,  so  as 
to  assist  in  the  subsequent  return  of  the  stump.  The  protruded 
mass  is  then  cut  away  below  the  ligatures,  and  the  stump 
replaced  after  seeing  that  no  bleeding  point  remains  unse- 
cured. The  sac,  being  now  emptied,  is  isolated  as  far  as  the 
internal  ring.  (4)  The  neck  is  then  transfixed  as  high  as 
possible,  and  ligatured  with  sterilized  silk,  and  the  sac  cut  off 
below  the  ligature,  the  stump  retracting  well  above  the  internal 
ring,  and  presenting  a  flush  surface  towards  the  intestines,  as  we 
have  been  able  to  demonstrate  in  a  recent  post-mortem  specimen, 
obtained  from  a  patient  who  died  of  pulmonary  embolus  ten  days 
after  operation.  (5)  The  tissues  of  the  cord  are  carefully  ex- 
amined, and  any  varicose  spermatic  veins  removed,  as  also  any 
downgrowths  of  the  subperitoneal  fat  and  possibly  portions  of  the 
cremaster.  (6)  The  opening  in  the  abdominal  parietes  is  closed 
by  a  row  of  sutures  passing  through  the  arched  fibres  of  the 
internal  oblique  and  transversalis  muscles,  or  through  the  con- 
joined tendon  on  the  inner  side,  and  through  Poupart's  ligament 
on  the  outer,  the  stitches  being  all  placed  behind  the  cord.  To 
effect  this,  the  cord  is  drawn  up  out  of  the  wound  and  held  aside 
by  a  retractor  (Fig.  357,  C),  whilst  the  divided  margins  of  the 
external  oblique  aponeurosis  are  grasped  by  pressure  forceps 
(A,  A1).  Gentle  traction  on  the  lower  pair  enables  the  deepest 
portion  of  Poupart's  ligament  to  be  defined  and  seen.  The 
stitches  must  secure  a  good  hold  of  the  tissues,  but  should  not 
include  the  external  oblique  aponeurosis,  and  when  dealing  with 
Poupart's  ligament  the  proximity  of  the  iliac  vessels  must  not  be 
forgotten.  It  is  wise  to  utilize  interrupted  stitches  and  not  looped 
or  mattress  sutures  as  recommended  by  some  authorities,  since 
the  latter  tend  to  strangle  the  portions  of  tissue  included  in  their 
grasp.  The  opening  in  the  abdominal  parietes  is  in  this  way 
commanded  as  far  down  as  the  pubic  spine,  but  sufficient  room 
must  be  left  at  the  upper  end  for  the  passage  of  the  cord,  undue 
constriction  of  which  would  cause  atrophy  of  the  testis  ;  some- 
times it  is  desirable  to  introduce  a  stitch  above  the  cord,  in  order 
to  command  a  spot  where  recurrence  is  not  uncommon.  When 
the  three  or  four  needful  stitches  have  been  introduced  and 
tightened,  the  cord  is  replaced,  and  the  divided  portions  of  the 
external  oblique  are  sutured  together  over  it,  (7)  The  wound  in 
the  skin  is  closed  by  a  continuous  suture,  and  usually  no  drainage- 
tube  is  needed. 

After-Treatment. — The  patient  is  placed  in  bed  with  the  head 
low,  and  the  knees  slightly  flexed  over  a  pillow.  The  wound,  as 
a  rule,  does  not  require  dressing  for  seven  or  eight  days,  when, 
on  removal  of  the  stitches,  it  should  be  found  completely  healed, 
if  asepsis  has  been  maintained.  The  patient  should  turn  to  the 
opposite  side  in  order  to  pass  water,  and  the  greatest  care  must 
be  taken  to  prevent  the  dressing  becoming  soiled.  Occasionally 
retention  of  urine  follows  this  operation,  necessitating  the  use  of 


HERNIA  987 

a  catheter.  In  the  case  of  children,  it  is  well  to  seal  the  parts 
down  by  a  collodion  dressing,  and  by  preference  the  collodion 
should  be  of  the  flexile  type,  but  with  the  guncotton  replaced  by 
celloidin  (cello  id  in  collodion). 

The  recumbent  posture  should  be  maintained  for  three  weeks, 
and  nothing  but  the  slightest  work  undertaken  for  at  least  six 
weeks,  and  no  violent  effort  until  six  months  after  the  operation. 
Under  such  circumstances  the  use  of  a  truss  is  unnecessary,  and, 
indeed,  we  consider  that  it  is  undesirable,  as  its  pressure  is  liable 
to  produce  atrophy  of  the  newly-formed  cicatricial  tissue.  When, 
however,  the  abdominal  walls  are  congenitally  weak,  or  if,  unfor- 
tunately, the  wound  has  suppurated,  the  deep  stitches  coming 
away,  it  is  advisable  to  use  a  light  truss  for  a  time. 

The  treatment  of  congenital  hernia  differs  in  no  particular  from 
that  already  described,  except  that  the  sac  must  be  divided  below 
as  well  as  above,  and  the  lower  opening  secured  by  suture  or 
ligature,  so  as  to  close  the  cavity  of  the  tunica  vaginalis.  The 
operation  often  proves  difficult  owing  to  the  intimate  adhesions 
between  the  sac  and  the  structures  of  the  cord,  and  it  is  some- 
times impracticable  to  completely  isolate  the  neck  of  the  sac.  In 
many  cases  the  old-fashioned  Mitchell  Banks'  operation  suffices 
for  a  congenital  hernia. 

The  other  operations  which  require  to  be  mentioned  are  as 
follows  : 

(a)  In  Mitchell  Banks'  Operation,  the  sac  is  isolated  and  removed 
as  high  as  the  internal  ring  without  any  division  of  the  external 
oblique.  Stitches  are  then  introduced  through  the  conjoined 
tendon  and  Poupart's  ligament  respectively,  including  the  external 
oblique  in  their  grasp,  and  passing  in  front  of  the  cord.  It  is 
obvious  that  by  such  a  plan  the  deep  ring  cannot  be  closed  as 
accurately  as  in  Bassini's  operation.  It  may  suffice,  however,  in 
a  few  of  the  simpler  congenital  cases. 

(b)  Ball's  Operation  consists  in  freeing  the  peritoneum  on  the 
inner  aspect  of  the  internal  abdominal  ring,  and  then  the  sac, 
after  being  isolated,  is  twisted  into  a  tense  cord,  so  as  to  throw 
it  into  a  series  of  folds,  thereby  producing  a  prominence  internally 
rather  than  an  infundibuliform  depression.  To  prevent  untwist- 
ing, a  ligature  is  tied  around  it  as  high  as  possible,  and  it  is  also 
transfixed  below  the  ligature  by  a  thread,  the  ends  of  which  are 
passed  through  the  abdominal  parietes. 

(c)  In  what  is  known  as  Barker's  Operation  the  neck  of  the  sac 
is  isolated,  ligatured,  and  divided,  the  fundus  being  left  in  situ, 
whilst  the  thread  used  in  tying  the  neck  is  employed  as  the  first 
suture  to  close  the  deep  part  of  the  canal  ;  by  this  means  it  is 
hoped  that  the  neck  of  the  sac  will  be  displaced,  and  hence  more 
satisfactorily  occluded.  It  is  very  doubtful,  however,  whether 
this  really  occurs. 

(d)  In  Macewen's  Method  the  aponeurosis  of  the  external  oblique 
is   most   carefully   maintained   intact,   and   the  inguinal   canal  is 


A  MANUAL  OF  SURGERY 


explored  through  the  external  abdominal  ring.  The  sac  is  freed 
from  its  surroundings,  and  this  liberation  goes  on  for  about  an 
inch  all  round  the  internal  abdominal  ring.  A  silk  suture  is  then 
tied  to  the  fundus  of  the  sac,  and  is  carried  by  a  curved  needle 
through  the  centre  of  the  sac  from  above  downwards  and  again 
through  the  neck  of  the  sac  from  below  upwards.  The  needle 
is  then  introduced  through  the  inguinal  canal  under  the  loosened 
abdominal  parietes,  and  is  made  to  emerge  through  the  abdominal 
muscles  a  little  above  the  inguinal  canal;  the  silk  thread  is  carried 
through  this,  and  by  a  little  traction  the  sac  is  carried  in,  doubled 
up,  and  implanted  as  a  pad  across  the  internal  ring.  This  thread 
is  held  by  an  assistant  during  the  next  step  of  the  operation.  This 
consists  in  closing  the  canal  by  one  or  more  looped  sutures,  passed 
in  such  a  way  as  to  draw  up  Poupart's  ligament  over  the  arched 
fibres  of  the  internal  oblique  in  front  of  the  cord.  Finally,  the 
thread  used  for  the  fixation  is  drawn  tight,  and  its  free  end 
employed  to  close  the  external  abdominal  ring  to  a  sufficient  extent. 
The  results  of  this  proceeding  are  very  good,  but  it  is  a  more  diffi- 
cult operation  than  Bassini's,  and  one  loses  the  advantage  of  opening 
the  canal  more  freely,  and  thereby  exploring  the  structures  of  the 
cord.  One  is  frequently  finding  subperitoneal  lipomata  in  the 
canal,  and  these  would  inevitably  be  left,  and  would  possibly  lead 
to  a  recurrence  of  the  hernia,  if  the  canal  had  not  been  opened  up. 

(e)  Halsted's  Operation  is  much  the  same  as  Bassini's,  except 
that  the  fibres  of  the  internal  oblique  are  also  divided  at  the  outer 
margin  of  the  internal  ring,  and  the  cord  displaced  upwards  and 
outwards  through  this  opening,  so  that  at  the  spot  at  which  it 
pierces  the  abdominal  parietes  it  may  be  surrounded  by  muscular 
fibres.  The  canal  is  then  closed  as  in  Bassini's  operation,  whilst 
the  external  oblique  is  also  sutured  behind  the  cord,  which  is  thus 
made  a  subcutaneous  structure.  We  see  no  special  advantage  to 
be  gained  by  this  departure  from  Nature's  method  of  conducting 
the  cord  and  its  structures  through  the  abdominal  wall  in  an 
oblique  direction. 

Recurrence  after  Operation  is  unfortunately  met  with  only  too 
frequently,  and  statistics  go  to  prove  that  in  the  great  majority 
of  cases  it  happens  within  the  first  twelve  months.  As  already 
stated,  it  may  be  due  partly  to  an  injudicious  selection  of  cases, 
partly  to  errors  of  technique,  and  in  part  to  a  faulty  after- 
treatment,  the  patient  being  given  too  much  liberty  at  too  early  a 
date.  In  connection  with  this  we  would  especially  emphasize  the 
necessity  for  isolating  the  sac  as  far  as  possible,  since  otherwise 
the  infundibuliform  opening  at  the  top  of  the  closed  peritoneal 
canal  is  certain  to  persist.  Another  not  uncommon  cause  of 
recurrence  is  septic  contamination  of  the  wound ;  if  the  deep 
stitches  are  not  involved,  no  great  harm  is  done,  but  whenever 
they  have  been  removed  or  come  away  it  is  wise  to  use  a  truss 
subsequently  as  a  precautionary  measure.  Again,  the  mere 
restoration  of  a  mass  of  intestine  or  omentum  into  the  abdominal 


HERNIA 


989 


cavity  may  suffice  to  raise  the  intra-abdominal  pressure,  and  thus 
predispose  to  a  recurrence  ;  hence  the  importance  of  removing 
as  much  omental  tissue  as  possible  in  all  bad  cases.  Relapses 
may  also  be  due  to  splitting  or  tearing  of  the  tendinous  structures 
around,  either  by  the  mere  passage  of  the  needle,  or  by  the  traction 
induced  by  tightening  the  sutures ;  indeed,  it  is  often  the  case 
that  a  hernia  originally  oblique  may  after  operation  be  followed 
by  one  that  is  direct,  and  probably  from  this  cause. 

Whenever  it  appears  likely  that  recurrence  may  occur,  a  truss 
should  be  ordered.  If,  however,  a  hernia  has  developed,  a  second 
operation  should  be  performed,  if  the  condition  of  the  abdominal 
parietes  warrants  it. 

Femoral  Hernia.  —  A  femoral  hernia  is  one  which,  travelling 
down  the  crural  canal,  presents  at  the  inner  and  upper  part  of  the 
thigh  through  the  saphenous  opening.  It  occurs  most  commonly 
in  women,  on  account  of  the  greater  expansion  of  the  iliac  crests 
allowing  increased  space  beneath  Poupart's  ligament,  and  especi- 
ally in  those  who  have  borne  children,.  During  parturition  the 
inguinal  regions  are  in  a  measure  protected,  and  hence  inguinal 
hernia  is  rarely  caused  in  this  way.  The  crural  canal  constitutes 
the  inner  compartment  of  the  femoral  sheath,  a  space  usually 
occupied  by  fatty  cellular  tissue,  lymphatic  vessels,  and  perhaps 
a  lymphatic  gland.  It  is  about  f  inch  in  length  anteriorly,  and 
1  \  inches  along  its  posterior  wall  ;  it  is  closed  above  by  a 
thickened  portion  of  the  subserous  cellular  tissue  known  as  the 
septum  crurale,  and  its  lower  end  is  formed  by  the  saphenous 
opening,  and  closed  by  the  cribriform  fascia.  Hence  a  femoral 
hernia,  as  it  passes  downwards,  receives  the  following  coverings: 
(a)  peritoneum ;  (b)  subserous  cel- 
lular tissue,  including  the  septum 
crurale,  a  layer  sometimes  known 
as  the  fascia  propria,  and  occa- 
sionally represented  by  a  thick 
fatty  envelope ;  (c)  the  anterior 
layer  of  the  femoral  sheath,  derived 
from  the  fascia  transversalis ;  (d) 
cribriform  fascia ;  (e)  subcutaneous 
tissue ;  and  (/)  skin.  In  its  passage 
it  is  situated  immediately  internal 
to  the  femoral  vein,  and  pressure 
upon  this  may  produce  cedema  of 
the  leg,  whilst  Gimbernat's  liga- 
ment lies  to  the  inner  side  of  the 

neck  of  the  sac.  The  spermatic  cord  or  round  ligament  passes 
just  above  and  internal  to  it,  but  on  a  superficial  plane,  whilst 
the  epigastric  artery  is  not  very  far  from  the  outer  side  of  the 
neck.  Occasionally  the  obturator  artery  arises  from  this  latter 
vessel  (once  in  three  and  a  half  subjects) ;  it  either  passes  to  the 


Fig.  358. — Femoral  Hernia. 


99Q  A   MANUAL  OF  SURGERY 


inner  side  of  the  neck  of  the  sac  along  the  border  of  Gimbernat's 
ligament  (once  in  seventy-five  times),  but  more  commonly  runs 
between  the  neck  and  the  femoral  vein.  When  once  it  has 
emerged  from  the  saphenous  opening,  a  femoral  hernia  tends  to 
pass  upwards  and  outwards  along  Poupart's  ligament  towards  the 
anterior  superior  iliac  spine,  being  guided  by  the  attachment  of 
the  deep  layer  of  the  superficial  fascia ;  when  of  large  size,  it 
may  extend  considerably  above  the  level  of  Poupart's  ligament. 
Femoral  herniae  are  less  likely  to  contain  omentum  than  the 
inguinal  variety  :  a  portion  of  the  ileum  is  most  often  present,  but 
occasionally  the  ovary  or  Fallopian  tube  may  be  found  in  the  sac. 
The  Signs  of  a  femoral  hernia  are  very  characteristic.  A 
swelling  with  an  impulse  on  coughing,  and  more  or  less  reducible, 
forms  on  the  inner  side  of  the  thigh,  its  neck  or  aperture  of  com- 
munication with  the  abdomen  lying  to  the  inner  side  of  the 
femoral  vessels,  and  to  the  outer  side  of  the  pubic  spine,  which 
can  always  be  felt  (Fig.  358).  There  is  usually  but  little  difficulty 
in  making  a  diagnosis,  although  occasionally  considerable  care 
is  needed,  and  especially  in  distinguishing  it  from  the  following 
conditions :  (a)  From  inguinal  hernia,  which  is  more  common 
in  young  males,  its  neck  occupying  the  inguinal  canal,  and  the 
saphenous  opening  being  free  ;  whilst  it  is  also  above  and  internal 
to  the  pubic  spine,  and  above  Poupart's  ligament  at  its  point  of 
exit ;  it  tends  to  pass  downwards  into  the  scrotum,  or  in  females 
into  the  labium.  Femoral  hernia,  on  the  other  hand,  usually  (but 
not  invariably)  occurs  in  women  over  twenty-five  years  of  age  ; 
the  inguinal  canal  is  free,  whilst  the  neck  is  in  the  situation  of  the 
crural  canal,  below  and  external  to  the  pubic  spine,  and  below 
Poupart's  ligament ;  moreover,  it  travels  upwards  and  outwards, 
the  labium  being  unaffected,  (b)  An  enlarged  lymphatic  gland  over 
the  saphenous  opening  may  simulate  this  condition  very  closely  ; 
but  the  absence  of  impulse  on  coughing  and  of  the  usual  hernial 
signs  is  generally  sufficient  to  distinguish  it ;  when,  however,  the 
hernia  is  purely  omental  and  irreducible,  the  impulse  is  so  slightly 
marked  that  correct  diagnosis  in  a  stout  woman  is  often  difficult 
without  an  exploratory  incision,  (c)  A  small  lipoma  in  the  canal 
somewhat  resembles  a  hernia,  but  the  limitation  of  the  tumour, 
its  greater  mobility,  and  the  absence  of  an  impulse  on  coughing, 
should  suffice  to  prevent  any  mistake.  (d)  A  psoas  abscess 
pointing  at  the  saphenous  opening  resembles  a  hernia  in  the 
existence  of  a  reducible  swelling  with  an  expansile  impulse  on 
coughing.  It  is  distinguished  from  it  by  the  facts  that  there  is  no 
gurgle  on  reduction  ;  that  the  abscess,  as  it  passes  under  Poupart's 
ligament,  lies  to  the  outer  side  of  and  behind  the  vessels  ;  and  that 
distinct  fluctuation  occurs  between  the  swelling  in  the  saphenous 
opening  and  the  tumour,  which  can  always  be  felt  in  the  iliac 
fossa  ;  the  characteristic  signs  of  spinal  caries  are  also  usually 
present,  (e)  In  vavix  of  the  saphena,  if  a  pouch  or  so-called  ampulla 
forms  close  to  its  entrance  into  the  femoral  vein,  it  may  be  mis- 


HERNIA 


991 


taken  for  a  femoral  hernia  on  account  of  the  marked  impulse  on 
coughing,  and  because  the  swelling  disappears  on  assuming  the 
recumbent  posture.  It  is,  however,  usually  associated  with  the 
signs  of  varix  below,  and  by  the  fact  that,  although  pressure  is 
made  over  the  upper  part  of  the  crural  canal  after  the  vein  has 
been  emptied,  the  swelling  regains  its  ordinary  size  when  the 
patient  stands  up. 

Treatment. — When  reducible  and  of  small  size,  a  femoral  hernia 
may  be  treated  by  the  use  of  a  truss,  similar  in  nature  to  that 
used  for  an  inguinal  hernia,  except  that  the  pad  extends  some- 
what lower,  so  as  to  maintain  pressure  along  the  course  of  the 
canal.  A  badly  fitting  truss  may  compress  the  femoral  vein,  and 
lead  to  cedema  of  the  leg. 

Operative  Treatment  is  undertaken  either  for  the  relief  of 
strangulation,  or,  if  a  radical  cure  is  desired,  as  an  operation  de 
complaisance.  The  remarks  already  made  as  regards  the  cure  of 
inguinal  hernia,  and  the  general  principles  there  enunciated,  apply 
also  to  this  variety.  Two  main  methods  of  operating  are  em- 
ployed :  (a)  The  sac  is  exposed  by  a  vertical  incision  along  the 
course  of  the  crural  canal,  emptied  of  its  contents  by  reduction  of 
intestine  and  removal  or  reduction  of  omentum,  and  cut  away 
after  transfixing  and  tying  the  neck.  The  deep  ring  is  then  com- 
manded by  one  or  two  sutures  passed  vertically  between  the  fascia 
over  the  pectineus  and  the  inner  end  of  Poupart's  ligament  ;  this 
must,  however,  not  be  tied  too  tightly,  for  fear  of  constricting  the 
femoral  vein,  (b)  W'atson  Cheyne  recommends  that  a  portion 
of  the  pectineus  muscle  should  be  dissected  up,  and  fixed  in  the 
crural  canal  by  means  of  sutures  ;  and  he  claims  thereby  to  have 
had  very  satisfactory  results.  The  same  precautions  as  to  after- 
treatment  must  be  adopted  as  in  inguinal  hernia. 

Umbilical  Hernia. — Three  different  forms  of  umbilical  hernia 
are  described. 

1.  Congenital  Umbilical  Hernia,  or  Exomphalos,  is  an  exceed- 
ingly rare  condition,  due  to  imperfect  closure  of  the  abdominal 
walls,  as  a  result  of  which  the  intestine  is  not  entirely  withdrawn 
into  the  abdomen  at  birth,  but  is  found  in  a  cavity  at  the  base  of 
the  umbilical  cord,  which  is  bulbous  and  enlarged.  If  the  con- 
dition is  overlooked,  it  may  be  included  in  the  ligature  with  which 
the  cord  is  tied,  and  fatal  strangulation,  or  at  the  best  a  faecal 
fistula,  will  result.  If  left  untreated  until  the  cord  has  separated, 
the  peritoneal  cavity  will  be  laid  open,  and  septic  peritonitis 
ensue.  The  only  treatment  is  immediate  laparotomy,  reduction 
of  the  gut,  and  closure  of  the  umbilical  opening  by  sutures. 

2.  The  Umbilical  Hernia  of  Infants  and  Young  People,  or,  as  it 
is  commonly  called,  '  starting  of  the  navel,'  is  due  to  weakness  of 
the  umbilical  cicatrix,  which  yields  before  the  intra-abdominal 
pressure.  Its  occurrence  is  often  determined  by  chronic  consti- 
pation or  phimosis,  necessitating  continual  straining  in  order  to 


992  A  MANUAL  OF  SURGERY 

evacuate  the  bowels  or  bladder.  The  condition  rarely  persists 
till  adult  life  is  reached,  and  it  is  readily  amenable  to  treatment. 
This  consists  in  regulating  the  bowels,  the  performance  of  cir- 
cumcision, if  necessary,  whilst  the  local  condition  is  dealt  with 
by  strapping  the  abdominal  wall  in  such  a  way  as  to  tuck  the 
umbilical  cicatrix  inwards  ;  no  pad  is  required.  In  persistent 
cases  it  may  be  necessary  to  lay  the  sac  open  and  remove  it, 
suturing  the  parts  together,  as  described  in  detail  below. 

3.  The  so-called  Umbilical  Hernia  of  Adults  is  usually  due  to  a 
protrusion  of  omentum  or  intestine  through  an  opening  in  the 
linea  alba,  either  immediately  above  or  below  the  umbilicus,  the 
former  being  the  more  common.  It  occurs  most  frequently  in 
women  who  have  borne  children,  being  sometimes  due  to  actual 
rupture  of  the  linea  alba  and  separation  of  the  recti  muscles.  In 
such  cases  it  is  possible  that  the  peritoneum  is  also  torn,  and  the 
intestines  extravasated,  as  it  were,  beneath  the  skin.  A  peritoneal 
sac,  is,  however,  usually  seen,  but  in  old-standing  cases  it  is  ex- 
tremely attenuated,  and  so  adherent  to  surrounding  parts  as  to  be 
unrecognisable,  whilst  the  contents  may  be  matted  together  in 
an  almost  inextricable  confusion.  In  such  cases  obstruction  is 
very  liable  to  ensue,  and  if  combined,  as  is  not  uncommon,  with  a 
subacute  form  of  inflammation,  it  may  even  run  on  to  strangula- 
tion. Moreover,  the  skin  over  the  tumour  becomes  stretched, 
atrophic,  and  not  unfrequently  ulcerated,  so  that  perforation  may 
threaten.  The  hernia  is  often  lobulated  in  character,  and  a  con- 
siderable deposit  of  fat  may  sometimes  surround  it. 

Treatment. — When  of  large  size,  and  occurring  in  stout  indi- 
viduals, it  should  be  supported  by  a  bag  truss,  whilst  the  patient 
is  placed  on  such  dietetic  and  hygienic  measures  as  shall  assist 
in  the  reduction  of  excessive  corpulency.  In  favourable  cases 
operative  treatment  can  be  undertaken.  A  vertical  incision  is 
made  over  the  site  of  the  tumour,  and  to  effect  this  without 
wounding  the  subjacent  gut,  it  may  be  advisable  to  pinch  up  the 
skin  on  either  side,  and  cut  it  by  transfixion.  The  sac  is  then 
opened,  the  incision  being  enlarged,  if  necessary,  so  as  to  allow 
the  contents  to  be  drawn  aside  and  the  opening  in  the  abdominal 
wall  exposed.  When  the  intestine  has  been  reduced  and  omentum 
removed,  the  sac  is  dissected  up  to  the  margins  of  the  opening 
into  the  abdomen,  which  is  usually  small  in  size  and  circular  in 
shape,  whilst  the  edges  are  firm  and  thickened.  The  sac  may  now 
be  cut  away  close  to  the  opening,  and  all  bleeding-points  secured. 
The  aperture  is  then  closed  in  the  following  way  :  Several  deep 
transverse  sutures  are  passed  through  the  whole  thickness  of  the 
abdominal  wall  on  each  side,  and  tightened  after  a  row  of  inter- 
rupted sutures  has  drawn  the  peritoneal  surfaces  into  contact. 
By  this  means  the  circular  aperture  is  obliterated  and  the  margins 
united  in  the  median  line.  The  external  wound  may  now  be 
closed,  any  redundant  skin  being  cut  away ;  it  is  usually  safer  to 
insert  a  drainage-tube  in  the  more  extensive  cases. 


HERNIA  993 

Most  surgeons  recommend  that  the  fibrous  margins  of  the  deep 
opening  should  be  freely  removed  by  dissection  before  the  passage 
of  the  sutures,  so  as  to  expose  the  fibres  of  the  recti  muscles,  and 
permit  of  their  approximation  after  the  peritoneum  has  been 
turned  in  and  stitched  ;  the  suggestion  is  a  good  one,  since  the 
union  of  healthy  vascular  tissue  must  always  be  more  favourable 
than  that  of  two  anaemic  cicatricial  edges.  To  accomplish  this 
satisfactorily,  it  is  often  necessary  to  prolong  the  incision  up  and 
down  for  some  distance,  since  the  recti  muscles  are  usually 
displaced  laterally  and  must  be  freely  detached  from  their  sheaths 
if  they  are  to  be  brought  together  in  the  middle  line.  Silkworm 
gut  may  be  used  with  advantage  in  these  cases  for  the  deep  sutures, 
since  it  remains  unabsorbed. 

A  Ventral  Hernia  is  the  term  used  in  describing  any  protrusion  occurring  at 
some  spot  in  the  anterior  abdominal  wall  other  than  those  already  mentioned. 
Several  forms  may  be  met  with  : 

1.  It  not  uncommonly  consists  of  a  protrusion  of  subserous  fatty  tissue 
through  a  congenital  or  acquired  opening  in  the  linea  alba,  lineae  semilunares, 
or  lineas  transversa?,  especially  at  the  junctions  of  the  former  and  latter.  They 
are  more  common  above  than  below  the  umbilicus,  and  if,  as  not  unfrequently 
happens,  the  fatty  tissue  proliferates,  a  localized  tumour  resembling  a  lipoma 
is  produced,  and  goes  by  the  name  of  a  '  fatty  hernia  of  the  linea  alba.'  A 
portion  of  peritoneum  is  drawn  through  the  opening  into  the  centre  of  these 
masses  when  they  have  persisted  for  some  little  time,  and  a  true  hernia  is  thus 
induced.  A  similar  condition  is  met  with  in  the  inguinal  and  crural  regions, 
and  probably  most  of  the  cases  described  as  lipomata  in  these  parts  are  of  this 
nature.  Considerable  pain  and  abdominal  disturbance  (vomiting,  colic,  etc.) 
accompany  almost  every  movement  of  the  body,  being  caused  partly  by  the 
traction  of  the  peritoneum,  partly  by  the  constriction  of  the  neck  of  the  sac 
against  the  sharp  edges  of  the  small  opening.  Treatment  consists  in  the 
removal  of  the  projecting  mass,  care  being  taken  not  to  include  any  viscera 
in  the  suture  with  which  the  base  is  surrounded.  The  stump  is  pushed  back 
into  the  abdomen,  and  the  opening  closed  by  deep  sutures. 

2.  After  operations  involving  the  division  of  the  abdominal  parietes,  ventral 
hernia  may  be  caused  by  the  yielding  of  the  cicatrix,  especially  if  the  wound 
suppurates,  and  the  deep  stitches  come  away  or  are  removed,  or  if  the  opening 
is  left  patent  for  the  purpose  of  draining  an  intra-abdominal  abscess.  Treatment 
of  such  cases  consists  in  dividing  the  skin  and  subjacent  fibrous  tissues,  defining 
and  refreshing  the  edges  of  the  parietal  wound,  and  drawing  them  together 
with  buried  sutures.  The  peritoneum  need  not  always  be  opened  in  such  a 
procedure,  but  it  is  sometimes  wiser  to  do  so.  Especially  is  this  the  case  when 
a  ventral  hernia  forms  after  an  operation  for  suppurative  appendicitis ;  the 
appendix  is  rarely  dealt  with  at  the  primary  operation,  and  the  surgeon  may 
rightly  take  the  opportunity  of  removing  it  during  the  operation  required  for 
the  cure  of  the  hernia. 

3.  Not  unfrequently  in  women  who  have  had  children  the  linea  alba 
stretches  and  yields,  allowing  considerable  separation  of  the  recti  muscles  for 
almost  their  whole  length.  If  placed  in  the  recumbent  posture,  and  told  to 
raise  their  head  and  shoulders  from  the  bed  without  using  their  elbows  for 
support,  the  linea  protrudes  as  a  longitudinal  ridge  of  considerable  breadth. 
Much  discomfort  and  dyspepsia  arises  from  this  cause,  owing  to  the  inefficient 
support  given  to  the  intestines.  A  firm  abdominal  belt  may  be  useful  as  a 
palliative  measure,  but  operation  is  very  desirable.  The  thinned  linea  alba 
is  split  down  the  middle  from  top  to  bottom  if  need  be  ;  on  one  side — say  the 
right — it,  together  with  the  neighbouring  rectus  muscle,  is  separated  from  the 
subcutaneous  tissues  and  tucked  under  the  rectus  on  the  left  side,  its  free  end 

63 


994  A   MANUAL  OF  SURGERY 

being  secured  by  mattress  sutures  passing  through  it  and  the  left  linea  semi- 
lunaris, and  being  tied  superficially.  The  left  free  edge  is  subsequently 
secured  to  the  right  linea  semilunaris  by  a  row  of  stitches.  In  this  way  the 
abdominal  wall  is  drawn  together  like  a  double-breasted  coat,  and  excellent 
results  follow. 

A  Lumbar  Hernia  is  a  condition  of  considerable  rarity,  in  which  the  abdominal 
viscera  protrude  by  the  side  of  the  erector  spinas,  coming  to  the  surface  between 
the  latissimus  dorsi  and  the  external  oblique,  in  the  space  known  as  Petit's 
triangle.  The  ordinary  signs  of  a  hernia  are  present,  and  with  a  little  care 
the  condition  is  readily  distinguished  from  a  lumbar  abscess.  Treatment  may 
be  conducted  along  the  same  lines  as  for  a  ventral  hernia. 

A  Diaphragmatic  Hernia  is  rarely  recognised  ante-mortem.  A  few  cases  of 
strangulation  have,  however,  been  diagnosed.  It  is  usually  congenital  in 
origin,  arising  from  imperfect  development  of  one  or  both  halves  of  the 
diaphragm  ;  it  is  most  common  on  the  left  side.  It  may,  however,  result  from 
traumatic  lesions,  such  as  stabs,  involving  the  diaphragm.  The  transverse 
colon  or  stomach  generally  protrudes  into  the  thorax,  and  there  is  usually  no 
peritoneal  sac.  Treatment  is  impracticable  in  the  majority  of  instances, 
although  one  or  two  cases  of  traumatic  hernia  have  been  successfully  operated 
on  through  the  chest  wall  and  pleural  cavity,  thus  permitting  the  closure  of 
the  hole  in  the  diaphragm. 

Obturator  Hernia  consists  in  a  protrusion  of  intestine  through  the  upper 
part  of  the  thyroid  foramen,  and  has  usually  been  observed  in  elderly  females. 
It  is  not  often  recognised  in  the  living,  except  when  strangulated,  and  even 
then,  unless  of  considerable  size,  it  is  likely  to  be  overlooked.  It  has,  how- 
ever, been  diagnosed  by  the  fact  that,  in  addition  to  the  general  signs  of 
strangulation,  there  was  a  sense  of  deep  resistance  and  of  fulness  close  to  the 
origin  of  the  adductor  muscles  ;  whilst  pain  was  referred  down  the  obturator 
nerve  to  the  inner  side  of  the  knee.  Rectal  or  vaginal  examination  may  throw 
some  light  on  the  nature  of  the  case.  Treatment  has  generally  been  confined 
to  cases  of  strangulation,  and  in  such  an  incision  is  made  over  the  inner  aspect 
of  Scarpa's  triangle,  and  the  pectineus  divided  or  displaced.  The  sac  when 
found  should  be  opened,  and  strangulation  relieved  by  cutting  upwards,  the 
obturator  vessels  being  usually  situated  below  the  neck  of  the  sac. 

Other  forms  of  hernia,  e.g.,  pudic,  pudendal,  vaginal,  sciatic,  etc.,  have  been 
described,  but  are  so  uncommon  that  they  need  no  special  mention. 

Abnormal  Conditions  of  Hernise. 

Irreducibility  of  a  Hernia  is  generally  due  to  the  presence  of 
adhesions,  either  between  the  contents  and  the  sac,  or  between 
the  contents  themselves,  which  are  thus  united  into  a  mass  too 
large  to  pass  through  the  aperture  of  communication  with  the 
abdomen.  This  is  often  associated  with  contraction  of  the  neck 
of  the  sac,  which  arises  either  from  the  pressure  of  an  ill-fitting 
truss  or  the  constant  drag  of  the  contents.  Overgrowth  or  an 
excessive  deposit  of  fat  in  the  omentum  may  result  in  irreduci- 
bility, whilst  cysts  may  occasionally  form,  as  already  described. 

The  local  signs  of  this  condition  are  very  evident,  whilst  dys- 
pepsia, colicky  pains,  and  a  sense  of  dragging  are  among  the  most 
prominent  symptoms. 

Treatment. — i.  It  may  sometimes  be  remedied  by  forcible  taxis 
applied  at  intervals,  between  which  the  patient  is  kept  in  bed, 
and  an  icebag  applied  so  as  to  contract  the  parts ;  moreover,  the 
patient,  if  fat,  should  be  carefully  dieted.     It  is  most  important 


HERNIA  995 

not  to  operate  on  large  herniae  of  this  nature  until  some  such 
preliminary  treatment  has  been  undertaken ;  the  sudden  reduction 
of  a  large  amount  of  intestine  into  the  abdominal  cavity  has  been 
responsible  for  several  deaths  from  interference  with  the  heart's 
action.  2.  Another  plan  consists  in  the  use  of  what  is  known  as 
the  hinged-cup  truss ;  the  hernia  is  supported  in  a  suitable  leather 
bag  hinged  to  the  lower  part  of  a  truss,  upward  pressure  being 
maintained  by  means  of  an  elastic  spring.  By  the  use  of  one  or 
other  of  these  plans  reduction  may  after  a  time  be  accomplished ; 
but  we  are  not  in  favour  of  any  such  proceedings,  except  in  very 
large  herniae.  3.  In  healthy  individuals,  and  if  the  rupture  is  not 
too  large,  operation  is  preferable  and  much  more  satisfactory, 
omentum  being  removed  and  adhesions  divided,  as  already  de- 
scribed (p.  986).  4.  In  a  few  very  aggravated  cases,  it  is  only 
possible  to  support  the  hernia  by  an  elastic  bag. 

Inflamed  Hernia  is  one  characterized  by  the  existence  of  a 
localized  peritonitis  involving  the  sac,  and  perhaps  also  the  con- 
tents. It  usually  arises  from  injury,  such  as  ill-directed  taxis,  or 
from  injudicious  truss  pressure.  The  symptoms  are  those  of  a 
local  inflammation,  the  part  becoming  hot,  painful,  tender,  and 
swollen,  and  perhaps  the  skin  over  it  red;  this  is  associated  with 
general  fever,  malaise,  nausea,  and  vomiting,  whilst  constipation 
is  usually  present.  A  condition  is  thus  induced  somewhat  re- 
sembling strangulation  ;  but  it  is  distinguished  from  the  latter  by 
the  presence  of  fever  instead  of  shock,  the  absence  of  tension  in  the 
sac,  and  the  character  of  the  vomiting,  which  is  not  faecal.  The 
hernia  is  irreducible,  at  any  rate  for  a  time,  probably  more  on 
account  of  the  pain,  which  prevents  taxis,  than  from  any  mechanical 
reason,  except  in  old-standing  cases  where  previously  formed 
adhesions  exist.  Lymph  is  deposited  on  the  serous  surfaces,  and 
this  usually  leads  to  the  formation  of  adhesions.  Occasionally, 
where  omentum  is  alone  present,  an  attack  of  this  type  may 
result  in  a  natural  cure,  especially  in  the  umbilical  variety. 

The  Treatment  consists  in  putting  the  patient  to  bed  and  re- 
stricting his  diet  to  fluids,  whilst  fomentations  are  applied  to 
the  part.  A  little  opium  may  also  be  administered  to  allay  the 
pain,  and  possibly  the  lower  bowel  emptied  by  an  enema. 

Obstructed  Hernia  is  a  condition  in  which  the  onward  passage 
of  faeces  through  the  gut  contained  in  a  hernial  sac  is  prevented. 
It  is  most  frequently  seen  in  the  umbilical  variety,  and  is  of  course 
irreducible.  It  is  due  to  an  accumulation  of  undigested  food  or 
faeces,  the  condition  being  aggravated  by  the  presence  of  flatus 
derived  from  the  decomposition  of  the  contents  of  the  bowel. 
Nausea  and  vomiting  are  induced,  the  latter,  however,  rarely 
becoming  fasculent,  whilst  constipation  is  usually  present,  although 
the  lower  bowel  may  empty  itself  and  flatus  may  pass.  Locally, 
the  tumour  becomes  distended,  but  not  tense  as  in  strangulation, 
and  a  doughy  mass,  which  can  be  moulded  and  indented  by  the 

63—2 


996  A   MANUAL  OF  SURGERY 


fingers,  is  felt  within  the  sac.  There  is  no  tenderness,  but  the 
patient  usually  complains  of  a  good  deal  of  intermittent  colicky 
pain.  If  unrelieved,  a  subacute  form  of  inflammation  may  super- 
vene, and  this  may  pass  on  to  strangulation,  and  even  death. 

Treatment  consists  in  the  use  of  copious  enemata,  and  the 
application  of  an  icebag  to  the  hernia,  followed  by  carefully  applied 
taxis,  so  as  to  assist  the  onward  passage  of  the  impacted  contents. 
As  soon  as  the  obstruction  is  overcome,  a  brisk  purge  should  be 
administered. 

Strangulated  Hernia. 

A  hernia  is  said  to  be  strangulated  when  the  contents  are  con- 
stricted in  such  a  way  as  to  obstruct  and  ultimately  arrest  the 
flow  of  blood  in  the  vessels  contained  therein.  Interference  with 
the  passage  of  faeces  is  not  an  essential  in  this  condition,  since 
omentum  alone  may  be  involved,  or  the  intestine,  if  present,  may 
only  have  a  portion  of  its  lumen  constricted,  as  in  the  form  known 
as  Kichter's  hernia,  or  in  Littre's  hernia,  where  a  diverticulum  is 
similarly  affected. 

Two  chief  varieties  of  strangulation  are  described :  those 
occurring  within  the  abdomen,  which  are  dealt  with  more  fully 
in  Chapter  XXXIV.,  and  those  which  are  extra-abdominal ;  it  is 
only  the  latter  to  which  we  shall  now  direct  attention. 

External  Strangulated  Hernia  arises  in  one  of  two  ways  :  (a)  The 
hernia  becomes  strangulated  immediately  after  its  formation  ; 
this  is  most  frequently  seen  in  children  or  adolescents,  the 
hernia  being  then  of  the  congenital  type,  and  having  a  long 
narrow  sac.  (b)  In  adults  it  more  frequently  results  from  ex- 
trusion of  an  additional  amount  of  the  abdominal  contents  into 
the  sac,  as  the  result  of  some  sudden  violent  effort.  This  condition 
usually  obtains  in  old-standing  herniae,  the  neck  of  the  sac  having 
previously  become  thickened  and  contracted,  either  by  the  pressure 
of  a  truss  or  the  irritation  of  the  protruded  viscera.  The  former 
of  these  two  conditions  is  usually  acute  in  character,  the  latter 
more  often  subacute. 

The  site  of  the  constriction  is  either  at  the  neck  of  the  sac,  or 
in  the  dense  tissues  external  to  it,  but  occasionally  it  exists  else- 
where. Most  frequently  the  active  agent  in  the  strangulation  is 
the  thickened  sac  wall  itself ;  but  in  femoral  and  umbilical  herniae 
structures  outside  the  sac,  such  as  Gimbernat's  ligament  or  the 
linea  alba,  may  be  the  actual  cause  of  the  constriction,  whilst  it 
may  also  be  produced  by  the  passage  of  a  coil  of  intestine  under 
a  tight  adhesion  or  through  a  slit  or  aperture  in  the  omentum 
contained  in  the  sac.  In  those  herniae  which  become  strangulated 
immediately  after  their  protrusion,  the  constricting  cause  is  in- 
variably the  resistance  of  the  tissues  surrounding  the  opening  in 
the  abdominal  parietes. 

Pathological   Phenomena. — The   effects   of    strangulation    vary 


HERNIA  997 

somewhat  with  the  tightness  of  the  constriction.  The  circulation 
is  seldom  entirely  arrested  at  the  onset  of  the  symptoms ;  but  the 
pressure  affects  first,  and  more  especially,  the  veins,  and  later, 
by  the  congestion  and  exudation  thus  produced,  the  flow  in  the 
arteries  is  brought  to  a  standstill.  Hence  the  constricted  tissues 
are  congested  to  begin  with,  and  pass  over  into  a  state  of  gangrene 
with  or  without  an  intermediate  period  of  inflammation. 

When  a  portion  of intestine  is  strangulated,  the  following  changes 
manifest  themselves  in  its  structure  and  appearance.  At  first  it 
becomes  of  a  dusky  red,  chocolate,  or  claret  colour,  owing  to 
vascular  congestion  ;  it  is  thickened  and  stiff  from  exudation  into 
its  walls,  and  distended  by  the  formation  of  gas  within  its  lumen, 
owing  to  the  arrest  of  peristalsis  and  the  putrefaction  of  its  con- 
tents. The  surface  at  first  remains  smooth  and  shiny,  but  as  the 
exudation  into  the  sac  increases,  the  endothelium  is  usually  shed. 
Occasionally  some  of  the  superficial  capillaries  rupture,  giving  rise 
to  ecchymoses,  whilst  in  rarer  instances,  and  possibly  as  the  result 
of  injudicious  taxis,  the  congested  vessels  completely  empty  them- 
selves into  the  sac,  which  is  thus  filled  with  clotted  blood,  the 
intestine  in  consequence  becoming  lax  and  yellowish -grey  in 
colour.  When  the  strangulation  is  relieved  in  this  early  stage, 
the  bowel  soon  regains  its  former  healthy  appearance.  If  inflam- 
mation occurs,  the  surface  becomes  rough  from  the  deposit  of 
lymph,  and  entirely  loses  its  shiny  and  polished  aspect.  Gangrene 
results  partly  from  the  prolonged  stagnation  of  blood,  and  partly 
from  the  action  of  the  Bac.  coli,  which,  as  soon  as  the  vitality  of 
the  intestinal  wall  is  sufficiently  impaired,  migrates  through  it, 
and  by  its  development  produces  toxic  bodies  which  still  further 
assist  the  gangrenous  process.  As  soon  as  it  is  established,  the 
intestine  turns  an  ashy  grey  or  black  colour,  usually  at  one  or 
more  spots  which  gradually  spread,  lose  all  lustre  and  polish, 
and  after  a  time  become  soft,  lacerable,  and  offensive.  At  the 
point  of  strangulation  the  gut  is  completely  anaemic  and  liable 
to  ulceration,  which  may  subsequently  result  in  perforation ; 
adhesions  may,  however,  form  between  it  and  the  neck  of  the  sac, 
thus  preventing  contaminaiion  of  the  general  peritoneal  cavity. 
The  intestine  above  the  site  of  strangulation  becomes  paralyzed,  and 
peristalsis  is  entirely  arrested,  even  in  a  Richter's  hernia.  Faecal 
material,  accumulating  and  undergoing  decomposition,  gives  rise 
to  a  catarrhal  enteritis,  and  even  occasionally  to  stercoral  ulcers, 
which  may  perforate  and  cause  general  peritonitis  ;  this,  however, 
is  not  very  common  in  external  strangulation,  since  the  small  in- 
testine is  usually  involved,  and  solid  faeces  are  absent.  In  more 
chronic  cases  gangrene  of  the  gut  may  be  induced  by  the  pressure 
of  the  accumulated  contents  and  the  action  of  the  Bac.  coli.  The 
portion  of  the  bowel  below  the  constriction  may  be  affected  in  a 
similar  manner,  owing  to  the  arrest  of  the  peristalsis,  but  to  a 
slighter  decree. 


998  A   MANUAL  OF  SURGERY 

Omentum,  when  strangled,  is  at  first  congested  and  of  a  dark 
red  or  purplish  colour,  and  later  on  infiltrated  and  matted 
together.  If,  however,  it  has  contracted  adhesions  to  the  sac, 
and  no  gut  is  present,  the  trouble  may  subside,  since  its  vitality 
may* be  maintained  through  the  adhesions,  and  a  natural  cure  of 
the  hernia  may  result.  Where  such  a  condition  is  not  present, 
gangrene  supervenes,  and  the  omentum  then  becomes  ashy  grey 
or  brown  in  colour,  and  is  pultaceous  and  friable.  It  does  not 
become  offensive  unless  associated  with  intestine,  since  it  does  not 
contain  any  intrinsic  source  of  putrefaction. 

The  sac  is  usually  distended  with  fluid,  which  at  the  commence- 
ment is  serous  in  character,  and  perhaps  blood-stained,  whilst 
subsequently  it  becomes  turbid  and  mixed  with  lymph  ;  finally,  it 
is  dark  brown  or  yellowish-green,  with  a  marked  and  most  objec- 
tionable odour.  Occasionally  there  is  but  little  or  no  effusion  of 
fluid,  a  condition  more  often  met  with  when  intestine  is  absent 
from  the  sac,  and  only  omentum,  or  some  solid  viscus,  such  as 
the  ovary,  is  present.  The  serous  lining  of  the  sac  is  but  slightly 
affected  in  the  early  stages  ;  as,  however,  the  case  progresses  to 
inflammation  or  death  of  the  contents,  it  also  becomes  inflamed, 
and  ultimately  gangrenous  owing  to  the  action  of  the  Bac.  coli, 
which  by  this  time  has  penetrated  to  the  turbid  serum  contained 
within  it.  The  skin  and  surrounding  tissues  become  cedematous, 
congested,  and  crepitant,  and,  finally,  a  natural  cure  may  be  deter- 
mined by  sloughing  and  the  establishment  of  an  artificial  anus. 

After  the  relief  of  strangulation,  even  if  no  gangrene  has 
occurred,  the  patient  is  not  free  from  risk,  owing  to  changes  which 
may  possibly  follow  the  temporary  arrest  of  the  circulation.  It 
has  been  shown  by  placing  a  ligature  around  the  ear  of  a  rabbit 
that  the  amount  of  reaction,  when  the  constriction  is  relieved, 
varies  directly  with  the  tightness  with  which  the  ligature  has  been 
applied,  and  with  the  period  of  constriction.  When  applied 
loosely  and  only  for  a  short  time,  the  restoration  of  circulation  is 
followed  merely  by  a  transient  hyperemia,  but  as  the  complete- 
ness and  duration  of  the  obstruction  are  increased,  the  inflamma- 
tion becomes  more  and  more  intense,  and  even  gangrene  may 
ensue.  Similar  results  follow  the  relief  of  strangulated  hernia. 
In  the  less  severe  cases  the  intestine  merely  becomes  temporarily 
congested,  but  in  the  more  acute  forms  the  paralysis  of  the  gut 
may  persist,  whilst  inflammation,  possibly  running  on  to  gangrene, 
may  be  produced,  either  in  the  strangulated  portion  or  in  that 
immediately  above,  and  thus,  although  the  operation  has  been 
skilfully  performed,  the  patient  may  succumb. 

The  Clinical  History  of  a  case  of  strangulation  is  usually 
so  characteristic  that  there  can  be  but  little  uncertainty  as  to  the 
diagnosis.  The  general  symptoms  are  similar  to  those  described 
at  p.  ioio,  as  occurring  in  all  cases  of  acute  intestinal  obstruction. 
The  patient   during  some   sudden    effort   notices  a  severe  pain, 


HERNIA  999 

localized  at  first  to  one  of  the  hernial  regions,  or  referred  to  the 
umbilicus  ;  this  is  accompanied  by  the  usual  evidences  of  shock 
— i.e.,  he  feels  faint,  the  pulse  becomes  slow  and  weak,  the  tem- 
perature falls,  and  the  surface  is  covered  by  a  cold,  clammy 
sweat.  This  shock  is  often  not  very  prolonged,  and  is  associated 
with  or  quickly  followed  by  vomiting,  at  first  gastric,  then 
bilious,  and  finally  stercoraceous  or  faecal.  As  this  continues, 
the  pain  increases  in  severity,  and  radiates  over  the  whole  of  the 
abdomen,  which  becomes  tense,  tender,  and  tympanitic.  Symptoms 
of  exhaustion  supervene,  caused  partly  by  the  pain  and  vomiting, 
and  partly  by  the  inability  to  take  food  ;  probably  the  absorption 
of  toxic  material  from  the  intestine  also  assists  in  its  production. 
Complete  constipation  is  usually  present  but  the  patient  may  pass 
flatus  or  fasces  from  the  lower  part  of  the  intestine.  The  onset  of 
gangrene  is  generally  accompanied  by  a  sudden  fall  of  temperature 
and  a  cessation  of  pain,  whilst  the  pulse  becomes  weak,  rapid, 
and  intermittent,  the  surface  is  covered  by  a  cold  sweat,  the 
countenance  becomes  shrunken  and  drawn  (the  so-called  '  facies 
Hippocratica '),  hiccough  follows,  and  finally  the  patient  dies, 
usually  as  a  result  of  toxaemia  due  to  the  absorption  of  products 
developed  either  in  the  bowel  wall  or  sac,  or  in  consequence  of 
acute  generalized  peritonitis.  Locally,  the  onset  of  the  symp- 
toms is  associated  with  the  formation  of  a  tumour  in  one  of  the 
usual  sites  of  a  hernia,  or  if  already  the  subject  of  this  condition, 
the  patient  may  notice  that  his  rupture  has  suddenly  become 
larger.  The  swelling  is  irreducible,  tense,  extremely  tender  and 
painful,  and  without  impulse  on  coughing.  It  is  hard  and 
rounded  if  bowel  is  involved,  softer  and  more  doughy  to  the  touch, 
if  omentum.  When  gangrene  ensues,  the  tension  within  the 
sac  is  reduced,  pain  and  tenderness  cease,  whilst  the  skin  over 
the  tumour  becomes  dusky,  inflamed,  and  cedematous  ;  finally, 
evidences  of  gangrene  show  themselves  externally,  the  parts 
becoming  dark  in  appearance,  and  soft  and  emphysematous  to  the 
touch.  If  the  patient  survive,  the  necrotic  tissues  separate,  and 
an  artificial  anus  is  produced  either  naturally  or  through  the  inter- 
vention of  the  surgeon.     Suppuration  within  the  sac  is  uncommon. 

Occasionally,  however,  cases  are  met  with  in  which  the  above 
described  signs  are  considerably  modified,  and  in  one  of  our 
cases  the  patient  complained  of  no  inconvenience  beyond  slight 
pain,  although  incipient  gangrene  was  present ;  he  walked  into 
hospital  saying  that  he  never  felt  better  in  his  life. 

The  early  symptoms  arising  from  strangulation  of  a  portion  of 
the  lumen  of  the  intestine  (Richters  hernia)  are  sometimes  less 
marked  than  when  a  complete  loop  is  constricted,  but  the  later 
phenomena  are  always  very  severe.  It  is  usually  of  the  femoral 
variety,  and  the  ileum  is  most  frequently  involved.  If  less  than 
half  the  circumference  of  the  bowel  is  constricted,  the  obstruction 
is  not  always  complete  at  first,  flatus  and  faeces  being  sometimes 


A  MANUAL  OF  SURGERY 


passed  ;  but  where  more  than  half  the  circumference  of  the  bowel 
is  engaged,  complete  obstruction  from  kinking  or  paralysis  of  the 
gut  ensues.  The  vomiting  is  less  marked  than  in  other  cases, 
and  is  not  so  commonly  faeculent.  The  tumour  produced  is 
small  in  size,  but  tense  and  tender.  The  prognosis  in  these 
cases  is  always  grave,  partly  from  the  difficulty  experienced  in 
diagnosis,  partly  from  the  tightness  of  the  constriction  ;  death 
usually  results  from  perforative  peritonitis,  which  is  occasionally 
due  to  wounding  of  the  gut  by  the  hernia  knife.  The  mortality 
in  these  cases  is  calculated  at  62  per  cent.,  which  is  in  marked 
contrast  with  that  of  about  35  per  cent.,  which  is  usually  said  to 
be  characteristic  of  strangulated  hernia.  Our  mortality  for  all 
cases  of  strangulated  hernia,  admitted  to  King's  College  Hospital 
during  the  years  1892  to  1897,  only  amounted  to  16*6  per  cent. 

The  occurrence  of  strangulation  in  a  pure  epiplocele  is  very  rare  ; 
the  symptoms  are  vague  in  character,  and  the  diagnosis  is  often 
difficult.  The  presence  of  a  soft,  doughy,  tender  swelling  in  any 
of  the  hernial  regions,  combined  with  pain,  bilious  vomiting,  and 
possibly  constipation,  is  always  a  significant  feature.  So  long  as 
no  kinking  of  the  bowel  is  caused  thereby,  the  symptoms  may 
remain  indefinite,  the  vomiting  never  becoming  faecal ;  but  as 
time  goes  on,  arrest  of  peristalsis  may  lead  to  true  obstruction,  or 
even  general  peritonitis.  As  already  mentioned,  strangulated 
omentum  does  not  per  se  become  offensive ;  but  occasionally  a 
neighbouring  coil  of  intestine  may  be  dragged  upon,  and  its  circu- 
lation disturbed  sufficiently  to  enable  the  Bac.  coli  to  escape,  and 
then  it  may  find  its  way  into  the  sac,  and  develop  therein  its 
characteristic  odour  without  any  serious  lesion  of  the  intestine  or 
peritoneum  being  conjoined. 

The  Treatment  of  a  strangulated  hernia  consists  in  reducing  the 
contents  by  taxis,  or  by  operation. 

Taxis  is  the  term  employed  for  the  manipulation  by  means  of 
which  a  hernia  is  reduced.  In  cases  of  strangulation,  it  must  be 
used  with  gentleness  and  great  care,  since  the  involved  portion  of 
intestine  is  congested  and  easily  torn.  The  patient  is  laid  on  a 
couch  with  the  head  supported,  and  the  thighs  slightly  flexed,  so 
as  to  relax  the  abdominal  muscles.  The  fundus  of  the  tumour  is 
then  grasped  with  one  hand,  and  steady  pressure  employed, 
having  for  its  object  the  emptying  of  the  congested  bloodvessels, 
and  consequently  a  diminution  in  the  size  of  the  hernia ;  the 
fingers  of  the  other  hand  manipulate  the  neck  of  the  sac,  in 
order  that  the  part  which  has  most  recently  been  protruded  may 
be  first  returned.  The  direction  in  which  taxis  is  made  varies  in 
different  cases.  In  inguinal  hernia,  it  should  be  directed  upwards, 
outwards,  and  backwards.  In  a  femoral  hernia  which  has  ex- 
tended beyond  the  saphenous  opening,  taxis  is  first  employed 
downwards  and  inwards  in  order  to  make  the  gut  re-enter  the 
crural    canal,    and     then     finally    backwards    and    upwards,    the 


HERNIA  1001 

margins  of  the  saphenous  opening  being  relaxed  by  flexing  and 
slightly  inverting  the  thigh.  In  umbilical  hernia,  the  pressure  is 
mainly  directed  backwards. 

Whilst  admitting  the  prima  facie  desirability  of  treating  a 
strangulated  hernia  by  taxis  (since  the  patient's  general  condition 
is  not  such  as  to  render  any  operation  free  from  risk),  it  must  not 
be  forgotten  that  injudicious  taxis  may  do  more  harm  than  even 
an  unnecessary  operation.  The  wall  of  the  gut  may  be  bruised 
or  even  ruptured,  haemorrhage  into  the  sac  may  occur,  and  even 
if  successful  one  never  knows  the  condition  of  the  bowel  that  has 
been  reduced.  The  greatest  caution  is  therefore  needed  in  select- 
ing cases  to  treat  by  this  means.  If  the  strangulation  has  lasted 
for  more  than  twenty-four  hours,  if  the  swelling  is  very  tense  and 
tender,  if  faecal  vomiting  is  present  and  the  face  becoming  drawn 
and  pinched,  a  very  perfunctory  attempt  at  taxis  should  be  made. 
But  if  the  swelling  is  free  from  tenderness  and  not  very  tense,  if 
the  vomit  consists  merely  of  unpleasant-smelling  bilious  fluid,  and 
is  not  constant,  and  if  the  general  condition  is  not  really  one  of 
gravity,  it  may  be  justifiable  to  prolong  one's  efforts  at  taxis  for 
ten  or  fifteen  minutes,  but  even  then  the  pressure  must  be  con- 
tinuous and  steady,  not  intermittent  and  jerky.  A  final  attempt 
may  always  be  made  before  operation  when  the  patient  is  anaes- 
thetized. 

In  some  of  the  slighter  conditions  of  strangulation,  and  especially 
if  the  patient  has  had  similar  attacks  before  which  have  been 
relieved  without  operation,  reposition  may  be  assisted  by  applying 
fomentations  for  half  an  hour,  followed  by  the  use  of  an  icebag, 
reduction  sometimes  taking  place  spontaneously  or  being  brought 
about  by  taxis.  The  heat  relaxes  the  tissues  around  the  neck  of 
the  sac,  and  the  effect  of  the  cold  is  not  only  to  constrict  these 
tissues,  but  also  to  induce  contraction  of  the  intestinal  bloodvessels 
and  muscles. 

Persistence  of  Symptoms  after  apparently  Successful  Taxis. — It 
occasionally  happens  that  although  the  surgeon  may  have  appar- 
ently reduced  the  hernia  satisfactorily,  the  symptoms  of  strangula- 
tion, viz.,  pain,  vomiting,  and  constipation,  persist.  Such  may  be 
due  to  a  variety  of  conditions,  and  considerable  judgment  is  needed 
in  coming  to  a  correct  decision  in  any  particular  case,  (i.)  The 
vomiting  may  possibly  be  due  to  the  anaesthetic,  but  then  does 
not  usually  last  for  any  length  of  time,  and  soon  loses  its  faecal 
character,  (ii.)  The  gut  remains  paralyzed  from  the  effect  of  the 
constriction  ;  inflammation  may  then  supervene,  involving  either 
the  released  coil  of  gut  or  the  portions  above  or  below  it,  and 
perhaps  running  on  to  ulceration,  perforation,  and  death  from 
peritonitis  or  toxaemia,  (iii.)  The  rupture  reduced  may  not  be 
the  one  which  has  given  rise  to  the  symptoms,  an  internal  hernia, 
or  one  in  some  other  region,  co-existing,  (iv.)  The  strangulation 
may  have  been  caused,  not  by  the  neck  of  the  sac,  but  by  a  slit  in 


A   MANUAL  OF  SURGERY 


the  omentum  contained  in  the  sac.  Reduction  in  such  a  case 
would  not  relieve  the  symptoms,  the  whole  mass  being  returned 
into  the  abdomen,  (v.)  The  hernial  sac  may  have  a  diverticulum 
or  pocket  communicating  with  it  at  its  upper  end  (intraparietal 
interstitial  hernia),  or  it  may  be  shaped  like  an  hour-glass.  It  is 
possible  to  reduce  the  intestine  from  the  lower  portion  of  this 
so-called  hernia  en  bissac  into  the  upper  pocket,  and  then  of  course 
the  symptoms  persist,  (vi.)  Reduction  en  bloc  or  en  masse  may 
occur,  but  only  when  considerable  force  is  employed  ;  in  this  the 
sac  and  its  contents  are  together  reduced  from  their  superficial 
position  to  the  deep  aspect  of  the  abdominal  parietes,  the  hernia 
then  lying  between  the  muscular  planes  or  in  the  subserous  areolar 
tissue,  and  the  constriction  remaining.  The  hernia  gradually 
disappears,  but  without  the  characteristic  gurgle.  In  such  a  case 
the  sac  sometimes  gives  way,  the  intestine  and  the  portion  of  the 
neck  which  compresses  it  being  pushed  upwards.  When  occurring 
in  the  inguinal  region  it  is  recognised  by  the  persistence  of 
symptoms,  and  by  the  fact  that  a  finger  inserted  into  the  canal, 
which  is  unduly  patent,  detects  a  tense  rounded  swelling  at  its 
upper  end.  It  also  occurs,  but  less  commonly,  in  the  femoral 
region,  and  in  either  variety  the  hernia  may  slip  down  again  a 
short  time  after  its  apparent  reduction. 

In  any  case  where,  after  an  apparently  successful  taxis,  the 
symptoms  of  strangulation  are  still  present,  a  most  careful 
investigation  is  needed  in  order  to  ascertain,  if  possible,  the  cause. 
Thus,  the  character  and  frequency  of  the  vomiting  must  be  con- 
sidered, since,  when  due  to  anaesthetics,  it  usually  loses  its  faecal 
character,  and  is  less  severe.  If  the  vomiting  is  associated  with 
a  certain  amount  of  local  pain,  and  possibly  with  some  blood- 
stained diarrhoea  or  the  passage  of  mucus,  the  probability  is  that 
the  coil  of  gut  has  been  in  reality  reduced,  but  has  subsequently 
become  inflamed.  Apart  from  such  indications  the  affected  region 
must  be  thoroughly  explored  with  the  finger,  so  as  to  ascertain 
whether  any  tumour  can  be  felt  at  the  upper  or  deeper  end,  as 
occurs  in  reduction  en  masse.  Should  this  throw  no  light  upon  the 
case,  the  other  hernial  apertures  must  each  in  turn  be  examined, 
and  finally  an  incision  is  made  over  the  supposed  site  of  strangu- 
lation, and  an  exhaustive  search  made  for  the  sac.  If  no  help  is 
thus  obtained,  the  abdomen  must  be  opened,  and  an  internal 
strangulation  sought  for.  In  the  inguinal  region,  all  that  is 
needed  is  to  prolong  the  first  incision  upwards  and  outwards ;  in 
a  femoral  hernia,  it  is  perhaps  wiser  to  make  a  separate  lapar- 
otomy wound  in  the  middle  line,  so  as  to  avoid  the  division  of 
Poupart's  ligament  ;  whilst  in  the  umbilical  variety,  the  require- 
ments of  the  case  are  met  by  simply  increasing  the  size  of  the 
communication  between  the  sac  and  the  abdominal  cavity. 

The  Operative  Treatment  of  strangulated  hernia  should  always 
be  undertaken  at  as  early  a  date  as  possible,  when  once  it  is  certain 


HERNIA  1003 

that  the  bowel  is  constricted,  and  taxis  has  failed.  Nothing  can 
be  gained  by  waiting,  whilst  even  the  delay  of  an  hour  may  make 
it  doubtful  whether  the  result  will  be  successful  or  not.  There 
is  always  sufficient  time  to  permit  of  efficient  purification  of  the 
parts,  whilst  it  may  be  desirable  to  empty  the  lower  bowel  by  an 
enema,  and  if  there  is  much  vomiting  to  wash  out  the  stomach. 
The  administration  of  an  anaesthetic  needs  care,  and  in  the  worst 
cases  local  anaesthesia  must  be  depended  on  (see  p.  1015).  A 
suitable  incision  is  then  made  down  to  the  sac,  which  should  be 
recognised  by  its  tense  and  rounded  outline.  It  is  isolated  as  far 
as  possible  from  surrounding  structures,  and  then  carefully  opened. 
There  is  usually  no  risk  of  injuring  the  bowel,  on  account  of  the 
fluid  poured  out  into  the  sac ;  but  if  no  effusion  is  present,  or  if 
the  gut  is  adherent  to  the  anterior  wall,  it  is  more  likely  to  be 
injured.  Having  given  exit  to  the  fluid  from  the  sac  and  noted 
its  characters,  the  surgeon  carefully  examines  the  bowel  or 
omentum.  The  cause  of  strangulation  is  then  looked  for  and 
divided  by  a  special  hernia  knife,  which  practically  consists  of  a 
curved  blunt-ended  bistoury,  the  cutting  blade  being  limited  to  an 
extent  of  about  f  inch  from  the  blunt  end.  If  such  is  not  to  hand, 
an  ordinary  curved  bistoury  will  suffice.  The  index-finger  is 
employed  to  repress  and  guard  the  intestine,  and  acts  better  than 
a  director,  since  intestine  is  likely  to  curl  up  on  either  side  of  the 
instrument,  and  may  thus  be  injured.  The  knife  is  then  slipped 
on  the  flat  under  the  constriction,  and  turned  so  as  to  divide  it  ;  it 
is  better  to  slightly  nick  it  in  two  or  three  places  than  to  incise  it 
by  one  deep  cut,  as  is  often  recommended. 

The  gut  is  drawn  down  into  the  wound,  and  its  condition  at  the 
site  of  strangulation  carefully  examined.  The  omentum,  if  small 
in  amount  and  recently  prolapsed,  may  be  reduced,  but  it  is  better 
practice  to  remove  any  congested  portion,  or  that  which  has 
evidently  been  in  the  sac  for  some  time.  The  method  of  its 
removal  has  been  already  described  (p.  986). 

According  to  the  condition  of  the  intestine,  the  further  steps  of 
the  operation  are  modified  as  follows  : 

1.  If  the  gut,  though  congested,  shows  no  sign  of  gangrene  or 
perforation,  it  may  be  safely  reduced.  This  is  not  always  a 
matter  of  ease,  owing  to  the  fact  that  the  effusion  into  its  walls 
has  made  it  stiff  and  firm.  Prolonged  and  steady  pressure  with 
the  fingers  will,  however,  sufficiently  remove  the  exudation  to 
permit  of  its  reposition  into  the  abdomen.  All  manipulation 
directed  to  the  intestine  must,  of  course,  be  of  the  gentlest  nature, 
since  its  congested  state  makes  it  more  friable  than  usual. 

2.  If  the  gut  has  been  tightly  strangled  and  gangrene  is  threaten- 
ing, it  may  be  advisable  to  resect  it  at  once,  the  incisions  being 
made  well  above  and  below  the  sites  of  constriction  ;  the  divided 
ends  are  united  by  one  of  the  plans  detailed  at  p.  932.  If,  how- 
ever, the  bowel  is  in  a  doubtful  condition,  but  recovery  thought 


io<h  A   MANUAL  OF  SURGERY 

possible,  it  is  gently  replaced  just  inside  the  abdomen,  after  freely 
dividing  the  constriction,  and  a  large  drainage  tube  is  inserted  down 
to  it.  There  is  no  need  to  fix  the  bowel ;  it  is  already  inflamed 
and  paralyzed,  and  hence  will  not  change  its  position,  especially 
if  a  small  dose  of  opium  is  subsequently  administered.  In  this 
way,  even  if  gangrene  or  perforation  occurs,  a  track  is  left  for  the 
escape  of  the  contents,  while  a  localized  plastic  inflammation  will 
shut  off  the  general  peritoneal  cavity.  A  faecal  fistula  may  thus 
be  formed,  but  it  often  closes  spontaneously  at  a  later  date. 

3.  If  the  gut  at  the  time  of  operation  is  evidently  gangrenous, 
the  treatment  is  always  a  matter  of  difficulty,  and  one  concerning 
which  very  different  views  are  held.  Two  chief  methods  have 
been  suggested  : 

(a)  The  gangrenous  loop  of  bowel  is  opened,  or  the  perforation, 
if  such  is  present,  is  enlarged  sufficiently  to  allow  of  the  entrance 
of  the  finger  into  the  lumen  of  the  gut.  A  free  flow  of  faeces 
should  result  from  this  proceeding,  but  if  the  constriction  at 
the  site  of  strangulation  is  considerable,  a  pair  of  dressing  forceps 
should  be  passed  up  the  bowel,  and  the  narrowed  portion  dilated, 
if  possible.  Failing  this,  the  adhesions  which  have  formed  at  the 
neck  of  the  sac  must  be  gently  broken  through,  and  the  constric- 
tion divided  ;  but  if  this  can  be  avoided,  so  much  the  better,  since 
by  such  means  the  general  peritoneal  cavity  is  exposed  to  the 
risk  of  septic  infection.  Hence  it  may  be  wiser  to  divide  the 
constriction  from  the  outside  without  freeing  the  adhesions.  An 
artificial  anus  is  thus  formed  through  which  for  a  time  the  patient 
can  discharge  the  intestinal  contents,  and  unless  this  desideratum 
is  at  once  attained,  failure  is  very  likely  to  follow  the  operation. 
The  wound  is  left  open  and  a  suitable  dressing  applied,  into  which 
the  faeces  can  be  received  ;  possibly  the  best  application  is  a  layer 
of  protective  with  a  sufficient  hole  in  the  centre  to  allow  the  faeces 
to  pass,  and  then  over  it  a  thick  layer  of  tenax. 

(b)  More  recently  primary  enterectomy  with  immediate  suture 
of  the  divided  ends  has  been  extensively  practised,  and  with  con- 
siderable success. 

The  selection  of  one  of  these  two  plans  in  any  particular  in- 
stance depends  mainly  upon  the  age  and  condition  of  the  patient. 
If  he  is  in  a  state  of  profound  collapse  or  exhaustion,  the  former 
method  should  be  adopted,  the  artificial  anus  being  subsequently 
dealt  with,  if  possible  within  a  week  or  ten  days.  In  the  majority 
of  cases,  however,  one  is  fully  justified  in  at  once  undertaking 
an  enterectomy,  the  advantages  of  which  are  obvious.  The 
intestinal  canal  is  at  once  restored  to  functional  utility,  so  that 
the  fluid  and  offensive  faecal  material  can  pass  onwards  ;  the 
absorption  of  toxins  from  the  stinking  gangrenous  gut  wall  is 
stopped,  and  the  patient  is  freed  from  the  risk  and  incon- 
veniences caused  by  the  passage  of  faeces  through  an  open 
wound.     The  relative  value  of  the  two  methods  cannot  be  fairly 


HERNIA  1005 

measured  by  the  death-rate,  since  so  many  of  the  cases  treated 
by  the  formation  of  an  artificial  anus  are  hopeless  from  the 
beginning.  There  can  be  no  question  that,  with  our  present 
methods  of  intestinal  suture,  a  large  measure  of  success  may  be 
expected  from  the  adoption  of  primary  resection  in  the  majority 
of  cases. 

Having  dealt  with  the  strangulation,  it  is  always  advisable  to 
perform  a  radical  cure  in  uncomplicated  cases,  so  as  to  prevent 
any  recurrence  of  the  hernia.  This  is  undertaken  according  to 
the  methods  already  described,  and  the  external  wound  subse- 
quently closed  and  drained. 

The  After-Treatment  in  cases  of  strangulated  hernia  is  of  the 
greatest  importance.  The  patient  is  placed  in  bed,  and  absolute 
quiet  is  maintained,  no  food  being  allowed  for  twenty-four  hours, 
although  a  little  ice  may  be  sucked  or  hot  water  sipped  in  order 
to  relieve  thirst.  If  there  is  no  pain,  opium  need  not  be  ad- 
ministered, as  it  tends  to  maintain  the  paralyzed  condition  of 
the  bowel  ;  severe  pain  may,  however,  call  for  the  hypodermic 
injection  of  a  small  dose  of  morphia.  Liquid  food  can  usually 
be  taken  at  the  end  of  twenty-four  hours,  and,  if  the  patient's 
condition  remains  satisfactory,  it  is  unnecessary  to  administer  any 
purgative,  the  bowels  often  acting  naturally ;  if  they  remain  un- 
relieved for  five  or  six  days,  a  dose  of  castor-oil  should  be  given. 

Various  Complications  may  arise  after  the  operation,  needing 
special  notice.  (1)  Vomiting  may  persist  for  a  time  as  a  result  of 
the  anaesthetic.  It  loses,  however,  its  faeculent  character,  and 
may  generally  be  stopped  by  washing  out  the  stomach  or  by  the 
hypodermic  injection  of  morphia.  (2)  The  Paralytic  condition  of 
the  gut  may  remain  for  some  considerable  time,  causing  prolonged 
constipation.  If  there  is  no  evidence  of  inflammatory  mischief, 
it  is  best  treated  by  the  administration  of  a  purgative  or  by  a 
turpentine  enema.  (3)  Acute  Enteritis  may  arise  either  in  the 
portion  of  strangulated  gut  or  just  above.  This  is  usually  indicated 
by  localized  pain,  and  perhaps  the  passage  of  mucus,  which  may 
be  so  abundant  as  to  amount  to  diarrhoea ;  the  vomiting,  more- 
over, persists,  but  is  no  longer  stercoraceous.  If  ulceration  or 
perforation  ensues,  peritonitis  will  follow,  but  whether  this  occurs 
or  not  the  case  is  very  likely  to  terminate  fatally  from  exhaustion. 
It  is  best  treated  by  the  administration  of  bismuth  combined  with 
morphia,  whilst  all  solid  food  is  interdicted,  and  stimulants  may 
be  freely  given.  (4)  The  occurrence  of  Peritonitis,  or  of  a  certain 
amount  of  peritoneal  activity,  is  inevitable  after  all  cases  of 
strangulated  hernia.  In  most  instances  it  is  productive  of  no 
harmful  results  ;  but  where  the  vitality  of  the  gut  wall  has  been 
so  lowered  as  to  allow  of  the  passage  of  the  Bac.  coli,  or  where 
its  integrity  has  been  interfered  with  by  laceration  or  perforation, 
an  acute  form  of  inflammation  is  set  up  which  is  seldom  localized, 
and  rapidly  becomes  general.     Lastly,  septic  infection  of  the  peri- 


ioo6  A  MANUAL  OF  SURGERY 

toneum  may  be  derived  from  the  external  wound,  or  as  a  result  of 
local  contamination  by  dirty  instruments  or  fingers.  Treatment. — 
As  soon  as  peritonitis  threatens,  the  administration  of  a  smart 
saline  purge  is  often  beneficial,  acting  by  unloading  the  intestines 
and  encouraging  peristalsis.  Subsequently  opium  in  carefully 
regulated  doses  may  be  ordered,  whilst  nutrition  is  maintained  by 
enemata,  or  by  small  quantities  of  fluid  given  by  the  mouth.  Dis- 
tension of  the  intestine  should  be  prevented,  if  possible,  by  passing 
a  long  tube,  or  by  giving  a  turpentine  enema ;  puncturing  the 
distended  coils  of  intestine  has  been  adopted,  but  is  extremely 
dangerous.  The  condition  is  necessarily  one  of  the  greatest 
gravity,  and  as  a  last  resource  laparotomy  may  be  performed, 
and  the  peritoneal  cavity  washed  out. 

Localized  Peritonitis  may  be  looked  on  as  a  conservative  measure, 
whereby  Nature  isolates  some  focus  of  danger  from  the  general 
peritoneal  cavity.  Occasionally  localized  suppuration  follows  as 
the  result  of  a  limited  ulceration  or  perforation  of  the  gut ;  the 
pus  must  then  be  let  out  at  the  earliest  possible  moment,  but  a 
faecal  fistula  is  very  likely  to  follow. 

It  is  impossible  to  describe  in  detail  every  form  of  strangulated 
hernia.  A  few  facts,  however,  must  be  stated  about  the  more 
important  varieties.  In  Strangulated  Inguinal  Hernia  the  constric- 
tion most  commonly  occurs  at  the  neck  of  the  sac,  usually  close  to 
the  external  abdominal  ring,  as  a  result  of  the  condensation  of  the 
surrounding  tissues.  The  signs  are  usually  very  characteristic, 
and  the  condition  can  rarely  be  mistaken.  Some  difficulty  may 
be  experienced  in  distinguishing  it  from  inflammation  of  an  unde- 
scended testis;  in  this,  however,  there  is  no  persistent  vomiting 
or  constipation,  whilst  the  absence  of  the  testis  below,  and  the 
existence  of  the  peculiar  testicular  sensation,  when  the  swelling 
in  the  canal  is  compressed,  should  clear  up  the  case.  Occasion- 
ally the  two  conditions  co-exist,  and  then  a  correct  diagnosis, 
apart  from  an  open  exploration,  may  be  almost  impossible. 
Torsion  of  the  testis,  and  subsequent  strangulation  of  the  organ, 
give  rise  to  a  swelling  not  at  all  unlike  a  strangulated  hernia, 
but  the  absence  of  constipation  and  faecal  vomiting  should  prevent 
mistakes. 

Division  of  the  stricture  in  the  course  of  the  operation  is 
always  performed  in  a  vertical  direction,  the  surgeon  cutting 
directly  upwards,  the  reason  being  that  it  is  impossible  in  old- 
standing  cases  to  be  certain  whether  the  hernia  is  oblique  or 
direct,  and  thus  the  liability  to  injury  of  the  epigastric  artery  is 
diminished. 

In  Strangulated  Femoral  Hernia  it  is  more  common  to  find  bowel 
than  omentum,  and  it  is  in  this  situation  that  partial  herniae 
(Richter's)  are  most  frequently  met  with.  A  tense  painful  swelling 
is  felt,  situated  in  the  neighbourhood  of  the  saphenous  opening, 


HERNIA  1007 

and  the  diagnosis  from  inflamed  lymphatic  glands  and  phlebitis  of 
a  varicose  saphena  vein  may  not  be  altogether  easy,  particularly 
if  omentum  alone  is  present.  The  history  of  the  case,  and  a 
careful  consideration  of  the  physical  signs  and  symptoms,  should 
generally  be  sufficient  to  clear  up  the  diagnosis.  The  constriction 
is  usually  met  with  opposite  Gimbernat's  ligament,  and  to  divide 
it  the  surgeon  must  cut  directly  inwards,  so  as  to  incise  that 
structure.  The  plan  already  mentioned  of  nicking  it  in  two  or 
three  places,  rather  than  freely  dividing  it,  is  especially  useful  in 
this  situation,  on  account  of  the  occasional  abnormal  course  of 
the  obturator  artery,  which  is  stated  to  be  wounded  once  in  every 
150  cases.  The  accident  would  be  recognised  by  the  occurrence 
of  free  haemorrhage  after  the  use  of  the  hernia  knife.  In  such  a 
case,  the  rupture  is  first  reduced,  the  wound  enlarged  upwards, 
and  both  ends  of  the  divided  vessel  secured,  if  possible ;  failing 
this,  carefully  adjusted  pressure  may  be  employed.  Where  the 
constriction  is  very  tight,  so  that  it  is  almost  impossible  to  pass 
a  director  between  Gimbernat's  ligament  and  the  intestine,  the 
plan  already  mentioned  of  dividing  the  constriction  from  without 
may  be  utilized  with  advantage. 

In  cases  of  gangrene  where  enterectomy  is  feasible,  it  will  often 
be  necessary  to  open  the  abdomen  by  an  additional  incision  above 
the  pelvic  brim,  and  then  having  divided  the  constriction  at  the 
neck  of  the  sac,  the  affected  coil  must  be  slipped  back  and  pulled 
out  of  the  upper  wound,  the  greatest  care  being  taken  not  to 
contaminate  other  coils  of  intestine.  The  shortness  of  the  mesen- 
tery renders  it  impossible  to  perform  the  necessary  manipulations 
through  the  wound  in  the  groin. 

Artificial  Anus  is  the  only  means  whereby  Nature  relieves  the  obstruction 
due  to  strangulated  hernia.  One  applies  the  term  to  a  condition  in  which 
an  opening  into  the  gut  has  been  produced  in  such  a  way  that  the  greater 
portion  of  the  faeces  finds  an  exit  through  it.  It  may  arise  from  the  sloughing 
of  the  intestine  and  overlying  skin  apart  from  operation ;  or  from  the  surgeon's 
interference,  either  by  his  opening  the  gut  in  mistake  for  the  sac,  or  by  his 
incising  it  when  gangrenous  ;  or  it  may  slough  subsequently,  if  left  in  situ 
when  gangrene  is  threatening.  If  no  operation  is  undertaken,  the  surround- 
ing parts  settle  down  after  a  time  and  heal  over,  the  diversion  of  the  fasces 
from  their  natural  course  becoming  more  and  more  complete,  owing  to  the  for- 
mation of  what  is  known  as  a  spur  of  mucous  membrane,  which  lies  across  and 
blocks  the  entrance  to  the  lower  portion  of  the  bowel  (Fig.  345).  This  spur 
arises  partly  as  a  result  of  the  kinking  of  the  gut,  partly  from  the  intra- 
abdominal pressure  which  pushes  the  exposed  inner  wall  of  the  intestine 
forwards.  The  effects  produced  by  an  artificial  anus  on  the  individual  vary 
with  the  portion  of  the  bowel  involved.  If  the  jejunum  or  upper  part  of  the 
ileum  is  thus  opened,  the  patient  soon  loses  ground  and  becomes  emaciated, 
owing  to  the  escape  of  the  intestinal  contents,  before  the  nutritive  elements  of 
the  food  have  been  absorbed.  Eczema  of  the  skin  in  the  neighbourhood  is 
usually  produced,  resulting  from  the  irritation  of  the  fasces. 

The  curative  Treatment  of  an  artificial  anus,  where  desirable,  consists  in 
the  re-establishment  of  the  lumen  of  the  gut,  and  the  closure  of  the  external 
wound.  To  effect  this,  two  chief  methods  have  been  recommended  :  (1)  The 
old-fashioned  plan  necessitates  the  repression  or  removal  of  the  spur  as  the 


ioo8 


A  MANUAL  OF  SURGERY 


first  stage  in  the  proceeding,  whilst  the  closure  of  the  external  wound  is 
effected  subsequently.  Dupuytren  recommended  that  the  spur  should  be 
destroyed  by  dragging  it  outwards  and  grasping  it  by  an  enterotome  (Fig.  359), 
which  consists  of  two  blades  fitting  into  one  another,  which  are  maintained  in 
apposition  by  a  screw.  The  portion  thus  grasped  sloughs  slowly  away,  the 
peritoneal  cavity  being  protected  by  a  plastic  inflammation.  After  destruction 
of  the  spur,  the  external  wound  may  be  closed  by  turning  in  flaps  of  skin. 
Such  treatment  of  an  artificial  anus  is  tedious  and  uncertain  ;  whilst  even  if 
successful,  the  patient  probably  suffers  from  recurrent  colic,  owing  to  the 
adhesion  of  the  intestine  to  the  abdominal  wall,  a  condition  which  may  also 
expose  him  later  on  to  the  risk  of  intestinal  obstruction.  (2)  A  much  better 
method  of  treatment  is  that  by  means  of  an  open  operation.  In  this  a  semi- 
lunar incision  is  made  on  either  side  of  the  artificial  anus,  by  deepening  which 
the  peritoneal  cavity  is  freely  opened,  and  the  artificial  anus,  together  with 
the  surrounding  tissues,  can  be  lifted  up,  exposing  the  coil  of  adherent  intestine. 
This  is  now  clamped  above  and  below,  divided  as  near  to  the  opening  as 
possible,  a  V-shaped  portion  of  mesentery  removed,  and  the  continuity  of  the 


359. — Dupuytren's  Enterotome. 
Brothers.) 


(Down 


intestinal  canal  restored  by  some  form  of  enterorrhaphy.  It  is  then  returned 
to  the  abdomen,  and  the  external  wound  closed  by  sutures.  In  the  inguinal 
and  femoral  regions  it  is  sometimes  impracticable  to  undertake  such  an  opera- 
tion, owing  to  the  important  nature  of  the  surrounding  structures,  and  then 
Dupuytren's  method  may  be  followed,  or  a  lateral  anastomosis  established 
through  a  separate  incision  into  the  abdomen  between  the  portions  of  intestine 
going  to  and  returning  from  the  opening  ;  the  external  aperture  is  subse- 
quently closed  by  a  plastic  operation. 

Faecal  Fistula  occasionally  results  from  a  strangulated  hernia,  owing  to  a 
perforative  inflammation  of  the  gut  after  the  relief  of  strangulation,  whether 
at  the  site  of  constriction  or  above  or  below  it,  in  the  latter  case  arising  from 
a  stercoral  ulcer.  Though  the  lesion  may  be  intraperitoneal,  it  by  no  means 
follows  that  general  peritonitis  need  result,  since  sufficient  plastic  material 
may  be  formed  around  it  to  shut  off  the  general  peritoneal  cavity,  and  to 
allow  the  extravasated  contents  of  the  bowel  to  find  their  way  outwards 
through  a  sinuous  tract  to  the  external  wound.  It  may  be  some  days  before 
any  evidence  of  the  existence  of  this  condition  appears.  Not  uncommonly  the 
opening  will  close  naturally  as  a  result  of  cicatricial  contraction,  and  hence 
no  steps  need  be  taken  to  deal  with  it  until  all  hopes  of  such  a  result  have 
faded.  Where,  however,  it  persists,  attempts  may  be  made  to  effect  this 
purpose  by  injecting  stimulating  lotions,  or  by  applying  the  actual  cautery  to 
the  interior  of  the  fistula  ;  but  more  frequently  an  operation  to  expose,  if 
practicable,  the  wound  in  the  gut,  and  to  close  it  by  suture,  or  to  remove  the 
affected  segment,  will  be  necessary. 


CHAPTER  XXXIV. 

INTESTINAL  OBSTRUCTION.* 

15y  Intestinal  Obstruction  is  meant  a  condition  in  which  the 
onward  passage  of  the  faeces  is  prevented.  In  acute  cases  it  is 
often  associated  with  strangulation,  owing  to  the  circulation 
through  the  vessels  being  impeded  and  finally  arrested. 

Many  different  types  of  classification  of  this  condition  have  been 
suggested,  and  many  of  them  are  more  or  less  valuable.  They 
may  be  described  as  congenital  or  acquired — under  the  former 
term  grouping  together  congenital  stenosis,  congenital  adhesions, 
etc.,  and  under  the  latter  all  the  ordinary  conditions  ;  or  they  may 
be  divided  into  classes  according  to  whether  the  obstruction  is 
due  to  causes  within  the  gut,  to  changes  in  the  structure  or  relative 
position  of  the  intestinal  wall,  or  to  pressure  from  without.  The 
most  useful  division  is  the  clinical,  grouping  together  those  cases 
which  present  a  similarity  in  the  symptoms ;  and  this  method 
will  be  employed  here,  the  subject  being  discussed  under  the 
three  headings — acute  obstruction,  chronic  obstruction,  and  in- 
tussusception. 

Acute  Intestinal  Obstruction. 

The  following  are  the  chief  Causes  which  give  rise  to  this 
condition  : 

i.  Strangulation  by  bands  or  adhesions,  or  through  aper- 
tures, etc. 

2.  Volvulus. 

3-  The  impaction  of  foreign  bodies. 

4.  Strangulation  over  a  band  or  acute  kinking  of  the  gut,  both 
\  ery  rare  conditions. 

5.  Acute  intussusception. 

6.  It  may  be  the  termination  of  a  chronic  obstruction. 

*  For  much  of  the  material  incorporated  in  this  chapter  we  beg  to  acknow- 
ledge our  indebtedness  to  Sir  Frederick  Treves'  classical  text-book  on  the 
subject  (published  by  Cassell  and  Co.),  than  which  nothing  better  has 
appeared,  and  which  we'have  freely  utilized. 

64 


A   MANUAL  OF  SURGERY 


Paralysis  of  the  gat,  such  as  that  induced  by  acute  peritonitis, 
localized  or  diffuse,  by  acute  enteritis  following  the  reduction  of 
a  strangulated  hernia,  by  a  Littre's  hernia,  etc.,  gives  rise  to 
phenomena  of  pseudo-obstruction,  but  the  cause  then  is  not  so  much 
mechanical  as  nervous  in  origin.  It  will  be  mentioned  again 
at  p.  1013. 

The  General  Symptoms  of  acute  obstruction  are  practically 
identical  with  those  of  a  strangulated  hernia.  The  patient  is 
suddenly  seized  with  severe  abdominal  pain  somewhat  of  the 
nature  of  colic,  and  referred  to  the  umbilicus,  coming  on  perhaps 
during  some  special  effort,  e.g.,  lifting  a  heavy  weight.  At  the 
same  time  he  suffers  from  shock,  as  evidenced  by  a  weak  pulse, 
pale  face,  and  cold,  clammy  sweat,  the  temperature  of  the  body 
falling  below  the  normal.  The  shock  is  usually  more  or  less 
recovered  from,  but  the  pain  persists,  and  is  liable  to  exacerba- 
tion and  intermissions,  soon  becoming  continuous.  Vomiting 
ensues,  being  at  first  limited  to  the  contents  of  the  stomach,  but 
quickly  changes  to  a  bilious,  stercoraceous,  or  even  faecal  character. 
Signs  of  constitutional  depression  and  exhaustion  follow  in  a  short 
time,  the  pulse  being  weak,  rapid,  and  thready,  the  temperature 
remaining  subnormal  (except  occasionally  after  the  supervention 
of  peritonitis,  when  it  may  rise  a  few  degrees),  the  face  looking 
pulled  and  drawn  (facies  Hippocratica),  and  the  abdomen  being 
distended  and  painful.  Finally  the  patient,  if  unrelieved  by  treat- 
ment, dies,  and  usually  within  seven  to  ten  days  from  the  onset, 
owing  to  exhaustion  or  perforative  peritonitis.  Constipation  may 
be  absolute  from  the  first,  but  at  any  time  the  lower  bowel  may 
empty  itself,  and  raise  false  hopes  as  to  the  prognosis. 

The  explanation  and  variation  of  these  symptoms  in  different 
cases  is  given  later  on. 

The  Special  Forms  of  Acute  Obstruction  must  now  be  considered 
seriatim. 

1.  Strangulation  by  Bands  or  Adhesions,  through  Apertures,  etc. 
Causes. — (a)  Isolated  peritoneal  bands  and  adhesions  are  usually  the 
result  of  old  plastic  peritonitis  of  a  localized  and  chronic  character. 
The  greatest  variety  is  met  with  in  the  appearance  and  situation 
of  these  adhesions  ;  most  frequently  they  are  single  and  cordlike  ; 
sometimes  they  are  broad  and  membranous,  constituting  a  false 
ligament ;  or,  again,  they  may  be  multiple.  A  common  situation 
is  between  different  parts  of  the  mesentery,  or  between  the 
mesentery  and  some  other  viscus,  the  cause  being  either  disease 
of  that  viscus  (usually  a  pelvic  organ,  the  caecum,  or  the  appendix), 
or  inflammation  of  a  mesenteric  gland  with  localized  peritonitis 
Two  methods  of  producing  strangulation  exist ;  either  the  bowel 
passes  under  the  arch  or  loop  formed  by  a  short  constricting  band, 
and  cannot  return ;  or,  if  the  band  is  long,  it  may  form  a  loop  or 
noose  through  which  the  bowel  passes,  and  so  becomes  strangled 
(Fig.    360).     (b)  Cords  formed   by  the  omentum  result    from   union 


INTESTINA  L  OBSTR  UCTION 


between  its  fimbriated  extremities  and  some  part  of  the  viscera  or 
parietes,  forming  at  first  a  broad  band-like  adhesion,  which  is 
gradually  moulded  into  a  rounded  cord  by  the  constant  dragging 
and  pulling  to  which  it  is  subjected.  They  are  usually  coarser 
and  thicker  than  those  due  to  peritonitis.  The  mechanism  of 
strangulation  is  identical,  the  noose  form  being  perhaps  the  more 
common,  since  the  adhesions  are  likely  to  be  longer,  (c)  Meckel's 
diverticulum  (p.  921)  is  liable  to  cause  strangulation  when  its  free 
end  becomes  adherent  either  to  the  parietes  or  to  the  viscera ;  it 
is  attached  most  frequently  to  the  mesentery  of  the  ileum,  and 
after  that  to  the  neighbourhood  of  the  umbilicus.  Occasionally 
the  diverticulum  ends  in  a  fibrous  cord,  which  may  remain  fixed 
to  the  umbilicus,  or  floats  free  in  the  abdominal  cavity,  and  sub- 
sequently becomes  adherent  to  some  other  structure,  thus  pro- 
ducing a  fibrous  cord.  Strangulation  may  be  effected  by  bowel 
passing  under  the  loop,  formed  by  the 
adherent  diverticulum.  (d)  The  vermiform 
appendix,  appendices  epiploica:,  or  Fallopian  tubes 
may  contract  abnormal  attachments,  and 
thus  form  arches  or  loops  under  which  bowel 
may  pass  and  become  strangled,  (e)  Slits, 
pouches,  and  apertures  in  the  peritoneal  invest- 
ment, whether  normal  or  abnormal,  may  lead 
to  strangulation.  All  external  herniae  may 
be  grouped  under  this  heading,  as  also  those 
rare  conditions  known  as  internal  hernia,  in 
which  the  abdominal  contents  find  their  way 
into  pouches  in  the  posterior  wall  of  the 
peritoneum,  e.g.,  into  the  lesser  sac  of  the 
(Tillmanns.)  omentum,    or    the   so-called  fossa   duodeno- 

jejunalis.  Slits  may  also  be  found  in  the 
omentum  or  mesentery,  either  congenital,  traumatic,  or  the  result 
of  operations. 

Phenomena. — This  form  of  obstruction  usually  occurs  in  young 
people,  and  is  rare  after  forty  ;  it  constitutes  above  one-fourth  of 
all  the  forms  of  internal  obstruction,  and  the  lower  2  feet  of 
the  ileum  are  most  frequently  involved.  There  is  commonly  a 
previous  history  of  peritonitis,  but  the  onset  is  usually  sudden, 
and  the  symptoms  of  strangulation,  as  detailed  above,  are  of  a 
typical  character.  The  abdomen  is  flaccid  at  first,  and  not  tender 
until  peritonitis  ensues,  on  about  the  third  or  fourth  day.  There 
is  generally  no  obvious  tumour,  and  no  peristalsis  or  dilated  coils 
of  intestine  are  to  be  seen.  The  average  duration  is  about  five 
to  seven  days,  the  patients  dying  of  exhaustion  or  toxaemia  follow- 
ing peritonitis. 

2.  Volvulus  is  the  most  common  cause  of  acute  primary 
obstruction  of  the  large  intestine.  By  it  is  meant  a  rotation 
of  the  gut  upon  its  own  mesenteric  axis  in  such  a  way  as  to 


A   MANUAL  OF  SURGERY 


interfere  not  only  with  the  passage  of  the  intestinal  contents,  but 
also,  sooner  or  later,  with  the  circulation,  determining  a  condition 
of  strangulation.  Occasionally  a  similar  result  is  brought  about 
by  the  intertwining  of  one  coil  with  another.  The  sigmoid  flexure 
is  the  part  mainly  affected,  although  it  occurs  in  the  caecum  or 
small  intestine.  In  the  former  situation  it  is  predisposed  to  by  a 
long  narrow  sigmoid  meso-colon,  so  that  the  two  ends  of  the  loop 
arc  brought  closely  together ;  this  condition  may  be  of  congenital 
origin,  but  is  usually  due  to  the  traction  induced  by  prolonged 
chronic  constipation  ;  a  distended  sigmoid  hanging  into  the  pelvic 
cavity  drags  upon  and  elongates  the  meso-colon,  tending  to 
approximate  the  two  ends  of  the  loop,  and  necessarily  causing  a 
slight  obstruction  at  these  spots.  Some  irregular  movement  of 
the  gut  or  of  the  abdominal  walls  suffices  to  cause  rotation  of  the 
pedicle,  and  thus  brings  about  the  volvulus.  When  once  present, 
plastic  peritonitis  soon  fixes  the  coil,  whilst  the  pressure  on  the 
vessels  causes  venous  congestion  and  such  obstruction  to  the 
arterial  supply  of  the  gut  as  almost  certainly  to  end  in  its  death. 
Distension  of  the  coil  with  gas  from  decomposition  of  the  retained 
fasces  also  aggravates  the  condition. 

Symptoms. — Volvulus  is  rare  before  the  age  of  forty,  and 
apparently  occurs  more  often  in  the  male  sex.  A  history  of 
chronic  constipation  precedes  it,  but  the  acute  symptoms  start 
abruptly.  Pain  is  always  present,  at  first  intermittent,  but  finally 
constant,  and  there  is  usually  early  tenderness  over  the  sigmoid 
flexure.  The  pain,  vomiting  and  collapse  are  not  so  severe  or 
marked  as  in  other  forms  of  strangulation,  but  abdominal  dis- 
tension from  excessive  flatus,  and  resulting  dyspnoea  and  thoracic 
embarrassment,  are  very  distressing.  Tenesmus  is  occasionally 
present.  A  localized  peritonitis  is  usually  developed,  but  it  some- 
times becomes  diffuse.  Natural  cure  is  unknown,  the  patient 
either  dying  in  five  or  six  days  from  collapse  and  interference  with 
respiration,  or  at  a  somewhat  later  date  from  peritonitis. 

3.  Impacted  Foreign  Bodies,  causing  intestinal  obstruction,  may 
be  of  three  types :  gallstones,  foreign  bodies  that  have  been 
swallowed,  or  intestinal  concretions  (enteroliths). 

Gallstones  can  only  cause  obstruction  when  of  large  size,  and 
such  usually  gain  entrance  to  the  intestine  by  ulceration  from  the 
gall-bladder  into  the  duodenum.  A  coating  of  faecal  material  is 
likely  to  form  around  them,  and  thus  they  increase  in  size  as  they 
pass  downwards,  whilst  the  intestine  gradually  diminishes  in 
calibre  from  the  duodenum  to  the  ileum ;  the  usual  site  of  im- 
paction is  in  the  lower  ileum.  Women  over  fifty  are  most  often 
the  subjects  of  this  condition,  and  there  may  be  only  a  history  of 
some  inflammatory  condition  in  the  region  of  the  gall-bladder, 
and  none  of  biliary  colic.  Such  patients  frequently  suffer  from 
intermittent  subacute  attacks  of  incomplete  obstruction,  which, 
though  severe  for  a  time,  are  relieved  by  purgatives.     If  the  gall- 


INTESTINAL  OBSTRUCTION 


stone  is  not  passed,  a  final  acute  attack  supervenes,  which  begins 
suddenly  with  the  typical  signs  of  acute  obstruction,  although  the 
pain  and  collapse  are  not  so  marked  as  in  cases  of  strangulation, 
death  resulting  from  peritonitis  or  exhaustion. 

"When  the  obstruction  is  due  to  foreign  bodies  which  have  been 
swallowed,  the  symptoms  are  usually  subacute  to  start  with,  but 
may  lead  to  perforation  if  of  irregular  shape. 

Enteroliths  are  of  three  classes  :  (a)  Calculi  of  phosphate  of 
lime  or  inspissated  fa'ces  form  around  some  foreign  body  as  a 
nucleus,  (b)  Masses  of  indigestible  vegetable  material  may  be 
matted  together  with  inspissated  faeces,  mucus,  etc. ;  they  are  said 
to  be  not  uncommon  in  Scotland  (the  so-called  avenolith),  being 
mixed  up  with  the  husks  of  the  coarse  oatmeal  there  eaten.  They 
have  also  been  known  to  consist  of  hair,  or  of  cocoanut  fibre  in  a 
patient  engaged  in  mat-making.  (c)  Calculi  have  been  found 
consisting  of  insoluble  mineral  salts,  e.g.,  carbonate  of  magnesia 
or  chalk,  taken  as  medicine.  Whatever  their  origin,  such  entero- 
liths are  usually  impacted  near  the  caecum,  and  if  causing  acute 
obstruction  the  symptoms  are  similar  to  those  produced  by  a 
large  gallstone,  being  preceded  by  chronic  attacks  and  severe 
colicky  pain.  In  thin  persons  their  presence  may  be  detected  by 
palpation  of  the  abdomen. 

4.  Acute  obstruction  ensues  when  a  coil  of  intestine  lodges 
across  a  tightly  drawn  adhesion,  the  lumen  at  each  end  being 
thereby  entirely  occluded,  and  the  circulation  arrested.  The 
usual  acute  symptoms  follow,  which  may,  however,  be  relieved 
spontaneously.  Sudden  kinking  of  the  gut  may  lead  to  the  same 
result,  being  due  to  the  contraction  of  fibrous  adhesions  or  the 
dragging  of  diverticula. 

5.  For  Acute  Intussusception,  see  p.  1018. 

6.  When  acute  symptoms  are  developed  at  the  termination  of 
a  case  of  chronic  obstruction,  the  pain  from  being  intermittent 
becomes  constant,  the  vomiting  more  violent  and  faecal  in  char- 
acter, and  the  fatal  termination  is  due  to  acute  peritonitis  or  to 
exhaustion  and  toxaemia.  Absolute  constipation  is  always  present, 
and  the  abdomen  is  much  distended. 

The  Diagnosis  of  acute  obstruction  is  not  per  se  a  matter  of 
much  difficulty,  since  the  phenomena  are  extremely  characteristic  ; 
but  it  is  usually  impossible  to  make  certain  of  the  cause  of  the 
obstruction  apart  from  an  exploratory  laparotomy. 

Some  care  is  also  needed  in  distinguishing  true  obstruction  from 
the  obstructive  symptoms  associated  with  acute  localized  enteritis 
or  peritonitis,  such  as  is  seen  in  appendicitis,  when  the  intestinal 
walls  are  paralyzed.  This  pseudo-obstruction  is  sometimes  very 
marked,  and  even  faecal  vomiting  may  occur,  but  by  a  careful 
attention  to  the  history  and  general  condition  of  the  patient  a 
correct  diagnosis  should  be  reached.  We  append  a  table  illus- 
trating the  chief   diagnostic  points  between  acute   strangulation 


ioi4 


A   MANUAL  OF  SURGERY 


and   acute   appendicitis   associated  with   peritonitis,    one   of  the 
commonest  causes  of  pseudo-obstruction  : 


Acute    Internal 

Acute  Appendicitis  with 

Strangulation. 

Peritonitis. 

Onset  - 
Rigor  - 
Temperature 

Abrupt. 
Absent. 
Subnormal  at  first,  rising  at 

Maybe  preceded  by  local  pain. 

Often  present. 

High  at  first,  falling  later  from 

onset  of  peritonitis. 

exhaustion  or  toxaemia. 

Pain     - 

Severe  ;  referred  to  the  um- 

Severe;  primarily  referred  to 

bilicus. 

the  right  iliac  fossa. 

Tenderness  - 

Absent  till  peritonitis  comes 

Present  over   caecum  even  in 

Vomiting 

on. 
Early,    marked,    and    soon 

early   stages,  and  gradually 
spreading. 
Less  urgent,  and  seldom  faecal, 

faecal. 

except  as  a  late  symptom. 

Abdominal 

Flaccid    till     peritonitis     is 

Tense  and  rigid  from  the  first. 

parietes     - 

present. 

The  Treatment  of  acute  obstruction  is  practically  included  in 
one  word — Laparotomy.  The  condition  of  the  gut  is  in  most 
cases  identical  with  that  found  in  a  strangulated  hernia,  and 
although  a  few  patients  may  recover  by  palliative  measures,  e.g., 
enemata,  opium,  ice,  etc.,  yet  the  majority  would  be  gravely 
injured  in  the  delay  caused  by  their  employment.  The  danger 
of  laparotomy  increases  directly  with  delay  ;  hence,  the  sooner 
it  is  undertaken,  the  better  for  the  patient.  Whilst  prepara- 
tions for  the  operation  are  being  made,  an  enema  may  be 
administered  to  clear  the  lower  bowel,  ice  being  given  to 
suck,  and  a  small  dose  of  opium  to  relieve  urgent  pain.  Two 
main  objects  must  always  be  kept  in  mind  in  the  operative 
treatment  of  such  cases,  viz.,  (a)  to  empty  the  distended  bowel, 
and  (b)  to  remove  the  cause  of  the  obstruction.  The  second  of 
these  requisites  is  always  most  desirable,  but  unless  at  the  same 
time  the  putrid  contents  of  the  upper  portion  of  the  intestine  are 
removed,  but  little  real  good  has  been  accomplished,  since  the 
patient  is  being  slowly  poisoned  by  septic  absorption.  The  late 
Mr.  Greig  Smith  has  declared  most  emphatically  that  '  no  opera- 
tion for  intestinal  obstruction  is  complete  if  the  patient  leaves  the 
operating  table  with  a  greatly  distended  abdomen.'  Moreover,  it 
must  be  remembered  that  the  formation  of  an  artificial  anus  is 
often  insufficient  to  give  relief,  owing  to  the  paralyzed  and  dis- 
tended condition  of  the  intestinal  wall  above.  Hence,  in  many 
cases,  it  is  desirable  to  deal  with  the  engorged  bowel  first,  and 
to  leave  the  search  for  the  obstructing  body  till  a  later  date.  A 
very  high  death-rate  must  always  be  expected  in  these  cases,  but 


INTESTINAL  OBSTRUCTION  icis 


statistics  prove  that,  in  cases  where  the  cause  of  the  obstruction 
is  not  at  once  obvious,  primary  enterostomy,  if  followed  by  a 
satisfactory  discharge  of  the  intestinal  contents,  gives  results  in 
many  instances  equal  to,  or  even  better  than,  treatment  directed 
towards  the  cause  of  the  trouble. 

In  the  most  urgent  cases,  where  the  patient's  abdomen  is  acutely 
distended,  and  faecal  vomiting  has  been  present  for  some  time,  it 
is  not  advisable  to  administer  a  general  anaesthetic  :  if  such  is 
attempted,  the  patient's  life  is  often  lost  from  stoppage  of  the 
respiration,  precipitated  possibly  by  a  severe  attack  of  faecal 
vomiting.  A  few  drops  of  cocaine  may  be  placed  under  the  skin, 
and  a  small  incision  made  through  the  linea  alba  below  the 
umbilicus ;  the  first  presenting  coil  of  intestine  is  withdrawn,  and 
after  protecting  the  peritoneal  cavity  with  gauze  or  sponges,  is 
tapped  with  a  large  trocar  and  cannula  so  as  to  allow  the  first 
gush  of  flatus  and  faeces  to  be  carried  away  from  the  wound. 
The  opening  is  then  enlarged  sufficiently  to  allow  a  Paul's  tube 
to  be  introduced  and  tied  in,  and  whilst  the  bowel  is  emptying 
itself,  it  is  fixed  by  stitches  to  the  abdominal  wall.  The  stomach 
should  always  be  thoroughly  washed  out  with  warm  water  before 
or  during  the  operation. 

In  less  severe  cases,  the  stomach  should  be  washed  out  as  a 
preliminary  measure  before  administering  the  anaesthetic.  The 
head  should  not  be  placed  on  a  lower  level  than  the  stomach,  for 
fear  of  fluid  regurgitating  along  the  oesophagus  and  choking  the 
patient ;  several  deaths  from  this  cause  have  been  reported.  The 
abdomen  is  then  opened  in  the  middle  line  below  the  umbilicus, 
and  a  definite  search  made  for  the  cause  of  the  obstruction. 
The  hand  is  first  passed  to  the  hernial  regions,  and  then  to 
the  right  iliac  fossa,  so  that  the  caecum  may  be  examined.  If 
this  is  distended,  the  cause  necessarily  lies  below  it ;  if  collapsed, 
above  it.  In  the  former  case,  the  condition  of  the  sigmoid 
flexure  should  next  be  investigated,  and  finally,  if  this  viscus 
is  collapsed,  the  hand  should  be  run  along  the  colon,  special 
attention  being  directed  to  the  splenic  flexure.  If  the  caecum 
is  collapsed,  perhaps  the  best  method  to  adopt  is  to  gently  with- 
draw from  the  abdomen  successive  portions  of  gut,  about  a  foot 
at  a  time.  These  are  carefully  examined,  and  replaced  by  the 
assistant  whilst  the  next  portion  is  being  withdrawn.  The 
remainder  of  the  intestines  during  this  process  are  protected  and 
kept  back  by  the  application  of  towels  which  have  been  sterilized 
in  hot  salt  solution.  The  obstruction  is  in  this  way  sooner  or 
later  discovered,  and  may  be  dealt  with  according  to  circum- 
stances. If  the  intestines  are  too  distended  to  allow  of  such 
manipulation,  it  may  be  advisable  to  open  or  tap  one  or  more 
of  the  dilated  coils,  and  thus  reduce  the  distension  before  pro- 
ceeding with  any  methodical  search  for  the  obstruction. 

Omental  bands  or  peritoneal  adhesions  should  be  divided 
between  ligatures.     The  vermiform  appendix  or  Meckel's  diverti- 


ioi6  A  MANUAL  OF  SURGERY 


culum  may  be  excised  according  to  the  method  described  at 
p.  951.  A  volvulus  should  be  untwisted,  if  possible;  but  this  is 
usually  impracticable,  owing  to  peritoneal  adhesions,  and  in  such 
cases  it  is  advisable  to  withdraw  the  coil  from  the  abdomen,  and 
if  the  large  intestine  is  involved,  an  artificial  anus  should  be  made. 
Foreign  bodies  are,  if  possible,  displaced  forwards  or  backwards 
to  a  more  healthy  portion  of  the  bowel,  and  then  removed  by  a 
longitudinal  incision  along  the  antimesenteric  border,  the  wound 
being  subsequently  closed  by  a  row  of  Lembert's  sutures.  Of 
course,  volvulus  of  the  small  intestine  or  gangrene  of  the  gut,  if 
present,  may  necessitate  an  entetectomy. 

Chronic  Intestinal  Obstruction. 

The  Causes  of  chronic  obstruction  are  very  numerous,  and, 
looked  at  from  an  anatomical  standpoint,  may  be  divided  into  the 
following  groups : 

1.  Intra-intestinal  conditions,  e.g.,  impaction  of  faeces,  foreign 
bodies,  etc. 

2.  Affections  of  the  intestinal  wall,  such  as  stricture,  new 
growths,  adhesions  or  matting  together  of  coils  of  intestine,  con- 
traction or  kinking  of  the  gut  from  mesenteric  gland  disease,  etc. 

3.  Compression  of  the  bowel  by  tumour,  cicatricial  bands, 
etc.,  developing  outside  the  intestine. 

The  General  Symptoms  of  chronic  obstruction  are  more  or  less 
as  follows :  The  patient  suffers  from  gradually  increasing  con- 
stipation, alternating  occasionally  with  watery  diarrhoea,  spurious 
in  nature,  and  set  up  partly  by  a  catarrhal  enteritis  due  to  the 
irritation  of  retained  faeces,  partly  by  decomposition  of  the 
faecal  material.  At  irregular  intervals  more  severe  symptoms 
arise,  consisting  of  pain,  colic,  vomiting,  and  absolute  constipation, 
owing  to  some  temporary  complete  obstruction,  as  by  a  mass  of 
undigested  food  or  faeces  becoming  impacted,  assisted  perhaps  by 
a  valve-like  fold  of  mucous  membrane  across  the  passage.  These 
attacks  usually  pass  off  after  a  time,  a  copious  evacuation  of 
the  bowels  taking  place  either  naturally  or  as  the  result  of  the 
administration  of  a  purgative.  Finally,  one  of  these  seizures 
persists  and  destroys  the  patient,  either  by  exhaustion,  or  perfora- 
tion followed  by  peritonitis,  unless  suitable  treatment  is  promptly 
adopted.  The  vomiting  is  never  such  a  marked  feature  as  in 
acute  obstruction,  until  the  final  stage,  when  it  becomes  faecal. 
The  abdomen  is  always  more  or  less  distended  and  tympanic, 
and  its  contour  varies  with  the  site  of  the  obstruction  ;  if  this  is 
situated  above  the  ileo-caecal  valve,  the  swelling  is  mainly  central, 
whilst  if  in  the  rectum  or  lower  portion  of  the  colon,  it  is  most 
marked  in  the  flanks.  Distended  coils  of  intestine  can  be  plainly 
seen  through  the  abdominal  walls  in  thin  subjects,  as  also  evident 
peristalsis.  When  arising  from  simple  stricture,  no  tumour  is 
to  be  felt  ;  but  if  due  to  malignant  disease,  and  if  the  abdomen  is 
not  very  distended,  the  growth  may  possibly  be  detected. 


INTESTINAL  OBSTRUCTION  1017 

Faecal  Impaction  occurs  in  adult  females  who  have  previously 
suffered  from  chronic  constipation.  The  caecum  and  sigmoid 
flexure  are  the  most  common  seats  of  obstruction,  and  a  doughy 
tumour  may  often  be  felt  at  one  of  these  spots,  which  can  in 
some  cases  be  indented  with  the  fingers,  whilst  in  others  it  may 
be  of  stony  hardness.  The  surface  of  the  mass  is  usually  more 
or  less  nodulated,  and  the  intestine  tender  from  the  accompanying 
inflammation.  The  acute  symptoms  are  always  preceded  by  a 
prolonged  period  of  malaise  and  ill-health,  the  appetite  being 
defective,  the  breath  offensive,  and  the  tongue  foul.  On  rectal 
examination  the  presence  of  scybala  may  often  be  detected. 

The  special  symptoms  arising  from  the  other  conditions  which 
give  rise  to  chronic  obstruction,  such  as  stenosis  of  the  bowel, 
have  been  already  referred  to  (p.  926). 

The  Diagnosis  of  chronic  obstruction  is  obvious,  but  it  is  often 
by  no  means  easy  to  ascertain  the  exact  cause  of  the  trouble.  A 
thorough  investigation  of  the  case,  according  to  the  plan  given 
hereafter,  must  be  undertaken,  and  by  this  means  some  con- 
clusion may  be  arrived  at  as  to  the  nature  and  seat  of  the 
obstruction. 

The  Treatment  of  chronic  obstruction  is  always  a  matter  of 
difficulty  and  anxiety,  owing  to  the  uncertainty  often  felt  as  to  the 
diagnosis.  It  ought  to  be  possible,  however,  to  decide  whether 
the  block  is  located  in  the  large  or  small  intestine,  since  the 
character  of  the  abdominal  distension  and  the  symptoms  are 
tolerably  distinctive  in  the  two  forms. 

If  the  case  is  not  of  the  most  urgent  type,  the  patient  is  put  to 
bed,  the  diet  restricted  to  fluids,  and  belladonna,  combined  with 
small  doses  of  calomel,  administered.  At  the  same  time  copious 
enemata  should  be  given  two  or  three  times  daily,  and  preferably 
in  the  genu  -  pectoral  position,  but  purgatives  are  studiously 
avoided,  as  also  opium  ;  probably  the  patient  has  taken  plenty  of 
the  former  before  coming  under  observation,  whilst  the  latter, 
although  it  may  check  vomiting  and  relieve  pain,  is  certain  to 
mask  symptoms,  and  thus  prevent  the  true  course  of  the 
disease  from  being  watched.  Should  the  symptoms  be  urgent 
from  the  commencement,  or  the  treatment  suggested  fail,  the 
question  of  operation  has  to  be  faced.  If  the  obstruction  is 
located  in  the  small  intestine,  a  laparotomy  must  be  undertaken, 
using  the  same  precautions  as  in  acute  cases.  If  the  cause  of  the 
trouble  is  easily  found,  a  coil  situated  just  above  is  withdrawn 
from  the  abdomen,  opened,  and  a  Paul's  tube  subsequently  tied 
in  so  as  to  allow  retained  faecal  material  to  escape.  It  is  wiser 
not  to  deal  with  the  local  trouble  (unless  strangulation  is  present) 
until  the  urgent  symptoms  have  disappeared.  If,  however,  the 
patient's  condition  is  serious  and  the  site  of  obstruction  cannot 
readily  be  found,  any  distended  coil  may  be  withdrawn  and 
opened.     The  practice  of  allowing  numerous  coils  of  intestine  to 


,oi8  A  MANUAL  OF  SURGERY 

escape  in  order  to  facilitate  the  exploration  of  the  abdomen  is  not 
to  be  recommended. 

When  the  cause  of  the  obstruction  is  located  in  the  large  intestine, 
colotomy  is  usually  required.  The  lumbar  operation  may  possibly 
be  undertaken  ;  but  the  majority  of  surgeons  at  the  present  time 
prefer  the  iliac  proceeding,  although  the  peritoneum  has  to  be 
opened,  and  the  risk  of  faecal  contamination  is  thus  increased.  If 
the  rectum  or  sigmoid  flexure  is  clearly  the  seat  of  the  trouble, 
the  usual  incision  on  the  left  side  can  be  made  ;  but  if  there  is  no 
indication  as  to  the  part  of  the  colon  involved,  a  median  lapar- 
otomy is  perhaps  preferable,  a  distended  portion  of  the  gut  being 
withdrawn  and  tapped,  and  a  Paul's  tube  tied  in. 

In  chronic  peritonitis,  where  the  intestines  are  hopelessly  matted 
together,  but  little  can  be  done  beyond  the  administration  of 
enemata,  and  possibly  abdominal  massage.  The  history  of  the 
case  will  generally  suffice  to  suggest  its  nature,  and  operative 
treatment  should  then  be  avoided. 

Faecal  impaction  requires  the  regular  and  repeated  administra- 
tion of  large  enemata,  given  through  a  long  tube,  whilst  belladonna 
and  calomel  may  also  be  administered.  Should  hard  scybala  be 
lodged  in  the  rectum,  it  may  be  necessary  to  break  them  up  in 
situ,  and  remove  them  piecemeal. 

Intussusception. 

By  Intussusception  is  meant  the  protrusion  or  invagination  of 
one  part  of  the  intestine  into  another,  giving  rise  to  the  condition 
illustrated  in  Fig.  361.  The  constituent  parts  are  seen  more 
diagrammatically  in  Fig.  362.  The  upper  portion  is  always  pro- 
lapsed into  the  lower,  except  occasionally  during  the  irregular 
peristalsis  which  takes  place  during  the  death-throes.  The 
invaginated  portion  (a)  is  known  as  the  intussusceptum,  whilst  the 
lower  portion  (b)  into  which  it  is  protruded  is  known  as  the  intus- 
suscipiens.  An  intussusception,  then,  consists  of  three  layers — the 
outer  or  ensheathing  layer  (i.),  an  inner  or  entering  layer  (hi.),  and 
between  the  two  the  returning  layer  (ii.).  Not  only  does  the 
intestine  enter,  but  with  it  a  certain  portion  of  the  mesentery  ; 
and  it  is  to  the  constriction  of  the  vessels  contained  therein,  and 
later  on  possibly  to  their  complete  obstruction,  that  the  more 
serious  phenomena  are  due,  e.g.,  gangrene,  perforation,  or  rupture 
of  the  gut.  In  addition  to  this,  actual  obstruction  to  the  passage 
of  the  intestinal  contents  may  be  brought  about  by  the  traction 
of  the  mesentery,  which  renders  the  orifice  of  the  intussusceptum 
slit-like,  by  the  swelling  and  congestion  of  the  intestinal  wall,  or 
perhaps  by  the  impaction  of  a  portion  of  undigested  food  within 
the  lumen  of  the  gut.  Peritonitis  usually  follows,  being  possibly 
due  to  the  invasion  of  a  portion  of  the  damaged  intestinal  wall 
by  the  Bac.  coli.  If  limited  in  extent,  it  may  merely  lead  to 
irreducibility  of  the  intussusception,  owing  to  adhesions  forming 
between  the  serous  coats  of  the  entering  and  returning  layers. 


INTESTINAL  OBSTRUCTION 


ioig 


In  other  cases,  and  especially  when  ulceration  or  gangrene  is 
present,  a  diffuse  peritonitis  may  be  lighted  up,  and  this  may 
result  in  the  death  of  the  patient.  The  bowel  above  the  site  of 
invagination  becomes  dilated,  and  possibly  stercoral  ulcers  may 
be  formed,  particularly  in  the  more  chronic  cases. 

The  Cause  of  intussusception  is  generally  stated  to  be  irregular 
and  violent  peristalsis,  however  induced,  whether  by  the  presence 
of  irritating  ingesta,  or  by  the  existence  of  polypoid  tumours, 
malignant  growths,  or  possibly  worms  ;  the  presence  of  scybalous 
masses  of  faeces  may  also  lead  to  its  occurrence.     In  a  few  cases 


.y 


Fig.  361. — Intussusception. 


(From  Specimen  in  College  of  Surgeons' 
Museum.) 


injury,    e.g.,  blows   on   the   abdomen,    or   severe   strains    during 
jumping,  have  been  held  responsible  for  its  onset. 

Intussusception  is  met  with  in  four  chief  situations:  (1)  The 
ileo-ccecal  variety  is  much  the  commonest,  constituting  44  per 
cent,  of  all  cases  (Treves).  In  it  the  ileum  is  protruded  into  the 
colon,  the  apex  of  the  intussusceptum  being  formed  by  the  ileo- 
cecal valve.  Owing  to  the  great  mobility  of  the  ileum,  a  con- 
siderable portion  of  gut  may  be  thus  invaginated,  and  a  good 
many  cases  have  been  observed  in  which  it  has  actually  projected 
through  the  anus.  (2)  The  enteric  variety  involving  the  small 
intestine  comes  next  in  order  of  frequency,  being  met  with  in 
30  per  cent,  of  the  cases.  It  is  most  often  seen  in  the  lower 
jejunum,  and  is  rarely  of  great  size.     (3)  The  colic   form  may 


I020 


A  MANUAL  OF  SURGERY 


occur  at  any  part  of  the  colon  or  rectum,  and,  owing  to  the  fixity 
of  this  portion  of  the  gut,  is  limited  in  extent.  It  is  met  with  in 
about  1 8  per  cent,  of  the  cases.  (4)  The  ileo-colic  only  occurs  in 
8  per  cent. ;  in  it  the  ileum  is  protruded  through  the  ileo-caecal 
valve,  which  for  a  time  retains  its  normal  position  ;  but  after  the 
intussusception  has  attained  a  certain  size,  the  valve  and  caecum 
are  also  invaginated  into  the  ascending  colon.  In  each  of  these 
varieties,  except  the  last,  the  intussusception  grows  at  the  expense 
of  the  external  or  ensheathing  layer,  the  apex  of  the  protrusion 
being  always  formed  by  the  same  portion  of  gut ;  but  in  the  ileo- 
colic variety,  as  just  stated,  it  increases  by  the  passage  of  more 


m 


(T\ 


U 


Fig.  362. — Diagram  of  Intussusception. 

a,  Intussusceptum  ;  b,  intussuscipiens  ;  I.,  ensheathing  layer  ; 
II.,  returning  layer;  III.,  entering  layer. 


and  more  of  the  ileum  through  the  valve ;  after  a  time  this  stops, 
and  is  replaced  by  the  ordinary  form  of  growth. 

Intussusception  is  occasionally  met  with  as  a  post-mortem 
phenomenon,  due  to  the  irregular  intestinal  movements  occurring 
during  the  death  crisis.  The  condition  is  recognised  as  being 
of  this  nature  by  the  absence  of  inflammatory  signs,  by  the  fact 
that  it  is  sometimes  due  to  a  reverse  peristalsis,  and  by  more  than 
one  intussusception  being  present. 

The  Clinical  History  varies  according  to  whether  the  condition 
is  acute  or  chronic. 

Acute  Intussusception  occurs  most  frequently  in  young  children, 
the  onset  being  usually  sudden.  The  child  is  attacked  with 
severe  pain,  possibly  localized  and  more  or  less  paroxysmal  at 
first,  but  rapidly  becoming  continuous  and  diffused  over  the 
abdomen.     This  is  followed  by  vomiting,  which,  however,  is  less 


INTESTINAL  OBSTRUCTION 


severe  than  in  acute  strangulation,  and  not  so  often  faeculent. 
The  patient  rarely  suffers  from  absolute  constipation,  diarrhoea 
and  the  discharge  of  blood-stained  mucus,  perhaps  associated 
with  tenesmus,  being  common.  Collapse  soon  supervenes,  and 
in  the  worst  cases  this  may  be  so  severe  as  to  kill  the  patient 
within  twenty-four  hours ;  otherwise  a  fatal  issue  from  exhaustion 
or  peritonitis  is  reached  within  a  week.  On  examining  the 
abdomen,  but  little  distension  or  tenderness  is  noted,  unless  acute 
peritonitis  is  present ;  in  about  half  the  cases  a  distinct  tumour 
can  be  felt,  cylindrical  in  outline,  and  sometimes  described 
as  'sausage-shaped,'  following  the  course  of  the  intussusception 
and  generally  curved,  owing  to  the  traction  of  the  mesentery. 
In  the  ileo-caecal  variety  it  extends  from  the  right  iliac  fossa 
across  the  brim  of  the  pelvis  to  the  left,  the  colon  being  dragged 
downwards.  This  may  be  associated  with  an  absence  of  resistance 
in  the  right  fossa,  which  feels  empty,  constituting  what  is  known 
as  the  '  signe  de  Dance.'  In  other  cases  the  tumour  may  be 
more  limited,  and  distinctly  moveable. 

A  natural  cure  occasionally  follows,  resulting  either  from 
spontaneous  reduction,  or  from  sloughing  of  the  intussusceptum, 
whilst  the  peritoneal  cavity  is  shut  off  by  a  circle  of  plastic  lymph 
uniting  the  ensheathing  and  entering  layers  of  the  gut.  When 
the  latter  takes  place,  the  subsequent  condition  is  not  very  satis- 
factory, owing  to  the  formation  of  a  fibrous  stricture. 

Chronic  Intussusception  occurs  more  frequently  in  adults  than 
in  children,  the  onset  being  gradual  and  the  course  varying 
widely  in  different  cases.  The  patient  complains  of  intermittent 
attacks  of  pain  of  a  colicky  nature,  which  recur  at  intervals, 
the  attacks  becoming  more  frequent  and  prolonged  as  the  case 
progresses.  Vomiting  is  often  but  little  marked  during  the  in- 
termissions. The  bowels  are  irregular  in  their  action,  and  there 
is  sometimes  a  blood-stained  mucous  discharge.  The  general 
condition  is  not  at  first  much  affected,  but  as  the  case  progresses, 
emaciation  and  general  asthenia  may  supervene.  On  examina- 
tion, the  abdomen  is  found  to  be  flaccid  and  free  from  tenderness, 
although  visible  coils  of  intestine  may  be  observed  in  some 
cases,  and  perhaps  a  tumour  felt.  The  symptoms  are  rather 
those  of  subacute  enteritis  and  chronic  obstruction  than  of 
strangulation,  and  the  case  may  be  brought  to  a  fatal  termina- 
tion either  by  an  acute  attack  of  obstruction  or  by  peritonitis. 
It  may,  however,  last  a  long  time  before  being  recognised. 

Treatment- — In  the  most  acute  forms  of  the  disease  but  little 
can  be  done,  owing  to  the  extreme  prostration  of  the  patient ; 
but  in  the  less  severe  and  in  the  chronic  cases  much  can  be 
attempted  to  prevent  a  fatal  issue. 

In  acute  intussusception  the  patient  should  be  at  once  placed 
under  the  influence  of  opium,  in  order  to  still  peristalsis  and  pre- 
vent the  increase  of  the  tumour.     Inflation  of  the  bowel  with  air, 


A  MANUAL  OF  SURGERY 


or  the  injection  of  copious  enemata  of  warm  water  or  oil,  may 
then  be  carefully  undertaken.  No  undue  force  should  be  em- 
ployed in  this  proceeding,  and  a  hand  placed  over  the  tumour 
may  enable  the  surgeon  to  detect  whether  or  not  it  has  been 
successful.  It  is  performed  by  raising  the  patient's  pelvis  and 
inserting  into  the  rectum  a  catheter,  with  which  is  connected 
an  indiarubber  tube  and  funnel,  held  about  i|  or  2  feet  above 
the  abdomen.  Should  this  not  succeed,  laparotomy  should 
be  performed  without  delay,  and  the  condition  of  the  intus- 
susception investigated.  An  attempt  is  then  made  to  reduce  it 
by  grasping  the  tumour  in  one  hand  and  gently  trying  to 
peel  off  the  ensheathing  layer  from  the  upper  portion  of  bowel, 
which  is  steadied  by  the  other  hand.  In  about  half  the  cases 
reduction  is  impracticable,  owing  to  the  presence  of  adhesions, 
and  if  the  general  condition  of  the  patient  is  fairly  good,  the 
intussusception  should  be  removed  and  the  divided  ends  of  the 
bowel  united  by  suture.  This  is  best  performed  by  a  modification 
of  Maunsell's  method,  an  incision  being  made  through  the  anti- 
mesenteric  border  of  the  intussuscipiens,  through  which  the  intus- 
susceptum  is  drawn  out  and  cut  away,  and  the  bowel  subsequently 
sutured  as  described  at  p.  934.  If,  however,  the  patient  is  in  a 
condition  of  profound  shock,  all  that  can  be  done  is  to  fix  the 
bowel  in  the  wound,  and  make  an  artificial  anus.  The  results  of 
these  procedures  are  anything  but  encouraging,  for  F.  H.  Wiggin* 
has  shown  that  few  children  recover  if  anything  more  than  simple 
reduction  is  required  during  a  laparotomy. 

Chronic  intussusception  is  more  favourable  in  its  prognosis. 
It  is  frequently  unrecognised  until  an  exploration  of  the  abdomen 
is  made,  and  hence  reduction  by  inflation  is  not  commonly 
attempted.  In  some  cases  the  tumour  may  be  reduced  by  simple 
manipulation,  but  as  a  rule  too  many  adhesions  are  present. 
Excision  of  the  mass  should  then  be  undertaken,  and  the  results 
gained  have  been  very  encouraging. 

Investigation  of  a  Case  of  Intestinal  Obstruction. 

As  already  indicated,  the  cause  of  intestinal  obstruction  is  by 
no  means  always  a  matter  of  easy  diagnosis,  whilst  the  localiza- 
tion of  the  lesion  with  a  view  to  accurate  operative  treatment  is 
never  simple.  In  every  case  the  surgeon  should  conduct  his 
examination  in  a  methodical  and  orderly  manner,  and  it  is  well 
to  make  one's  investigation  along  the  following  lines : 

1.  The  Previous  History  of  the  case  should  be  carefully  gone 
into,  in  order  to  ascertain  whether  or  not  the  patient  has  suffered 
from  biliary  colic,  chronic  constipation,  acute  diffuse  or  localized 
peritonitis,  uterine  derangements,  syphilis  or  dysentery,  etc. 

2.  The  History  of  the  Present  Attack   should   then   be  con- 

*  Medical  Record,  January  18,  1896. 


INTESTINAL  OBSTRUCTION 


sidered,  noting  especially  the  manner  of  onset,  whether  acute 
or  gradual,  the  duration  of  the  symptoms,  and  whether  or  not 
preceding  subacute  attacks  have  occurred  from  time  to  time. 
By  this  means  it  is  possible  to  ascertain  whether  the  patient 
is  suffering  from  acute  or  chronic  obstruction,  as  also  whether 
the  causative  lesion  has  been  in  existence  for  some  time  or  not. 
3.  The  more  prominent  Symptoms  must  then  be  considered. 

(a)  Collapse  is  due  partly  to  reflex  nervous  disturbance,  partly 
to  the  absorption  of  toxic  materials,  and  partly  to  withdrawal 
of  fluid  from  the  body  as  a  result  of  the  vomiting ;  the  portal 
area  is  also  much  engorged,  and  this  adds  to  the  want  of 
fluid  in  the  systemic  circulation.  The  nervous  cause  is  most 
active  in  the  early  stage  of  acute  obstruction,  especially  in  infants, 
whilst  the  toxic  is  largely  responsible  for  the  exhaustion  seen  at 
the  end  of  an  acute  attack  or  in  the  chronic  variety.  Hence 
collapse  is  early  in  acute  cases,  late  in  chronic.  Moreover,  the 
higher  the  lesion,  the  greater  the  shock,  owing  to  the  fact  that 
the  upper  portion  of  the  bowel  is  more  intimately  associated  with 
the  sympathetic  nervous  centres. 

(b)  Pain  is  a  very  marked  symptom,  being  usually  referred 
at  first  to  a  little  above  the  umbilicus,  and  is  more  severe  in 
lesions  of  the  small  intestine  than  in  the  colon.  It  varies  greatly 
with  the  completeness  or  not  of  the  obstruction.  This  matter 
has  been  especially  emphasized  by  Treves,  who  has  pointed  out 
that  when  the  obstruction  is  but  partial  the  pain  is  intermittent, 
whilst  when  the  block  is  complete  the  pain  becomes  continuous. 
Hence  in  acute  strangulation  pain  is  almost  invariably  constant, 
whereas  in  stricture  it  is  markedly  intermittent  and  of  a  colicky 
nature.  The  amount  of  pain,  moreover,  varies  with  the  nervous 
excitability  of  the  patient ;  it  is  increased  by  anything  which 
induces  peristalsis,  e.g.,  food  or  purgatives,  and  it  is  diminished 
on  the  supervention  of  gangrene. 

(c)  Abdominal  tenderness  is  rarely  observed  in  the  early  stages, 
being  caused  by  the  onset  of  inflammation  of  the  peritoneum. 

(d)  Vomiting  is  an  almost  invariable  accompaniment  of  obstruc- 
tion. Its  cause  is  still  a  matter  of  some  doubt,  since  some 
authorities  claim  that  it  is  due  to  a  reverse  peristalsis,  whilst 
others  maintain  that  the  ordinary  onward  movements  of  the 
bowel  are  quite  sufficient  to  explain  it ;  the  intestinal  contents 
are  urged  forwards  against  the  face  of  the  obstruction,  and, 
being  unable  to  pass,  an  axial  regurgitant  stream  is  produced. 
It  is  a  little  difficult  to  see  how  this  could  occur  when  the  lower 
end  of  the  colon  is  the  part  affected.  Whatever  the  mechanical 
explanation,  there  is  no  question  as  to  the  influence  of  the  nervous 
system  in  its  production,  or  as  to  its  being  chiefly  reflex  in 
character,  which  is  evident  from  the  fact  that  it  occurs  equally 
when  omentum  or  bowel  is  strangled.  Hence,  it  is  easy  to  under- 
stand that  it  commences  early  in  children  and  sensitive  women,  on 


1024  A   MANUAL  OF  SURGERY 

account  of  the  greater  irritability  of  their  nervous  centres,  whilst 
it  is  also  more  marked  when  the  small  intestine  is  involved. 
Anything  that  increases  peristalsis  naturally  intensifies  its  occur- 
rence. When  the  obstruction  is  situated  in  the  jejunum  or  upper 
part  of  the  ileum,  the  vomiting  is  never  really  faecal  in  character, 
although,  if  it  has  been  temporarily  checked  by  opium,  the  ejecta 
may  be  exceedingly  offensive  and  dark  in  colour,  owing  to  decom- 
position ;  true  faecal  vomiting  can  only  come  from  an  obstruction 
to  the  lower  ileum  or  colon. 

(e)  Constipation,  although  usually  present,  is  not  necessarily 
absolute,  as  it  is  possible  for  the  lower  bowel  to  be  emptied  in 
cases  of  obstruction,  whilst  the  patient  sometimes  passes  a  motion 
as  gangrene  supervenes  or  death  is  approaching. 

4.  A  most  careful  Physical  Examination  must  now  be  instituted. 

(a)  An  inspection  of  the  uncovered  abdomen  should  first  be 
made.  The  amount  and  character  of  the  distension  is  observed, 
and  whether  or  not  it  is  situated  in  the  centre,  as  when  small 
intestine  is  involved,  or  in  the  flanks  when  the  obstruction  is 
in  the  rectum  or  sigmoid  flexure.  The  existence  of  visible  peri- 
stalsis or  enlarged  coils  of  intestine  should  be  noted  ;  such  are 
rarely  seen  in  the  acute  cases,  but  may  be  very  evident  in  the 
chronic  forms.  The  rise  and  fall  of  the  abdomen  during  respira- 
tion should  be  watched  to  ascertain  whether  the  movements  are 
equal  on  both  sides,  or  if  any  prominence,  such  as  would  be 
caused  by  a  tumour,  is  noticeable.  The  general  condition  of  the 
patient,  whether  emaciated  or  not,  as  also  the  appearance  of  the 
face  and  the  position  in  which  he  lies,  should  be  observed. 

(b)  All  the  normal  and  abnormal  hernial  apertures  are 
thoroughly  investigated,  as  also  the  rectum  and  vagina. 

(c)  The  abdomen  is  carefully  palpated,  so  as  to  ascertain  the 
existence  of  any  tumour  or  increased  resistance  of  the  abdominal 
walls. 

(d)  Percussion  may  also  throw  some  light  on  the  case. 


CHAPTER  XXXV. 
RECTUM    AND    ANUS. 

Congenital  Malformations. 

The  lowest  portion  of  the  intestinal  canal,  4  inches  in  length, 
which  is  commonly  known  as  the  rectum,  arises  from  the  union 
of  two  separate  divisions.  The  upper,  developed  from  the  lowest 
portion  of  the  primitive  hind-gut,  is  originally  in  communication 
with  the  bladder,  and  forms  a  joint  cavity  or  cloaca,  the  two, 
however,  being  early  separated ;  the  posterior  segment,  which 
becomes  the  rectum,  extends  down  into  the  pelvis,  to  be  joined 


Fig. 


A  B 

-Three  Varieties  of  Malformation  of  Rectum. 


363. — Three  Varieties  of  Malformation  of  Rectum.     (Tillmanns.) 

In  A,  the  bowel  ends  at  the  brim  of  the  pelvis  in  a  cul-de-sac,  and  there  is  no 
evidence  of  an  anus ;  in  B,  the  anus  is  also  absent,  but  the  bowel  opens 
into  the  bladder ;  in  C,  the  anus  and  bowel  are  only  separated  by  a  small 
space. 

by  an  epiblastic  pit  or  involution  growing  in  from  the  perineum, 
known  as  the  '  proctodeum.'  Failures  in  typical  development 
may  be  due  either  to  the  proctodeum  being  absent  or  stenosed,  to 
the  rectum  either  being  absent  (Fig.  363,  A)  or  retaining  in 
measure  its  cloacal  condition  and  opening  into  some  other  viscus 
— e.g.,  the  bladder,  urethra,  vagina,  or  vulva  (Fig.  363,  B) — or  to 
want  of  union  between  the  upper  and  lower  segments  (Fig.  363,  C). 
The  following  are  the  chief  clinical  varieties  of  malformation  met 
with  ' 

6.5 


1026  A  MANUAL  OF  SURGERY 

(i.)  Absence  of  the  anus,  with  or  without  development  of  the 
rectum,  which,  if  present,  may  open  in  some  abnormal  situation. 
In  such  cases,  the  important  question  to  be  settled  by  the 
practitioner  is  the  existence  or  not  of  a  rectum,  and  this,  unfor- 
tunately, cannot  always  be  determined  without  an  open  explora- 
tion through  the  perineum  ;  if,  however,  during  crying  and 
straining  there  is  a  distinct  bulge  in  the  middle  line  at  the 
spot  where  the  anus  should  be,  there  is  every  likelihood  of  the 
viscus  being  present.  If  so,  it  is  always  expanded  in  a  club-like 
extremity,  usually  lined  with  peritoneum  in  front,  and  often  below. 
If  the  rectum  is  absent,  it  usually  ends  near  the  pelvic  brim, 
and  is  merely  represented  by  a  fibrous  cord  below  that  level 
(Fig.  363,  A),  whilst  the  bony  pelvis  is  often  atrophic  and  its 
outlet  much  reduced  in  size.  Thus  in  a  case  seen  recently  an 
interval  of  half  an  inch  was  present  between  a  sound  passed  into 
the  urethra  and  the  tip  of  the  coccyx. 

(ii.)  A  membranous  septum  may  persist  between  the  upper  and 
lower  segments,  placed  about  an  inch  from  the  anus,  and  allowing 
the  retained  meconium  to  push  it  downwards.  This  is  the  type 
of  malformation  most  commonly  observed  (Fig.  363,  C). 

(iii.)  An  anus  is  occasionally  present,  whilst  the  rectum  ends 
blindly  above  the  pelvic  brim,  or  opens  elsewhere. 

(iv.)  The  anus,  though  present,  may  be  contracted. 

The  Treatment  of  these  cases  must  be  instituted  at  as  early  a 
date  after  birth  as  possible,  so  as  to  prevent  intestinal  obstruction. 

Anal  stenosis  is  readily  dealt  with  by  regular  dilatation  with 
bougies. 

Where  a  membranous  septum  persists  between  the  proctodeum 
and  rectum,  a  large  trocar  and  cannula  may  be  passed  through  it, 
and  the  meconium  allowed  to  escape  ;  the  aperture  thus  made  is 
enlarged,  and  maintained  by  the  subsequent  passage  of  bougies. 

Where  the  anus  is  absent,  whether  there  is  any  indication  of 
the  presence  of  a  rectum  or  not,  a  perineal  incision  is  first  made 
through  the  site  of  the  anus,  and  carried  upwards  and  backwards 
along  the  concavity  of  the  sacrum  strictly  in  the  middle  line  for 
not  more  than  2  inches.  It  is  an  open  question  whether  it  is 
justifiable  to  proceed  further  by  removing  the  coccyx  and  part  of 
the  sacrum  (Kraske's  operation,  p. 1039),  since  the  membranes  of 
the  spinal  cord  extend  much  further  down  in  the  infant  than  in 
the  adult.  If  found,  the  dilated  and  bulbous  cul-de-sac  is  drawn 
down  as  far  as  possible,  and  opened  towards  its  posterior  aspect ; 
the  mucous  membrane  is  then,  if  feasible,  stitched  all  round  to 
the  skin  so  as  to  leave  no  surface  to  granulate,  thereby  preventing 
subsequent  stenosis.  In  cases  where  no  rectum  is  present, 
colotomy  must  be  performed,  and  by  preference  the  iliac  operation, 
since  the  space  between  the  crest  of  the  ilium  and  the  last  rib  is 
exceedingly  small  in  an  infant.  When  once  a  passage  for  the 
faeces  is  established,  abnormal  openings  into  the  bladder,  etc., 
usually  close  without  difficulty. 


RECTUM  AND  ANUS  1027 


Various  malformations  in  connection  with  the  post-anal  gut 
have  been  already  described  (p. 649). 

Inflammation  of  the  Rectum  (Proctitis)  causes  pain  of  a  bearing- 
down  character,  a  sensation  of  fulness,  constantly  recurring 
tenesmus,  accompanied  by  a  discharge  of  mucus,  muco-pus,  or 
blood.  It  may  arise  from  any  local  source  of  irritation,  e.g., 
the  introduction  of  foreign  bodies,  or  the  presence  of  a  polypus, 
parasites,  or  piles ;  gonorrhoea  is  an  occasional  cause — in  women 
possibly  owing  to  infection  from  the  vaginal  discharge,  in  men 
probably  from  direct  infection.  In  dysentery  the  rectum  is  often 
involved  as  well  as  the  colon.  If  the  inflammation  becomes  chronic, 
a  simple  fibrous  stricture  may  result.  Treatment. — Injections  of 
lead  and  opium  or  of  borax  may  be  used  locally,  whilst  the  patient 
is  kept  in  a  recumbent  position  and  on  a  low  diet,  the  bowels  being 
regularly  opened  by  the  administration  of  laxatives  or  enemata. 

Thread-worms  (Oxyuris  vcrmicularis)  are  the  most  constant 
source  of  irritation  of  the  rectum  in  infants  and  children.  They 
give  rise  to  pruritus  ani,  a  discharge  of  muco-pus,  and  many  reflex 
phenomena.  In  treating  such  a  case,  a  sharp  purgative  may  be 
given  every  morning  (e.g.,  pulv.  scamm.  co.,  grs.  v.),  and  salt  and 
water  or  an  infusion  of  quassia  used  as  an  injection. 

The  Bilharzia  hsematobia  is  occasionally  found  in  the  rectum  as 
well  as  in  the  urinary  passages  (p.iogo).  It  gives  rise  to  fibro- 
adenomatous  polypi,  in  which  the  ova  can  be  readily  demonstrated ; 
they  are  rounded  or  oval  bodies,  differing  from  those  found  in  the 
urine  in  that  they  possess  a  lateral  spine-like  projection,  whilst  in 
the  latter  it  is  terminal.  Considerable  tenesmus,  diarrhoea  and 
discharge  of  blood  are  present,  and  the  haemorrhage  may  become 
so  abundant  as  to  destroy  the  patient's  life,  especially  when  urinary 
symptoms  are  coexistent.  They  occur  in  children  who  have  been 
in  Africa,  and,  unfortunately,  no  satisfactory  treatment  is  known. 

Ischio- Rectal  Abscess. 

Suppuration  in  the  ischio-rectal  fossa  (localized  periproctitis) 
is  very  frequently  met  with,  and,  from  the  fact  that  it  commonly 
results  in  a  fistula,  is  of  considerable  surgical  interest.  It  may 
arise  from  a  variety  of  causes,  but  for  convenience  may  be 
described  under  the  three  following  headings  : 

1.  Acute  Ischio-Rectal  Abscess  is  due  to  infection  of  the  loose 
fatty  tissue  filling  the  ischio-rectal  fossa  (Fig.  364,  I.R.A.)  with 
some  pyogenic  organism,  reaching  it  either  through  the  perineum 
or  from  the  bowel.  In  the  latter  case  some  solution  in  the 
continuity  of  the  mucous  membrane  occurs,  such  as  follows  its 
penetration  by  a  fish-bone  or  other  foreign  body,  or  some  form  of 
ulceration  ;  the  Bac.  coli  is  thereby  set  free,  and  in  consequence 
the  pus  has  the  usual  characteristic  offensive  odour.  If  the 
infection  is  derived  from  the  perineum,  the  usual  cocci  of  sup- 
puration are  present,  and  the  pus  has  no  objectionable  smell.  A 
red,  painful  swelling  is  noticed  on  one  side  of  the  anus,  which  is 


1028 


A   MANUAL  OF  SURGERY 


at  first  hard  and  brawny,  but  soon  becomes  soft  and  fluctuating. 
Defalcation  is  exceedingly  painful,  as  also  digital  exploration  of  the 
bowel ;  and  the  patient  is  unable  to  sit  with  any  comfort.  If  left  to 
itself,  it  may  burst  internally  or  externally,  or  in  both  directions, 
and  a  fistula-in-ano  is  very  liable  to  follow.  Treatment. — In  the 
early  stages  the  part  should  be  well  fomented,  but  when  there  is 
no  doubt  that  pus  is  forming,  a  free  opening  should  be  made,  the 
cavity  washed  out,  and  stuffed  with  some  antiseptic  dressing.  If 
taken  early  enough,  rapid  recovery  may  ensue  without  the  bowel 
becoming  involved,  but  when  the  mucous  membrane  has  been 
encroached  upon  or  perforated,  the  wound  will  not  heal  without 
division  of  the  sphincter. 

Occasionally  a  more  diffuse  type  of  acute  suppuration  occurs  in 
the  ischio-rectal  fossa,  constituting  a  cellulitis,  and  not  uncommonly 


Fig.  364. 


-Diagrammatic  Section  of  Lower  End  of  Rectum,  Anus  and 
Ischio-Rectal  Foss^. 


L.A.,  Levator  ani ;    E.S.,  external  sphincter;    I.R.A.,  ischio-rectal  abscess; 
A. A.,  anal  abscess  ;  F.I. A.,  fistula-in-ano  ;  A.F.,  superficial  anal  fistula. 

resulting  in  gangrene  (gangrenous  periproctitis).  It  is  most  likely  to 
be  seen  in  weakly  individuals  and  old  people,  and  the  symptoms 
are  very  asthenic  in  type.  The  suppuration  may  extend  above 
the  levator  ani,  and  lead  to  deep  fistulous  tracks.  The  parts 
must  be  freely  opened  up,  the  gangrenous  tissue  scraped  away, 
and  the  raw  surfaces  treated  with  peroxide  of  hydrogen.  The 
wounds  are  then  stuffed  with  iodoform  gauze,  and  subsequently 
well  irrigated  twice  a  day.  Free  stimulation  is  always  required  in 
these  cases,  but  the  prognosis  is  very  bad,  death  being  probably 
caused  by  acute  toxaemia  or  pyaemia. 

2.  Chronic  Ischio-Rectal  Abscess  is  usually  met  with  in  run- 
down or  tuberculous  individuals  during  young  adult  life,  and  is 
not  unfrequently  a  complication  of  phthisis.  It  arises  from  injuries 
to  the  perineum  or  bowel,  and  may  even  be  induced  by  exposure 


RECTUM  AND  ANUS  1029 


to  wet  or  cold,  as  by  sitting  on  a  damp  stone.  A  deposit  of  tuber- 
culous material  replaces  the  fat  ordinarily  occupying  the  ischio- 
rectal fossa,  and  this  after  a  time  undergoes  caseation  or  forms  an 
abscess,  which  gradually  spreads  without  pain  or  other  inflam- 
matory disturbance,  until  it  may  extend  very  widely  and  almost 
entirely  surround  the  bowel.  After  it  has  burst,  the  orifices  of 
sinuses  may  be  found  at  a  considerable  distance  from  the  anus. 
The  Signs  and  Symptoms  are  those  of  a  chronic  tuberculous 
abscess.  An  indurated  and  painless  mass  may  be  first  felt  in  the 
fossa,  and  this  slowly  spreads,  softens,  and  is  transformed  into  a 
more  or  less  extensive  abscess  sac.  The  Treatment  is  as  for  all 
tuberculous  deposits,  viz.,  in  the  early  stages,  and  even  before 
suppuration  has  occurred,  incision,  removal  by  a  sharp  spoon  of 
all  tuberculous  tissue,  the  application  of  pure  carbolic  acid,  and 
dressing  the  wound  with  gauze  infiltrated  with  iodoform.  Where 
extensive  sinuses  or  fistulae  exist,  treatment  as  for  fistula-in-ano 
mast  be  adopted. 

3.  Suppuration  in  the  ischio-rectal  fossa  may  occasionally  be 
dependent  on  disease  of  neighbouring  or  distant  structures,  e.g., 
the  sacro-iliac  or  hip  joints,  the  pelvic  bones,  the  spine,  prostate, 
pelvic  cellular  tissue,  etc.,  the  pus  finding  its  way  down  by  the 
side  of  the  rectum  and  burrowing  through  the  levator  ani,  to  reach 
the  surface.  The  usual  treatment  of  such  condition  must  be 
adopted,  but  if  practicable  the  abscess  is  opened  elsewhere,  as,  of 
course,  the  existence  of  a  sinus  near  the  anus  is  a  fertile  source  of 
septic  contamination. 

Anal  Abscess. — This  term  is  applied  to  an  abscess  forming 
immediately  under  the  anal  integument,  and  superficial  to  the 
sphincter  (Fig.  364,  A. A.);  it  is  usually  due  to  inflammation  of 
one  of  the  numerous  sebaceous  follicles  in  that  locality.  It  may 
be  acute  or  chronic,  in  the  latter  case  being  usually  tuberculous, 
and  is  one  of  the  most  frequent  causes  of  fistula-in-ano.  It  must 
be  freely  opened  throughout  its  whole  length,  and  stuffed. 

Fistula-in-Ano. 

The  term  fistula-in-ano  is  somewhat  loosely  applied  to  all  those 
conditions  in  which  suppurating  tracks  are  found  in  the  neigh- 
bourhood of  the  anus  and  the  lower  end  of  the  rectum.  Many  of 
these  are  merely  sinuses  which  have  but  one  opening. 

The  Cause  of  fistula  is  usually  some  suppurative  condition,  e.g., 
an  ischio-rectal  or  anal  abscess,  in  the  neighbourhood  of  the 
bowel ;  but  it  is  sometimes  the  result  of  a  stricture  of  the  gut,  the 
inner  opening  being  either  above,  in  the  substance  of,  or  below 
the  cicatricial  mass.  This  is  more  likely  to  be  the  case  when 
multiple  fistulae  exist. 

Varieties. — 1.  The  Complete  Fistula  (Fig.  365)  is  one  in  which 


1030  A   MANUAL  OF  SURGERY 

there  are  openings  both  externally  and  into  the  bowel.  When 
following  an  anal  abscess,  they  are  both  close  to  the  anus,  and 
the  track  lies  immediately  beneath  the  skin  and  mucous  mem- 
brane (Fig.  364,  A.F.).  When  following  an  acute  ischio-rectal 
abscess,  the  external  opening  is  a  variable  distance  from  the  anus, 
and  the  inner  about  1  inch  up  the  bowel,  being  situated  in  relation 
with  the  so-called  internal  sphincter  (Fig.  364,  F.I.  A.);  occasionally 
blind  extensions  are  met  with  branching  off  from  this,  but  not  so 
frequently  as  when  the  fistula  follows  a  chronic  abscess.  In  the 
latter  case  the  skin  may  be  extensively  undermined,  looking  blue 
and  congested,  and  the  fistulous  tracks  may  burrow  widely,  open- 
ing even  on  the  thigh,  or  in  the  perineum  or  buttock.  The 
so-called  horseshoe  fistula  passes  round  the  bowel,  usually  behind 
the  anus,  either  superficial  to  the  external  sphincter  or  beneath 
it,  and  opens  also  on  the  other  side.  Moreover,  the  mucous 
membrane  of  the  bowel  is  often  undermined,  and  stripped  from 


Fig.  365. — Complete  Fig.    366. — Incomplete  Fig.    367. — Incomplete 

Fistula-in-Ano  with  External      Fistula.  or    Blind    Internal 

External     and     In-  (Tillmanns.)  Fistula         (Till- 

ternal  Openings.  manns.) 
(Tillmanns.) 

the  muscular  coat  for  some  distance  above  the  internal  opening  by 
sinuses  or  an  abscess  cavity. 

2.  The  Blind  External  Fistula  (Fig.  366)  is  the  term  applied  to  a 
sinus  resulting  from  the  opening  of  an  ischio-rectal  abscess  in 
which  no  communication  with  the  bowel  can  be  discovered.  A 
probe  passed  into  the  wound  can  often  be  felt  by  a  finger  in  the 
rectum  with  only  the  thickness  of  the  mucous  membrane  between. 
In  dealing  with  these  external  fistulae  the  possibility  of  the  original 
cause  being  at  a  distance  must  not  be  overlooked. 

3.  The  Blind  Internal  Fistula  (Fig.  367)  is  constituted  by  a  sinus 
opening  into  the  bowel  just  above  the  anus.  Attention  is  usually 
drawn  to  the  condition  by  the  passage  of  pus  with  the  motions  or 
independently,  and  perhaps  by  preceding  inflammatory  disturb- 
ance. The  orifice  can  sometimes  be  felt  by  digital  exploration, 
and  on  the  insertion  of  a  speculum  may  perhaps  be  seen  and  care- 
fully examined  by  a  straight  probe  or  one  bent  in  the  form  of  a 
hook  ;  it  is  often  associated  with  considerable  undermining  of  the 
mucous  membrane,  and  if  chronic  with  stenosis  of  the  bowel. 

In  all   these   conditions   it   is  very  difficult  to  obtain   healing, 


RECTUM  AND  ANUS  1031 


owing  to  the  state  of  unrest  in  which  the  parts  are  kept  by  the 
continuous  movements,  voluntary  and  involuntary,  of  the  sphincter ; 
hence  division  of  this  muscle  is  almost  always  necessary.  It  may, 
however,  be  advisable  to  leave  the  case  alone  when  the  fistula 
complicates  the  later  stages  of  phthisis,  or  when  a  small  blind 
internal  fistula  exists  in  elderly  people,  causing  but  little  incon- 
venience and  no  injury  to  the  general  health. 

Operation. — The  bowels  must  have  been  completely  evacuated, 
both  by  means  of  castor-oil  or  some  suitable  purgative,  and  about 
an  hour  previous  to  operation  by  enema,  a  most  important 
preliminary,  not  only  for  the  comfort  of  the  operator,  but  also 
because  it  is  very  desirable  that  no  further  action  should  be 
required  for  some  days.  The  patient  is  placed  in  the  lithotomy 
position,  and  the  perineal  and  anal  regions  shaved  and  purified. 
A  probe  is  passed  along  the  fistula  into  the  rectum,  and  guided 
by  it  a  grooved  director,  along  which  a  curved  pointed  bistoury 
is  introduced,  and  the  intervening  structures  divided  ;  this  will  in 
most  cases  include  the  external  sphincter.  A  careful  search  is 
made  for  pockets  or  tributary  branches  of  the  main  track,  and 
such,  if  found,  are  opened  up  and  scraped  out,  undermined  and 
unhealthy  skin  being  snipped  away  with  scissors;  bleeding  points 
are,  if  necessary,  tied,  and  the  cavity  carefully  powdered  with 
iodoform,  and  lightly  stuffed  with  oiled  lint  or  gauze  soaked  in 
iodoform  and  glycerine.  Pressure  by  a  graduated  antiseptic  wool 
compress  should  be  applied  by  means  of  a  T-bandage.  The  wound 
is  allowed  to  granulate,  and  care  taken  that  irregular  healing  does 
not  lead  to  a  re-formation  of  the  fistula.  With  this  object  in  view, 
it  is  often  advisable  to  pass  a  moderate-sized  bougie  from  time  to 
time  at  the  end  of  a  fortnight. 

When  a  sinus  extends  for  some  distance  under  the  mucous 
membrane  from  the  upper  end  of  the  original  fistula,  it  may  not 
be  always  desirable  to  lay  it  open  to  its  whole  extent,  since  such 
might  involve  serious  haemorrhage  at  a  spot  where  it  cannot  well 
be  checked.  It  will  often  suffice  to  partly  divide  and  scrape  it, 
and  then,  if  the  main  fistula  has  been  satisfactorily  dealt  with,  it 
will  probably  heal  without  difficulty,  especially  if  syringed  out 
occasionally  with  stimulating  lotions. 

In  the  case  of  a  horseshoe  fistula,  the  sphincter  need  only  be 
divided  at  one  spot,  and  that  usually  in  the  middle  of  the  horse- 
shoe. The  whole  track  must,  however,  be  opened  up,  the  cavity 
scraped,  loose  tags  of  skin  removed  by  the  scissors,  and  an 
ordinary  dressing  applied. 

After -Treatment. — The  bowels  should,  if  possible,  be  prevented 
from  acting  for  four  days,  and  most  scrupulous  care  taken  to  keep 
the  parts  clean.  The  deep  dressing  need  not  be  changed  for  the 
first  twenty-four  or  forty-eight  hours,  provided  that  the  surround- 
ing skin  is  well  flushed  with  a  warm  carbolic  solution.  When  the 
plugs  are  removed,  fresh  small  strips  of  gauze  soaked  in  iodoform 


1032  A  MANUAL  OF  SURGERY 


and  glycerine  are  introduced  night  and  morning  after  the  wound 
has  been  syringed.  On  the  fourth  day  a  good  dose  of  castor-oil 
should  be  given,  and  subsequently  care  taken  to  secure  an  action 
of  the  bowels  daily. 

Fissure  of  the  Anus. 

This  is  a  most  painful  and  troublesome  complaint,  met  with 
most  commonly  in  men,  though  not  unfrequently  in  women  of  a 
neurotic  temperament.  It  is  occasionally  due  to  injury  or  to  the 
irritation  of  a  polypus,  but  more  often  to  the  passage  of  large 
scybalous  masses  in  patients  suffering  from  chronic  constipation. 
The  fissure  is  usually  single,  extending  through  the  posterior  border 
of  the  anus  towards  the  coccyx ;  a  '  sentinel '  external  pile  is  often 
situated  immediately  over  it,  and  the  crack  may  lead  to  a  definite 
ulcer  just  within  the  external  sphincter.  According  to  Ball  of 
Dublin,  it  is  due  to  one  of  the  valve-like  tags,  left  at  the  junction 
of  the  proctodeum  and  rectum,  being  caught  by  a  scybalous  mass, 
and  torn  from  its  upper  connections.  Each  time  a  motion  passes 
the  sore  place  is  reopened,  and  the  valve  pushed  further  on,  until 
finally,  having  become  swollen  and  cedematous,  it  appears  at  the 
orifice  as  the  '  sentinel '  pile,  with  an  ulcerated  surface  behind  or 
beside  it.  Sometimes  several  fissures  are  met  with  in  the  same 
individual,  and  then  a  syphilitic  cause  is  probable,  especially  if 
they  are  placed  at  the  side  or  front  of  the  anus. 

The  Symptoms  of  this  condition  are  very  distressing,  consisting  of 
burning  pain  during  defsecation,  which  often  lasts  for  some  hours. 
The  pain  is  usually  associated  with  tenesmus,  and  may  radiate  down 
the  thighs  or  up  the  back,  and  not  uncommonly  to  the  left  sacro- 
iliac joint ;  it  may  be  so  severe  as  to  lead  the  patient  to  refrain  from 
defalcation  for  prolonged  periods.  The  faeces  may  be  streaked  with 
blood  or  pus,  and  there  is  a  certain  amount  of  discharge  from  the 
anus.  On  examining  the  part,  the  sphincter  is  found  to  be  spas- 
modically contracted,  and  the  entrance  of  a  finger  is  forcibly  resisted. 

Treatment  in  the  earlier  stages  is  undertaken  by  regulating  the 
action  of  the  bowels  by  suitable  laxatives,  by  the  use  of  cocaine 
suppositories  prior  to  defaecation,  and  by  improving  the  general 
health.  Sometimes  the  application  of  a  hamamelis  ointment,  com- 
bined with  the  ung.  hydrargyri  nitratis  dil.,  is  most  effective  in 
giving  relief.  In  confirmed  cases  the  sphincter  has  been  forcibly 
dilated  by  the  thumbs,  and  the  crack  or  ulcer  cauterized ;  but 
by  far  the  most  efficient  treatment  consists  in  dividing  its  base 
with  a  straight  probe-pointed  bistoury,  the  incision  at  the  same 
time  including  the  external  sphincter.  The  ulcer  and  the  edges 
of  the  wound  are  snipped  away  with  scissors,  to  facilitate  the 
dressing  and  healing  of  the  wound.  The  lower  bowel  should  in 
all  cases  be  carefully  explored  with  the  finger,  especially  with  a 
view  to  the  possible  existence  of  a  polypus,  which,  if  undetected, 


RECTUM  AND  ANUS  1033 


would   cause   a   recurrence   of  the   mischief.      Rest    being   thus 
obtained,  healing  soon  follows. 

Fibrous  Stricture  of  the  Rectum. 

One  of  the  most  important  conditions  associated  with  or 
resulting  from  inflammatory  lesions  of  the  lower  gut  is  stenosis. 
It  is  usually  met  with  in  advanced  life,  especially  in  women 
over  forty  years  of  age,  and  is  most  often  situated  2  or  3  inches 
from  the  anus,  or  as  high  as  its  junction  with  the  sigmoid  flexure. 
In  this  position,  it  is  usually  due  to  the  cicatrization  and  con- 
traction of  ulcers  following  prolonged  diarrhoea  and  dysentery, 
although  occasionally  due  to  tuberculous  or  syphilitic  ulceration. 
Any  form  of  chronic  proctitis,  e.g.,  gonorrhoea,  may  also  lead  to 
it.  It  occurs  sometimes  as  a  sequela  of  pelvic  cellulitis  and 
suppuration,  from  the  contraction  of  fibrous  bands  which  may 
bind  the  rectum  backwards  to  the  sacral  wall,  or  may  merely 
constrict  it ;  the  stricture  is  in  these  cases  usually  at  a  lower  point 
than  in  the  former.  Repeated  attacks  of  inflamed  piles  may  also 
lead  to  stenosis  at  or  just  above  the  anus.  A  stricture  sometimes 
results  from  traumatism,  or  follows  operations  involving  the  whole 
or  at  any  rate  the  greater  portion  of  the  circumference  of  the 
bowel.  As  already  mentioned,  it  may  be  associated  with  a  fistula, 
especially  if  the  latter  has  existed  for  long ;  the  inner  opening 
may  then  be  found  in  the  substance  of  the  stricture,  as  pointed 
out  by  the  late  Mr.  Henry  Smith. 

The  earliest  Symptoms  of  stricture  are  often  alternating  attacks 
of  diarrhoea  and  constipation,  in  which  the  constipation  is  primary, 
and  the  diarrhoea  due  to  a  catarrhal  enteritis  arising  from  the 
irritation  of  the  retained  faeces.  Gradually  the  difficulty  in 
passing  motions  becomes  more  and  more  marked,  and  the 
faeces  themselves  become  narrowed,  flattened,  and  elongated, 
something  like  pipe-stems,  or  small  masses  like  shrimps  may 
alone  succeed  in  passing.  This  is  associated  with  pain  and  un- 
easiness referred  to  the  lower  bowel ;  a  certain  amount  of  blood 
and  mucus  may  be  mixed  with  the  excreta,  and  sooner  or  later 
marked  dyspepsia  and  abdominal  distension  supervene.  If  the 
case  is  allowed  to  run  on  without  treatment,  absolute  obstruc- 
tion of  a  chronic  type  may  result,  and  lead  to  a  fatal  issue ; 
or  the  mucous  membrane  of  the  bowel  above  the  stricture 
becomes  ulcerated,  an  abscess  forms,  and  subsequently  a  fistula, 
through  which  a  certain  small  amount  of  faecal  material  passes. 
If  several  of  these  fistulae  are  established,  the  patient  may  finally 
succumb  to  chronic  septic  poisoning  and  exhaustion. 

An  examination  of  the  bowel  with  the  finger  may  reveal  a 
smooth,  regular  constriction  of  the  gut  as  if  a  band  had  been  tied 
round  it,  the  fibrous  mass  and  the  aperture  in  it  feeling  something 
like   an   os   uteri.      In    other  cases,  the   bowel   is   stenosed   for 


io34  A   MANUAL  OF  SURGERY 


some  distance,  and  its  surface  more  or  less  ulcerated  ;  whilst  it 
due  to  pelvic  cellulitis,  it  may  be  drawn  up  and  fixed  to  the 
posterior  pelvic  wall.  When  the  stricture  is  too  high  for  the 
finger  to  reach,  the  gut  may  appear  normal,  though  somewhat 
dilated  (ballooning).  Sometimes  the  stricture  is  smooth,  and  free 
from  nodular  irregularities  and  excrescences ;  often,  however,  it 
is  ulcerated  and  irregular,  the  examination  causing  great  pain. 
The  gut  above  the  contraction  is  hypertrophied,  distended,  and 
if  filled  with  retained  faeces,  the  mucous  membrane  may  show 
signs  of  inflammation,  or  even  stercoral  ulcers.  The  gut  below 
the  stricture  is  usually  dilated  (ballooned),  partly  from  paralysis 
of  its  walls,  and  partly  by  invagination  of  the  mass  from  above. 

The  Treatment  in  the  early  stages  consists  in  keeping  the 
bowels  regular  and  the  motions  soft  by  means  of  laxatives,  such 
as  castor-oil  or  salines,  whilst  the  passage  of  the  excreta  is  assisted 
by  enemata.  The  diet  is  regulated,  and  the  strength  maintained, 
if  need  be,  by  tonics.  Locally,  the  stricture,  if  within  reach, 
should  be  dilated  by  means  of  bougies  passed  in  increasing  sizes 
every  two  or  three  days,  care  being  taken  that  the  point  of 
the  instrument  engages  the  stricture,  and  is  not  caught  against 
folds  of  mucous  membrane  or  turned  backwards.  The  utmost 
gentleness  must  be  used,  in  order,  as  far  as  possible,  to  stretch 
the  mucous  membrane,  and  not  tear  it.  Laminaria  or  compressed 
sponge  tents  are  of  use  in  some  cases,  followed  subsequently 
by  bougies.  When  situated  low  down,  the  stricture  may  be 
notched  posteriorly,  or  slightly  nicked  in  several  places  with  a 
probe-pointed  bistoury,  and  bougies  then  passed.  There  is 
always  a  great  tendency  in  these  strictures  to  contract  again,  and 
the  patient  should  be  instructed  to  pass  a  bougie  for  himself  at 
short  intervals.  If  the  stricture  is  out  of  reach,  or  signs  of 
obstruction  manifest  themselves  in  spite  of  treatment,  colotomy  is 
the  final  resource. 

Syphilitic  Disease  of  the  Rectum  and  Anus. 

The  rectum  and  anus  are  attacked  by  syphilitic  disease  in  a 
variety  of  ways,  the  most  prominent  being  as  follows  : 

(a)  The  initial  lesion  or  primary  chancre  is  occasionally  met 
with  in  the  neighbourhood  of  the  anus,  but  presents  no  features 
that  demand  special  attention. 

(b)  In  the  secondary  stage  mucous  tubercles  or  condylomata 
are  frequently  seen,  being  placed  either  at  the  anal  margin  or 
symmetrically  on  either  side  of  the  gluteal  fold,  the  sores  on 
one  side  having  evidently  infected  the  other.  They  are  of  the 
usual  type  (p.  128),  and  are  treated  by  dusting  with  powdered 
calomel,  and  keeping  a  piece  of  dressing  between  the  lips  of  the 
fold. 

(c)  In  the  tertiary  period  diffuse  syphilitic  disease  of  the  rectum  is 


RECTUM  AND  ANUS  10.55 


not  uncommon,  occurring  most  usually,  but  not  solely,  in  young 
married  women  amongst  the  poorer  classes,  and  especially  in 
hospital  patients.  It  is  a  somewhat  early  tertiary  manifestation, 
and  usually  commences  within  easy  reach  of  the  finger,  about 
3  inches  from  the  anus.  It  starts  as  a  diffuse  gummatous  infil- 
tration of  the  rectal  mucous  membrane  and  submucous  tissue, 
which  become  thickened  and  indurated,  ulceration  soon  following. 
These  phenomena  are  not  limited  to  the  rectum,  but  frequently 
spread  up  the  intestine  towards  the  sigmoid  flexure  and  down 
to  the  anus,  and  likewise  involve  the  recto-vaginal  septum  and 
vagina,  passing  down  the  latter  canal  to  invade  the  perineum  and 
neighbouring  structures,  so  that  in  a  neglected  case  the  whole 
external  genitals  and  anus  may  be  involved  in  an  irregular  hyper- 
trophic mass,  somewhat  resembling  elephantiasis.  In  addition, 
the  ulcerative  process  may  extend  more  deeply,  leading  to  the 
formation  of  fistulae,  not  only  between  the  rectum  and  neighbour- 
ing viscera  (e.g.,  vagina  or  bladder),  but  also  communicating  with 
the  exterior.  From  the  cicatrization  occurring  in  the  submucous 
tissue,  contraction  of  the  gut  results,  causing  a  syphilitic  stricture, 
which  may  extend  for  some  distance  up  the  bowel.  The  symptoms 
consist  in  pain,  increased  on  defaecation,  irritability  of  the  bowel, 
and  discharge  of  blood  and  pus  by  the  anus,  whilst  obstructive 
phenomena,  or  alternating  attacks  of  constipation  and  diarrhoea, 
may  also  be  present.  On  examination,  the  diffuse  ulceration  and 
infiltration  of  the  part  are  suggestive  of  malignant  disease,  but  the 
patient's  age  and  history,  and  the  course  of  the  case,  are  usually 
sufficient  to  determine  the  diagnosis.  The  general  health  re- 
mains good  in  the  earlier  stages  of  the  affection,  but  later  on 
may  be  undermined  by  the  pain  and  constant  purulent  dis- 
charge. 

Treatment  consists  in  administering  mercury  and  iodide  of 
potassium,  the  former  perhaps  in  the  shape  of  suppositories, 
whilst  locally  dilatation  by  bougies  is  necessary.  In  advanced 
cases  colotomy  is  essential  in  order  to  secure  rest  to  the  parts, 
and  give  them  a  chance  of  healing.  Possibly  in  a  few  instances 
only  a  temporary  opening  of  the  bowel  may  be  required,  but 
where  much  contraction  exists  and  a  considerable  tendency  to 
obstruction,  the  artificial  opening  must  remain  permanently. 
Sometimes  the  ulceration  persists  in  spite  of  colotomy,  and  care 
must  then  be  taken  to  prevent  the  retention  of  discharges  by  the 
occasional  passage  of  bougies. 

Tumours  of  the  Rectum. 

Polypus  Recti  occurs  most  frequently  in  children,  and  consists 
usually  of  an  adenoma  of  Lieberkuhn's  follicles,  but  occasionally 
of  simple  fibrous  tissue  covered  with  mucous  membrane.  They 
are  commonly  found  within  easy  reach  of  the  anus,  and  present 


1036  A  MANUAL  OF  SURGERY 


an  appearance  something  like  a  small  cherry  with  a  long  pedicle, 
pendulous  and  freely  mobile.  The  Symptoms  caused  are  irri- 
tability of  the  bowel  and  the  passage  of  blood  by  the  anus,  which 
latter  when  occurring  in  a  child  without  symptoms  of  obstruction 
is  almost  pathognomonic  of  polypus.  The  tenesmus  excited  may 
lead,  as  mentioned  elsewhere,  to  prolapse  or  to  the  occurrence 
of  an  intussusception.  It  is  occasionally  associated  with  a  fissure 
of  the  anus,  which  probably  arises  as  a  secondary  result  of  the 
irritation  caused  by  the  partial  extrusion  of  the  polypus  during 
defalcation.  A  natural  cure  can  be  effected  by  rupture  of  the 
attenuated  pedicle,  which  is  at  first  attended  by  a  certain  amount 
of  haemorrhage.  Treatment. — The  polypus  is  cut  away  after  tying 
or  twisting  its  pedicle,  or  the  clamp  and  cautery  may  be  employed. 

Papilloma  of  the  rectum  is  a  rare  disease,  and  gives  rise  to 
haemorrhage  from  and  irritability  of  the  bowel,  or,  if  large,  even  to 
obstruction.  This  condition  is  not  always  limited  to  the  rectum, 
but  may  extend  through  the  greater  portion  of  the  intestine,  and 
then  proves  fatal  from  haemorrhage.  Treatment  consists  in  removal 
by  ligature  or  wire  snare,  where  practicable. 

Sarcoma  is  another  uncommon  disease  in  the  rectum.  It  occurs 
in  the  shape  of  a  large  fleshy  tumour  growing  from  the  submucous 
tissue,  and  projecting  into  the  lumen  of  the  gut  so  as  to  cause 
obstruction.  It  is  less  painful  than  cancer,  and  usually  occurs  at 
an  earlier  age.  The  symptoms  are  much  as  in  the  latter  disease, 
and  the  treatment,  where  feasible,  is  the  same,  viz.,  extirpation  of 
the  growth,  but  it  will  very  probably  recur. 

Epithelioma  of  the  Anus  (i.e.,  of  the  skin  covering  the  anal 
margin)  occurs  as  a  primary  development  similar  to  that  on  the 
lip,  and  is  then  of  the  squamous  type.  It  presents  the  usual 
features,  viz.,  an  indurated  nodular  mass,  which  readily  ulcerates, 
and  runs  the  typical  course  of  such  a  disease,  infecting  the 
inguinal  glands.  It  is  readily  dealt  with  in  the  earlier  stages 
by  an  operation  somewhat  similar  to  that  for  excision  of  the 
rectum. 

Cancer  of  the  Rectum  appears  in  the  form  of  columnar  epithe- 
lioma, consisting,  as  described  elsewhere  (p.  179,  Fig.  42),  of  an 
overgrowth  of  Lieberkiihn's  follicles,  not  only  into  the  lumen  of 
the  gut  (centrifugal  or  papillomatous  type  of  growth),  but  also 
invading  the  deeper  portions  of  the  bowel  wall,  infiltrating  the 
submucous  and  muscular  layers  (centripetal  growth).  A  cer- 
tain amount  of  vascular  fibro-cellular  stroma  is  found  between 
the  glandular  elements,  and,  according  to  the  relative  amount  of 
these  structures,  two  types  of  the  disease  are  described :  (a)  The 
nodular  variety  commences  at  one  spot  in  the  form  of  a  localized 
malignant  wart-like  mass,  which  is  hard  in  consistency,  and  con- 
tains an  excess  of  fibrous  stroma.  This  type  becomes  ulcerated 
after  a  time,  and  does  not  grow  very  rapidly,  (b)  The  annular 
variety  is  characterized  by  the  mass  being  more  cauliflower-like, 


RECTUM  AND  ANUS  1037 


growing  more  quickly,  and  tending  early  to  involve  the  whole 
circumference  of  the  gut.  This  latter  form  ulcerates  early,  bleeds 
freely,  and  causes  greater  destruction  of  tissue,  so  that  obstruc- 
tion to  the  onward  passage  of  faeces  is  much  less  likely  to  occur 
in  it  than  in  the  former  type,  where  cicatricial  contraction  is  a 
marked  feature. 

Both  varieties  sooner  or  later  involve  neighbouring  structures, 
and  hence  lead  to  fixation  of  the  mass,  either  to  the  pelvic  walls 
or  to  the  bladder,  vagina,  or  prostate ;  sometimes  the  iliac  vessels 
or  sciatic  nerves  are  compressed,  causing  cedema  or  neuralgia 
respectively.  Fistulae  may  develop  in  connection  with  the 
bladder,  in  which  viscus  the  growth  may  actually  form  a  con- 
siderable mass.  Secondary  deposits,  similar  in  microscopic,  struc- 
ture to  the  primary  growth,  are  found  in  the  lumbar  glands,  or, 
if  the  anus  is  affected,  in  the  inguinal  region  ;  they  commonly 
involve  the  liver,  and  may  even  be  disseminated  throughout  the 
body.     The  peritoneal  cavity  may  also  be  invaded. 

The  Symptoms  of  the  disease  are  often  so  slight  and  the  onset 
so  insidious  as  to  raise  no  suspicions  of  the  existence  of  any 
growth  until  it  has  attained  considerable  size.     It  then  leads  to 
recurring  attacks  of  constipation,  alternating  with  diarrhoea,  and 
to  the  discharge  of  large  quantities  of  mucus,  often  blood-stained. 
A  sense  of  weight  or  dragging  pain  is  noticed  in  the  rectum,  and 
the  patient  after  defaecation  feels  as  if  there  is  still  something  to  be 
passed.     This  sensation  increases  until  true  tenesmus  and  strain- 
ing at  stool  are  present,  together  with  constant  pain,  which  may 
radiate  up  the  back  and  down  the  legs,  causing  sitting  on  any 
hard  substance  to  be  painful.     At  first  a  blood-stained  discharge 
may  be  seen  on  the  faeces,  which  become  flattened  and  pipe-like, 
but  later  it  passes  independently  of  the  motions.     On  examina- 
tion, an  ulcerating,  crateriform  mass  is  met  with,  which  may  either 
be  limited  to  one  segment  of  the  gut  wall,  and  is  then  usually 
firm,  and  perhaps  associated  with  stenosis,  or  it  may  surround  the 
bowel,  and  feel  soft  and  spongy,  readily  breaking  down  under  the 
finger,  and  bleeding  freely.     This  examination  is  generally  painful, 
as  also  the   process   of  defaecation,  and   sometimes   the  patient 
abstains  from  the  latter  for  lengthened  periods  on  account  of  the 
exquisite  agony  caused  thereby.     When  the  anterior  wall  is  in- 
volved, the  bladder  is  often  fixed  to  the  mass,  and  micturition 
becomes  painful ;  moreover,  every  time  the  bladder  is  emptied  a 
discharge  may  occur  from  the  bowel,  and  this  may  continue  even 
after  colotomy  has  been  performed.    Marked  cachexia  supervenes, 
the  digestion  becomes  impaired,  any  meal  causing  pain  and  flatu- 
lent distension  ;  natural  sleep  is  impossible,  and  if  a  recto-vesical 
fistula  forms,  the  patient's  troubles  are  further  aggravated  by  the 
passage  of  faeces  and  flatus  by  the  urethra. 

The  case  runs  a  more  or  less  rapid  course  to  the  fatal  issue, 
which  on  an  average  ensues  about  seventeen   months  after  the 


1038  A  MANUAL  OF  SURGERY 

onset  of  symptoms,  if  no  operation  has  been  undertaken  (Jessop:;:), 
and  may  be  due  to  a  variety  of  causes.  Faecal  obstruction 
occurs  in  about  30  per  cent,  of  the  cases,  being  more  marked 
in  the  chronic  forms,  and  in  those  where  the  disease  starts  high 
up  the  bowel,  on  account  of  the  peristalsis  causing  invagina- 
tion of  the  mass  and  occlusion  of  the  tube ;  whilst  if  ulceration  is 
excessive,  or  the  disease  situated  low  down,  obstruction  is  much 
less  common,  invagination  being  here  impossible,  and  peristalsis 
being  expended  on  the  onward  passage  of  the  faeces.  Exhaus- 
tion from  haemorrhage,  pain,  sleeplessness,  or  septic  absorption, 
accounts  for  most  of  the  fatal  results,  whilst  septic  peritonitis 
following  the  perforation  of  stercoral  ulcers  above  the  growth 
occurs  in  a  few  instances. 

The  Treatment  of  cancer  of  the  rectum  consists  in  the  radical 
measure  of  excision  of  the  mass,  or  in  the  palliative  operation  of 
colotomy. 

Excision  of  the  Rectum,  or  proctectomy,  is  only  applicable  to 
those  cases  in  which  there  is  a  reasonable  prospect  of  the  whole 
disease  being  eliminated.  When  the  finger  can  be  passed  into 
healthy  bowel  beyond  the  growth,  and  where  the  mass  is  not 
fixed  anteriorly  so  as  to  endanger  other  viscera,  e.g.,  the  prostate 
or  bladder,  the  case  is  a  favourable  one  for  excision.  Fixation 
of  the  mass  laterally  or  behind  is  not  so  important,  although 
where  extensive  it  also  contra-indicates  operation.  If  there  is 
any  reason  to  suspect  secondary  deposits  in  the  lumbar  glands  or 
liver,  it  is  needless  to  put  the  patient  through  the  very  trying 
ordeal  of  excision.  Formerly  it  was  considered  of  vital  importance 
to  avoid  opening  the  peritoneum  ;  but  at  the  present  day  it  is 
frequently  done,  and  with  no  untoward  result,  if  due  precau- 
tions are  taken  ;  so  that,  although  the  growth  may  be  situated 
high  up,  if  it  is  freely  moveable,  and  there  is  no  evidence  of 
secondary  deposits,  an  attempt  should  be  made  to  take  it  away. 
It  must  be  remembered  that  in  the  male  the  peritoneum  is 
reached  on  the  anterior  aspect  of  the  gut  about  i%  inches  from  the 
anus  with  an  undistended  bladder,  whilst  it  may  be  pushed  up 
another  inch  when  that  viscus  is  full  ;  in  the  female  the  peri- 
toneum is  situated  about  4  inches  from  the  anus,  being  reflected 
to  the  posterior  aspect  of  the  cervix  uteri.  Posteriorly,  the  lower 
4  or  5  inches  of  the  bowel  are  uncovered  by  serous  membrane 
in  both  sexes. 

It  is  good  practice  to  anticipate  the  radical  operation  by  a 
preliminary  colotomy,  unless  the  case  is  a  very  early  one.  Where 
the  whole  circumference  of  the  bowel  has  to  be  removed  for 
3  inches  or  more,  the  passage  of  faeces  through  the  wound  is  not 
only  a  source  of  septic  contamination,  but  also  causes  extreme 
pain,  whilst  the  condition  subsequently  left  is  almost  certain  to 
err  on  the  side  either  of  patulency  or  of  contraction,  and  there  is 
total  loss  of  control.  An  effective  anus  in  the  iliac  region  obviates 
*  British  Medical  Journal,  1889,  ii.,  p.  407. 


RECTUM  AND  ANUS  1039 


all  these  difficulties,  whilst  the  preliminary  operation  gives  the 
surgeon  a  chance  of  investigating  the  condition  of  the  lumbar  or 
sacral  glands,  and  of  ascertaining  the  extent  of  the  growth  up  the 
bowel. 

Two  forms  of  operation  are  described,  according  to  whether 
the  growth  is  situated  high  up  or  low  down.  The  latter,  or 
low  operation,  sometimes  known  as  Langenbeck's,  is  performed 
through  the  perineum  ;  the  former,  for  dealing  with  cancer  situ- 
ated higher  up,  necessitates  partial  removal  of  the  sacrum  or 
coccyx,  and  is  known  as  Kraske's. 

1.  Loiv  Operation. — The  rectum  having  been  thoroughly  washed 
out  and  emptied,  and  the  patient  placed  in  the  lithotomy  position, 
the  perineum  is  shaved  and  purified,  and  the  posterior  wall  of  the 
rectum  and  anus  slit  open  in  the  middle  line  as  far  as  the  tip  of 
the  coccyx.  An  incision  is  now  made  all  round  the  anus  at  the 
junction  of  the  skin  and  mucous  membrane,  if  the  anus  is  healthy  ; 
when  diseased,  the  incision  is  extended  beyond  the  margin  so  as 
to  include  the  growth.  The  rectum,  together  with  the  tumour, 
is  then  separated  from  surrounding  structures  by  scissors  and 
fingers,  commencing  posteriorly,  where  this  is  readily  effected, 
dividing  the  levator  ani  on  each  side,  and  working  gradually 
upwards  and  to  the  front,  where  greater  care  must  be  taken  to 
ensure  the  vagina,  prostate  or  membranous  urethra  from  harm. 
In  the  male,  a  bougie  or  catheter  may  be  passed  into  the  urethra 
with  advantage.  Bleeding-points  can  be  secured  during  this 
process  by  pressure-forceps.  The  upper  attachments  of  the  gut 
are  divided  either  by  scissors,  ecraseur,  or  clamp  and  cautery. 
Haemorrhage,  which  is  generally  very  free,  is  arrested  by  ligature 
or  cautery,  and  the  gaping  wound  powdered  with  iodoform,  and 
plugged  for  twenty-four  hours  with  gauze,  the  posterior  incision 
not  being  closed  by  suture,  and  no  attempt  made  to  drag  down 
the  mucous  membrane.  Subsequently  the  wound  may  be  left 
without  any  internal  dressing,  an  external  pad  of  salicylic  wool 
sufficing  ;  it  is  thoroughly  washed  out  two  or  three  times  a  day 
with  some  dilute  antiseptic,  such  as  sanitas  (1  in  10),  Condy's 
solution,  or  carbolic  acid  lotion  (1  in  60),  which  may  be  used 
alternately ;  granulations  gradually  cover  the  surface,  and,  as 
cicatrization  progresses,  the  mucous  membrane  is  by  degrees 
approximated  to  the  skin  margin,  and  the  patulous  cavity  dimin- 
ished in  size  until  healing  is  complete. 

If  the  growth  affects  one  side  of  the  gut  alone,  the  operation  is 
modified  by  only  removing  that  half.  If  fixed  posteriorly,  the 
coccyx,  and  even  a  part  of  the  sacrum,  may  be  taken  away  with- 
out hesitation  to  facilitate  the  extirpation  of  the  mass. 

2.  Kraske's  or  the  High  Operation. — The  patient  reclining  on  his 
ri«^ht  side,  an  incision  is  made  in  the  median  line  from  just  behind 
the  anus  to  the  middle  of  the  sacrum,  but  without  opening  the 
bowel.  The  coccyx  is  excised,  and  the  great  sacro-sciatic  liga- 
ment  and   gluteus  maximus  detached  from  the  left  side  of   the 


1040 


A   MANUAL  OF  SURGERY 


sacrum.  Part  of  the  left  wing  of  the  latter  bone  is  now  removed 
by  chisel  and  hammer,  the  incision  being  curved,  and  extending 
from  the  median  line  below,  through  or  above  the  fourth  pos- 
terior sacral  foramen  to  the  under  border  of  the  third,  and  then 
to  the  left  border  of  the  bone  at  that  level  (Fig.  368,  a  b).  The 
loose  cellular  tissue  surrounding  the  upper  part  of  the  rectum  is 
thus  exposed,  and  the  gut,  together  with  the  tumour,  is  freed  from 
its  connections,  and  amputated  from  the  sound  gut  above,  the 
peritoneum  being  usually  encroached  on  in  this  stage  of  the  pro- 
ceedings. If  the  growth  extends  to  the  anus,  the  whole  length  of 
the  rectum  below  is  excised  ;  but  if  the  sphincter  and  lower  inch 
or  two  are  free  from  disease,  they  are  left  in  situ,  and  not  divided 
posteriorly,  whilst  the  upper  end  of  the  gut  is  in  all  cases  drawn 


Fig.  368. — Pelvis  seen  from  Behind  to  indicate  the  Lines  of  Section 
of  the  Sacrum  and  Coccyx  in  Kraske's  Operation. 

a  b,  Kraske's  original  operation  ;  a  c,  Bardenheuer's  modification. 

down,  and  fixed  by  a  few  points  of  suture  either  to  the  anal  portion 
along  its  anterior  wall,  or  to  the  skin.  The  wound  is  carefully 
washed  out,  and  stuffed  with  gauze  sprinkled  with  iodoform  ;  even 
if  the  peritoneal  sac  has  been  opened,  no  harm  will  usually  come 
of  it,  since  a  careful  packing  of  the  wound  will  close  it  off  in 
twenty-four  hours.  The  results  which  have  followed  this  severe 
operation  are,  on  the  whole,  encouraging,  always  provided  that  a 
preliminary  colotomy  has  been  performed. 

Various  modifications  of  Kraske's  proceeding  have  been 
suggested,  one  of  the  best  being  that  performed  by  Bardenheuer. 
The  sacrum  is  exposed,  sawn  across  just  below  the  third  fora- 
mina (Fig.  368,  a  c)  and  the  portion  thus  detached  is  totally 
removed.  By  this  means  a  much  more  extensive  view  is  obtained 
of  the  pelvic  contents,  and  the  scope  of  the  operation  increased. 


RECTUM  AND  ANUS  1041 


Excision  of  the  rectum  is  a  proceeding  only  practicable  in  com- 
paratively few  cases  of  the  disease  (Jessop  states  15  to  20  per 
cent.),  and  fatal  results  are  not  uncommon  from  shock,  haemor- 
rhage, or  peritonitis.  The  tendency  to  recurrence  is  considerable, 
but  the  disease  is  not  then  so  painful  as  before,  since  the  nerve 
terminals  have  been  removed.  In  the  cases  that  are  cured  a 
certain  amount  of  inconvenience  is  certain  to  follow  either  from  a 
patulous  or  stenosed  condition  of  the  anal  orifice,  and  it  is  still 
a  moot  point  whether  in  many  cases  a  simple  colotomy  is  not  as 
valuable  as  excision. 

As  already  stated,  if  the  radical  operation  is  not  feasible, 
Colotomy  is  the  only  means  whereby  the  patient's  condition  can 
be  temporarily  ameliorated.  The  surgeon  should  not  wait  until 
urgent  symptoms  develop,  but  should  operate  at  the  earliest 
possible  date,  and  for  the  following  reasons :  (a)  It  allows  the 
patient  to  indulge  in  solid  food,  and  thus  assists  in  maintaining 
the  general  health ;  (b)  it  frees  him  from  the  pain  arising  from  the 
passage  of  faeces  over  the  ulcerated  surface ;  (c)  it  retards  the 
growth  of  the  disease  by  eliminating  the  irritating  action  of  the 
faeces ;  (d)  it  removes  a!)  chance  of  intestinal  obstruction  from 
the  growth  itself;  and  (e)  it  diminishes  the  absolute  risk  of  the 
operation  by  doing  it  when  the  patient  is  comparatively  well  and 
hearty,  and  when  there  is  no  urgency.  Formerly,  when  under- 
taken for  obstruction  alone  the  death-rate  was  about  30  or  40  per 
cent.  ;  in  an  early  iliac  operation  it  is  now  practically  nil,  01  at 
most  3  or  4  per  cent. 

Should  the  patient  refuse  colotomy,  or  should  it  be  for  any 
reason  contra-indicated,  treatment  consists  in  limiting  the  diet 
to  such  materials  as  strong  broths,  arrowroot,  etc.,  with  some 
stimulant,  so  as  to  give  as  little  faecal  remains  as  possible,  and  to 
enable  him  to  do  without  an  action  of  the  bowels  for  about  a  week 
at  a  time.  The  strength  is  husbanded  by  keeping  him  in  bed, 
and  pain  is  checked  by  the  administration  of  morphia. 

Haemorrhoids,  or  Piles. 

By  the  term  Piles  is  meant  a  varicose  condition  of  the  veins 
surrounding  the  anus  and  lower  inch  or  two  of  the  rectum. 

The  character  of  the  blood  supply  of  this  portion  of  the  bowel, 
and  the  conditions  under  which  it  is  carried  on,  go  far  to  explain 
the  frequency  of  this  affection.  The  circulation  in  the  lowest 
portion  of  the  colon  is  similar  to  that  in  the  intestine  generally, 
the  vessels  being  distributed  transversely  around  the  gut ;  but  in 
the  rectum  they  run  in  longitudinal  series  along  the  bowel,  being 
connected  by  transverse  branches,  which  form  a  plexus  around 
and  just  above  the  anus.  Their  situation  in  the  loose  submucous 
tissue,  where  there  is  but  little  support,  necessarily  exposes  them 
to   great   and   sudden    variations   of    pressure   before    and  after 

66 


I042  A   MANUAL  OF  SURGERY 


defecation.  Their  dependent  position  at  the  lowest  part  of  the 
portal  area,  together  with  the  absence  of  valves,  and  the  fact  that 
they  constitute  an  important  communication  between  the  portal 
and  general  systems,  and  thus  afford  the  chief  means  of  escape 
from  a  block  on  the  portal  trunk — all  these  reasons  may  be  looked 
on  as  Predisposing  Causes  of  the  condition.  In  addition  to  these 
we  must  also  mention  a  sedentary  occupation,  alcoholic  excess, 
and  chronic  constipation,  which,  by  leading  to  congestion  of  the 
liver,  are  frequent  precursors  of  piles.  They  are  exceedingly 
common  in  young  people,  especially  in  men  about  twenty  years 
of  age  forced  to  lead  a  sedentary  life  ;  up  to  middle  age  the 
tendency  diminishes,  but  in  elderly  individuals  many  conditions 
arise  which  favour  their  development.  Young  women  are  re- 
markably exempt  from  piles,  owing  probably  to  the  regularity  of 
the  menstrual  discharge  ;  but  uterine  conditions,  such  as  preg- 
nancy, displacements,  or  tumours,  which  cause  obstruction  to  the 
venous  return,  are  liable  to  be  associated  with  them.  Many  forms 
of  abdominal  tumour,  e.g.,  aneurisms,  may  also  determine  their 
existence. 

A  varicose  condition  of  the  veins  in  the  neighbourhood  of  the 
anus  is  often  present  without  being  recognised  by  the  individual ; 
but  many  different  circumstances  may  bring  the  symptoms  into 
prominence  by  causing  an  attack  of  thrombosis,  such  as  the  use 
of  drastic  purgatives,  especially  aloes,  local  exposure  to  damp  and 
cold,  as  by  sitting  on  a  cold  wet  stone  or  in  a  draughty  closet,  or 
sudden  congestion  of  the  liver,  as  by  alcoholic  excess,  or  a  chill. 

Two  chief  varieties  of  piles  are  described,  viz.,  the  external  and 
internal ;  but  frequently  a  combination  of  the  two  conditions  is 
present. 

External  Piles  are  found  at  the  margin  of  the  anus,  and  are 
covered  with  skin.  They  consist  of  a  small  central  vein  in  a  vari- 
cose state,  surrounded  by  a  development  of  subcutaneous  fibro- 
cellular  tissue,  which  latter  is  much  more  abundant  than  the 
vascular  element ;  in  fact,  they  practically  consist  of  longitudinal 
folds  of  skin  of  a  dark  brown  colour  radiating  from  the  anus,  and 
superficial  to  the  sphincter.  In  the  usual  relaxed  state  in  which 
they  are  found  they  give  rise  to  no  Symptoms  beyond  a  little 
pruritus,  and  perhaps  a  sense  of  fulness  and  irritation  imme- 
diately before  and  after  defalcation.  They  are  very  liable, 
however,  to  become  inflamed  from  local  irritation  or  cold,  and 
then  appear  as  tense,  bluish,  rounded  swellings,  exceedingly 
painful  and  tender,  and  often  preventing  the  patient  from  walking 
or  sitting  in  comfort.  In  such  a  state  the  vein  contained  in  the 
pile  is  distended  with  blood-clot.  Under  suitable  treatment  the 
swelling  subsides  in  a  few  days,  usually  leaving  the  fleshy  fold 
more  bulky  and  harder  than  previously,  owing  to  the  partial  or 
complete  organization  of  the  thrombus. 

The  Treatment   of  external  piles,   when   uninflamed,   is   very 


RECTUM  AND  ANUS 


1043 


simple.  Constipation  must  be  relieved  ;  the  parts  should  be  kept 
clean  and  well  washed ;  a  hamamelis  ointment  or  extract  may  be 
occasionally  applied,  and  great  care  taken  not  to  irritate  the  anus 
after  defalcation  by  the  use  of  hard  paper  (e.g.,  newspaper).  Very 
soft  curl  paper,  well  crumpled,  should  be  employed,  or  preferably 
absorbent  wool.  It  is  but  rarely  that  operative  measures  are  re- 
quired in  a  simple  case  of  external  piles  ;  where,  however,  ex- 
ternal and  internal  piles  coexist,  it  is  advisable  to  complete  any 
operation  undertaken  for  the  latter  condition  by  the  removal  of 
the  more  prominent  fleshy  folds  surrounding  the  anus.  This  is 
accomplished  by  grasping  them  with  forceps,  and  snipping  them 
away  by  scissors  in  a  direction  radiating  from  the  centre  of  the 
anus.  We  would  warn  the  practitioner,  however,  against  a  too 
free  use  of  the  scissors,  whereby  a  subsequent  contraction  of  the 
anus  may  be  induced.  For  inflamed  external  piles  the  patient 
should  be  kept  in  bed,  the  bowels  opened  by  a  copious  warm 
enema,  and  fomentations  applied.  If  the  pain  and  tension  are 
very  great,  the  tumour  should  be  incised  and  the  clot  turned  out ; 
the  margins  of  the  fold  may  then  be  cut  away,  and  the  wound 
dressed  with  iodoform  and  salicylic  wool. 

Internal  Piles  consist  of  dilated  veins  held  together  by  a  certain 
amount  of  connective  tissue,  and  covered 
by  mucous  membrane.  At  first  they  are 
quite  soft  and  compressible,  and  easily 
emptied  on  pressure ;  but  when  they 
have  existed  for  some  time  the  connec- 
tive tissue  may  be  increased  in  amount, 
and  arterial  twigs  are  often  found  run- 
ning into  the  mass. 

The  condition  is  limited  to  the  lower 
2  inches  of  the  bowel,  and  may  present 
very  varied  appearances  in  different 
cases.  Thus,  there  may  be  a  general 
varicosity  of  the  veins  in  the  submucous 
tissue  without  the  formation  of  any  dis- 
tinct tumours.  The  mucous  membrane 
is  then  of  a  deep  claret  colour,  somewhat  thickened,  and  liable 
to  protrude  during  defalcation.  There  is  a  certain  amount  of 
mucous  glairy  discharge,  and  the  faeces  may  be  streaked  with 
blood ;  but,  as  a  rule,  the  haemorrhage  is  not  great.  Such  a 
condition  is  usually  followed  by  a  definite  formation  of  haemor- 
rhoidal  tumours,  and  not  unfrequently  runs  on  to  prolapse. 

When  distinct  haemorrhoidal  masses  form,  they  may  be  of  two 
types  :  (a)  The  longitudinal  or  fleshy  pile  (Fig.  369),  consisting  of 
broad  sessile  masses,  dusky  in  colour,  soft  and  compressible  in 
consistency,  and  usually  covered  by  mucous  membrane,  which, 
although  thin  and  stretched,  still  remains  smooth  and  shiny,  like 
the  skin  of  a  black  grape.      Between  the  piles  depressions  are 


'1MIA1\I 


369. — Internal 

i'lLES. 


1044  A   MANUAL  OF  SURGERY 


found,  in  which  small  portions  of  faeces  may  lodge  and  produce 
irritation.  This  form  usually  bleeds  but  little,  (b)  The  globular 
or  bleeding  pile  is  single  or  multiple,  and  usually  somewhat  pedun- 
culated ;  the  surface  of  the  tumour  is  roughened  and  granular, 
like  a  strawberry,  due  to  the  existence  of  dilated  capillaries. 
When,  however,  a  portion  of  it  has  been  repeatedly  protruded, 
the  exposed  mucous  membrane  becomes  hard,  and  practically 
converted  into  skin.  The  haemorrhage  is  often  abundant,  and 
comes  either  from  the  dilated  superficial  capillaries,  or  occasion- 
ally from  a  central  arterial  twig. 

The  Symptoms  arising  from  internal  piles  are  often  not  very 
marked  until  haemorrhage  occurs  ;  but  there  is  usually  a  sense 
of  weight  or  fulness  about  the  anus,  with  sometimes  pain,  which 
is  increased  before  and  after  defaecation.  The  patient  feels  as 
if  a  foreign  body  were  present  in  the  bowel,  and  the  mass  not 
unfrequently  protrudes,  giving  rise  to  much  pain  and  incon- 
venience until  replaced  by  the  patient,  owing  to  the  grip  of  the 
sphincter.  Sooner  or  later  haemorrhage  is  almost  certain  to  be 
noticed,  coming  on  at  first  after  defaecation,  and  only  a  few  drops 
being  lost.  After  a  time,  however,  the  flow  increases,  and  may 
continue  to  such  an  extent  as  to  cause  marked  anaemia.  If  the 
case  remains  untreated,  the  pain  and  inconvenience  increase  ;  a 
blood-stained  mucous  discharge  from  the  rectum  is  noticed,  soiling 
the  linen  ;  reflex  irritation  of  neighbouring  organs  is  produced, 
and  a  condition  of  nerve  prostration  from  pain  and  haemorrhage 
may  result.  In  cases  where  the  piles  are  due  to  portal  obstruc- 
tion, as  in  cirrhosis  of  the  liver,  the  bleeding  may  be  beneficial, 
and  must  not  always  be  checked.  Moreover,  when  the  menstrual 
flow  is  diminished,  a  vicarious  discharge  of  blood  from  the  piles  is 
sometimes  observed. 

Complications  of  Piles. — Inflammation  of  the  venous  ampullae 
contained  in  piles  leads  to  what  is  popularly  termed  an  '  attack 
of  piles,'  although  this  is  much  less  common  with  the  internal 
than  the  external  variety,  and  the  fleshy  form  is  that  usually 
affected.  Evidences  of  a  localized  phlebitis  manifest  them- 
selves in  the  shape  of  a  painful  distension  and  swelling  of  the 
parts,  which  become  blue  in  colour  and  exquisitely  sensitive. 
They  subside  with  or  without  suppuration  ;  in  the  latter  case  a 
spontaneous  cure  may  result,  whilst  in  the  former  general  blood 
contamination  may  follow,  death  from  pyaemia  having  even 
occurred.  Strangulation  of  the  piles  by  the  sphincter  ani  may 
follow  protrusion  where  reposition  is  not  effected,  the  mass  then 
becoming  painful,  tense,  swollen,  and  livid  in  colour ;  inflamma- 
tion running  on  to  ulceration  and  even  sloughing  follows,  the 
patient  suffering  meanwhile  from  sickness,  pain,  and  toxaemia. 
Pyaemia  is  likely  to  ensue  unless  the  case  is  effectively  treated, 
preceded  by  pylephlebitis  (i.e.,  septic  inflammation  of  the  branches 
of  the  portal  vein  in  the  liver).    On  the  other  hand,  a  spontaneous 


RECTUM  AND  ANUS 


1045 


cure  may  be  effected.  Prolapse  may  become  chronic,  and  fissure 
of  the  anus  develop. 

The  Diagnosis  of  piles  from  other  swellings  which  occur  in  the 
neighbourhood  is  not  difficult.  From  prolapse  they  are  recognised 
by  their  irregularity,  the  swelling  not  being  of  a  rounded  smooth 
annular  variety,  as  in  the  former  case  ;  the  two  conditions  are, 
however,  often  associated.  From  polypus  piles  are  distinguished 
by  being  multiple  rather  than  single,  by  being  softer  and  more 
compressible,  by  their  situation  close  to  the  anus,  by  the  absence 
of  a  pedicle,  and  by  the  haemorrhage  being  usually  more  marked. 
Mucous  tubercles  and  condylomata  are  often  mistaken  for  external 
piles,  but  are  easily  recognised  by  being  symmetrically  placed, 
owing  to  infection  of  one  lip  of  the  gluteal  fold  from  the  other, 
by  their  moist  surface,  and  their  situation  at  a  little  distance  from 
the  anus.  The  consistency,  appearance,  and  history  of  an 
epithelioma  should  effectually  prevent  any  error  in  diagnosis. 

It  is  important  also  to  remember  that  blood  may  be  passed 
per  anum  from  many  other  conditions  besides  piles.  In  the 
latter  case  the  blood  is  of  a  bright  red,  florid  colour,  and  often 
coats  the  fasces,  whereas  if  it  originates  higher  in  the  intes- 
tinal canal  it  is  dark  or  tarry  in  colour  (melecna),  and  is  more 
intimately  mixed  with  the  excreta.  A  digital  examination  of 
the  rectum  will  also  in  the  latter  case  eliminate  the  presence  of 
piles. 

The  Treatment  of  internal  piles  is  both  general  and  local. 

General  Treatment  consists  in  removing  all  possible  sources  of 
venous  congestion,  in  regulating  the  bowels  and  assisting  the 
functions  of  the  liver.  The  latter  may  be  effected  by  the  judicious 
administration  of  natural  mineral  waters,  such  as  Hunyadi  Janos 
and  Friedrichshall,  or  by  the  use  of  some  such  mild  aperients  as 
the  confections  of  senna  and  sulphur,  or  castor-oil.  These  may 
be  given  daily,  whilst  at  the  same  time  the  food  and  drink  of  the 
individual  are  regulated,  all  excess  of  alcohol  being  avoided,  and 
suitable  exercise  enjoined.  In  weakly  and  debilitated  individuals 
it  is  advisable  to  adopt  a  more  stimulating  and  tonic  plan  of 
treatment.  Aloes  should  generally  be  avoided.  When  dependent 
on  the  pressure  of  a  gravid  uterus,  little  can  be  done  beyond 
attending  to  the  regular  action  of  the  bowels  until  the  child  is 
born. 

Local  Treatment  in  the  earlier  stages  consists  merely  in  palliative 
measures.  Thus  the  parts  must  be  protected  from  injury  and 
cold  ;  only  soft  paper  or  cotton-wool  used  after  defalcation  ;  and, 
when  protruding,  the  piles  should  be  sponged  with  cold  water 
and  gently  returned.  An  ointment  containing  an  extract  of 
witch-hazel  (hamamelis),  or  the  injection  of  a  hazeline  lotion 
(1  in  8)  is  also  advisable,  and  bleeding  from  piles  can  often  be 
arrested  by  this  means.  The  ung.  gallae  c.  opio  of  the  Pharma- 
copoeia is  recommended,  but  is  not  so  efficacious. 


1046  A   MANUAL  OF  SURGERY 


When  there  is  much  pain  or  bleeding,  and  the  piles  have 
attained  some  size,  Radical  Treatment  by  operation  is  necessary. 
Care  must  be  taken  before  advising  it  to  ascertain  the  condition 
of  the  liver,  as  the  bleeding  may  be  beneficial  in  relieving  hepatic 
congestion,  and  an  operation  is  then  injudicious  and  harmful. 
In  all  cases  the  bowels  are  thoroughly  emptied  by  a  dose  of 
castor-oil  given  the  night  before  and  an  enema  on  the  morning  of 
the  operation,  whilst  the  patient  sits  over  hot  water  for  half  an 
hour  beforehand.  The  lithotomy  position  is  adopted,  the  perineum 
is  shaved  and  cleansed,  and  the  "surgeon  thoroughly  stretches  the 
sphincter  by  introducing  the  two  index-fingers  and  then  separating 
them  forcibly,  by  this  means  bringing  into  view  the  whole  of  the 
diseased  area  of  mucous  membrane,  which  never  extends  beyond 
2  inches  from  the  anus.  The  following  plans  of  treatment  are 
those  chiefly  used : 

1.  Removal  by  clamp  and  cautery,  as  introduced  by  the  late  Mr. 
Henry  Smith.  The  mucous  membrane  having  been  everted,  as 
just  described,  each  of  the  haemorrhoidal  tumours  is  grasped  by  a 
pair  of  ring-ended  catch  forceps,  and  thus  temporarily  secured  ; 
by  this  means  the  scope  of  the  operation  required  can  be  readily 
gauged.  The  clamp  is  then  applied  to  each  mass  successively  in 
a  direction  corresponding  to  the  long  axis  of  the  gut,  great  care 
being  taken  not  to  include  the  external  skin.  The  clamp  is 
tightened  by  the  screw  attached  to  its  handle,  and  the  projecting 
mass  of  the  pile  removed  by  scissors.  The  cut  surface  is  then 
thoroughly  seared  by  a  cautery  at  a  dull  red  heat,  and  the  pressure 
of  the  clamp  slowly  relaxed,  so  as  to  ascertain  that  all  bleeding 
has  ceased.  External  piles  may  be  snipped  away  as  indicated 
above  (p.  1043),  the  mucous  membrane  re-inverted,  the  parts 
dusted  with  iodoform,  and  a  carefully  graduated  compress  of  anti- 
septic wool  applied  with  a  T-bandage.  The  parts  are  bathed 
each  day  with  some  mild  antiseptic  lotion,  and  should  be  healed 
in  ten  to  fourteen  days.  The  use  of  the  catheter  may  be  necessary 
for  the  first  forty-eight  hours  after  a  severe  case,  owing  to 
retention  of  urine.  The  bowels  are  not  opened  until  the  fourth 
or  fifth  day,  and  then  a  good  dose  of  castor-oil  (e.g.,  1  ounce  in 
adults)  should  be  administered.  It  is  better  to  allow  the  patient 
to  sit  on  a  commode  for  the  evacuation  of  the  bowels.  From  a 
very  large  experience  of  this  operation,  gained  both  at  hospital 
and  in  private,  we  have  no  hesitation  in  maintaining  that,  if 
efficiently  carried  out,  and  combined  with  the  use  of  a  powerful 
and  properly  constructed  screw-clamp,  it  is  absolutely  safe  and 
free  from  danger ;  that  any  complications  from  sepsis,  haemorrhage, 
etc.,  are  due  to  the  carelessness  of  the  surgeon,  and  not  to  the 
character  of  the  operation ;  and  that  for  all  practical  purposes  it 
is  the  best  means  of  dealing  with  internal  piles. 

2.  Ligature  is  also  an  operation  much  in  vogue  for  the  treatment 
of  piles,  and  as  now  carried  out  with  due  antiseptic  precautions, 


RECTUM  AND  ANUS  1047 


a  large  amount  of  success  attends  its  use,  although  it  is  doubtful 
whether  recovery  is  as  speedy  or  painless  as  after  the  cautery. 
The  hemorrhoidal  tumours  are  grasped  by  forceps,  the  mucous 
membrane  divided  around  them,  and  the  base  ligatured  with  silk ; 
the  mass  is  then  snipped  off,  and  the  ligature  cut  short,  the  knot 
being  allowed  to  separate  by  subsequent  ulceration. 

3.  Crushing  by  means  of  a  powerful  clamp  has  also  been 
recommended  by  Benham,  Allingham,  and  others,  the  base  of 
the  mass  being  thoroughly  compressed,  and  the  pile  then  cut 
away.  We  think  it  safer  to  combine  such  treatment  with  the 
styptic  and  antiseptic  qualities  of  the  cautery. 

4.  Where  the  veins  of  the  lower  inch  or  two  of  the  mucous 
membrane  are  in  a  varicose  condition,  but  no  definite  haemor- 
rhoidal tumours  are  present,  Whitehead's  operation  may  be  em- 
ployed. It  consists  in  the  total  removal  of  this  pile-bearing  area 
in  the  same  way  as  for  excision  of  the  rectum.  An  incision  is 
made  round  the  margin  of  the  anus  at  the  junction  of  the  skin 
and  mucous  membrane,  and  the  latter  dissected  up  from  the 
muscular  coat  of  the  bowel  by  successive  snips  of  the  scissors ;  it 
is  then  cut  away,  all  bleeding-points  are  secured,  and  the  lower 
end  of  the  divided  mucous  membrane  united  by  suture  to  the  skin, 
the  stitches  passing  deeply  under  the  surface  of  the  wound  and 
not  merely  through  the  margins.  Excellent  results  have  followed 
such  treatment  in  suitable  cases. 

Rectal  Prolapse. 

A  certain  tendency  to  eversion  of  the  mucous  membrane  of  the 
bowel  is  a  constant  and  normal  accompaniment  of  the  act  of 
defalcation  ;  if,  however,  this  becomes  abnormally  increased,  the 
condition  may  be  maintained  after  the  evacuation  of  the  bowels 
is  concluded,  constituting  a  condition  of  prolapse.  At  first  only 
the  mucous  membrane  is  protruded,  and  this  is  known  as  an 
incomplete  prolapse  ;  if,  however,  the  condition  persists,  the  whole 
thickness  of  the  bowel  may  become  involved,  mucous  membrane, 
submucosa,  and  even  the  muscular  and  serous  coats,  giving  rise 
to  the  complete  variety  (Fig.  369).  The  former  condition  (some- 
times badly  termed  a  prolapsus  ani)  is  more  commonly  met  with 
in  adults,  and  the  latter  (the  so-called  prolapsus  recti)  in  children  ; 
but  it  must  be  understood  that  the  latter  is  always  preceded  by 
an  incomplete  stage,  limited  to  the  mucous  membrane,  and  that 
in  adults  complete  prolapse  is  occasionally  observed. 

Causes. —  1.  It  may  be  produced  by  a  simple  relaxation  of  the 
tissues,  as  met  with  in  weakly  individuals,  and  those  who  have 
been  much  exposed  to  the  debilitating  effects  of  residence  in 
tropical  climates,  especially  when  chronic  constipation  or  diarrhoea 
has  caused  the  evacuation  of  the  bowels  to  be  accompanied  by 
straining:  efforts.    2.  Conditions  which  have  led  to  chronic  tenesmus 


1048 


A   MANUAL  OF  SURGERY 


or  violent  expulsive  efforts,  e.g.,  piles,  chronic  constipation,  diar- 
rhoea, rectal  irritation,  as  from  worms  in  children,  or  diseases  of 
neighbouring  organs,  such  as  vesical  calculus,  stricture,  enlarged 
prostate,  may  also  determine  prolapse. 

Symptoms  and  Diagnosis. —  The  anal  orifice  is  occupied  by  a 
smooth  rounded  swelling,  red  or  purplish  in  colour,  covered  by 
mucous  membrane ;  this  protrusion  in  the  early  stages  can  be 
easily  replaced  by  a  little  pressure,  but  returns  if  the  patient 
strains  or  coughs.  When  the  swelling  is  of  large  size,  reduc- 
tion is  increasingly  difficult  and  painful  from  infiltration  and 
fibrous  overgrowth  of  the  submucosa,  and  it  is  very  liable  to 
become  inflamed  and  ulcerated  from  friction.  Incontinence  of 
faeces  is  also  a  common  result.  When 
the  whole  thickness  of  the  gut  is 
protruded,  the  serous  lining  may 
accompany  the  tumour,  but  is  usually 
limited  to  the  anterior  surface,  and 
into  the  sac  thus  formed  small  intes- 
tine may  pass,  and  even  become 
strangulated  (Fig.  370,  X).  The 
prolapse  itself  may  also  be  con- 
stricted if  allowed  to  remain  for 
long  unreduced ;  the  mass  is  then 
livid,  swollen,  and  intensely  painful, 
and  if  left  to  itself  may  slough  away, 
and  thus  lead  to  a  spontaneous  cure, 
although  severe  septic  symptoms 
may  supervene,  and  even  perforative 
peritonitis. 

There  should  be  but  little  difficulty 
in   recognising  a  prolapse  ;    the  only    x  jndicates  the  serous  sac  in  the 
condition  for  which  it  can  be  mistaken       anterior  wall  due  to  protrusion 
is  an  intussusception  protruding  from       of  the  peritoneum, 
the  anus ;  in  such,  however,  the  finger 

or  a  probe  can  be  inserted  into  the  rectum  by  the  side  of  the  pro- 
truding gut,  which  is  impossible  with  a  prolapse. 

Treatment.  —  In  the  earlier  stages,  all  that  is  needed  "is  the 
removal,  if  possible,  of  the  cause  of  the  tenesmus,  e.g.,  dilata- 
tion of  a  urethral  stricture,  removal  of  a  vesical  calculus,  or  the 
regulation  of  the  bowels  so  as  to  check  either  chronic  diarrhoea 
or  constipation.  When  piles  are  present,  they  should  be  treated 
as  described  above,  and  the  prolapse  will,  as  a  rule,  subsequently 
disappear.  Thread -worms  must  be  dealt  with  by  suitable  means 
(q.v.).  Beyond  this,  cold  or  astringent  injections  may  be  employed, 
e.g.,  sulphate  of  iron  (1  to  3  grains  to  1  ounce),  and  it  is  advisable 
for  the  individual  to  acquire  the  habit  of  having  the  daily  motion 
at  bedtime,  whilst  children  are  made  to  defalcate  lying  on  the 
side,  one  buttock  being  pulled  up  for  the  purpose.     The  prolapse 


Fig.  370. — Longitudinal  Sec- 
tion of  Complete  Prolapsus 
Recti.     (Tillmanns.) 


RECTUM  AND  ANUS  1049 


is  carefully  washed,  reduced  by  pressure  with  the  fingers,  and 
retained  by  strapping  the  nates  together,  particularly  in  children, 
or  by  applying  some  suitable  pad  and  a  T-bandage.  The  great 
hope  of  obtaining  a  cure  in  this  way  consists,  in  never  allowing 
the  prolapse  to  remain  unreduced  for  any  length  of  time. 

When  such  palliative  measures  fail,  Operative  Treatment  must 
be  undertaken. 

In  the  slighter  cases  of  incomplete  prolapse,  it  will  suffice  to 
diminish  the  size  of  the  anal  orifice  by  snipping  away  ladiating 
folds  of  skin  and  mucous  membrane,  and  allowing  the  wounds 
thus  produced  to  cicatrize.  In  the  worse  cases  it  may  be  neces- 
sary, in  addition,  to  remove  strips  of  the  mucous  membrane  in  a 
longitudinal  direction  by  means  of  the  clamp  and  cautery ;  or  a 
larger  area  of  the  posterior  wall  of  the  prolapse  may  be  denuded 
of  its  mucous  covering,  and  the  edges  brought  together  by  deep 
stitches.  Where  such  has  failed,  or  is  thought  undesirable,  the 
prolapse  may  be  dissected  away  by  incising  the  circumference  of 
the  anal  orifice  at  the  junction  of  the  skin  and  mucous  membrane, 
and  turning  down  the  outer  layer  of  the  mucous  coat  like  a  cuff. 
A  finger  inserted  in  the  bowel  suffices  to  draw  down  all  the  slack 
inner  lining,  and  to  ascertain  that  nothing  is  present  but  the 
mucous  membrane.  The  whole  of  the  prolapsed  portion  is  re- 
moved by  scissors,  all  bleeding-points  being  secured  as  divided ; 
the  upper  edge  of  the  mucous  membrane  is  then  united  by  suture 
to  the  cutaneous  margin  of  the  anal  orifice. 

In  cases  of  total  prolapse  of  the  bowel  in  children,  nothing 
but  palliative  treatment  is  generally  necessary  ;  but  in  adults  a 
modification  of  the  above  described  operation  is  required.  The 
patient's  buttocks  are  well  raised,  so  as  to  prevent  any  protrusion 
of  intestine  if  the  peritoneal  cavity  is  opened.  The  base  of  the 
prolapse  is  divided  anteriorly  on  a  level  with  the  anus,  the  open- 
ing in  the  peritoneum  plugged  with  a  sponge,  and  the  remainder 
of  the  mass  removed  by  scissors,  bleeding-points  being  secured  as 
divided.  The  serous  cavity  is  then  carefully  closed  by  sutures, 
and  the  divided  end  of  the  bowel  united  to  the  skin  at  the  anus. 
No  motion  is  allowed  to  pass  for  a  week,  but  the  anal  orifice  and 
lower  gut  should  be  thoroughly  washed  out  twice  or  thrice  daily 
to  prevent  accumulation  of  septic  material.  Control  over  the 
bowel  is  usually  regained,  though  often  somewhat  slowly,  and  the 
after-treatment  is  likely  to  be  prolonged. 

In  obstinate  cases  where  the  prolapse  recurs  again  and  again 
after  operation,  the  sigmoid  flexure  should  be  cut  down  upon 
from  the  groin  and  anchored  by  sutures  to  the  abdominal  wall 
(colopcxy),  or  even  a  temporary  colotomy  performed. 


CHAPTER  XXXVI. 
SURGICAL  AFFECTIONS  OF  THE  KIDNEYS. 

Congenital  Affections  of  the  Kidney. — Many  different  malformations  and  dis- 
placements are  met  with  affecting  these  organs. 

The  chief  Malformations  are  as  follow  :  (a)  Complete  absence  of  one  organ, 
a  very  rare  condition,  and  (b)  congenital  atrophy  of  one  kidney,  it  being  repre- 
sented by  a  mass  of  fatty  tissue  :  in  both  cases  the  other  organ  is  correspond- 
ingly enlarged  and  hypertrophied.  (c)  The  kidneys  may  be  fused  together, 
either  constituting  one  large  organ  in  the  median  line,  and  more  or  less 
normal  in  shape,  or  sometimes  constituting  the  so-called  horseshoe-shaped 
variety,  the  convexity  being  directed  downwards,  (d)  Deep  lobulation  of 
the  kidney,  as  in  some  animals,  is  sometimes  seen,  especially  if  the  organ 
is  displaced  ;  occasionally  this  is  carried  to  such  an  extent  as  to  divide  it 
into  two  or  more  portions,  (e)  The  ureter  and  pelvis  may  be  double,  this 
malformation  affecting  the  pelvis  alone,  or  extending  as  far  as  the  bladder. 
(/)  The  renal  artery  may  arise  from  the  aorta  in  two  or  more  main  branches. 

The  majority  of  these  malformations  are  of  very  little  clinical  importance, 
except  in  the  operation  of  nephrectomy,  when  they  may  necessitate  a  slight 
modification  of  the  usual  proceedings. 

Congenital  Displacement  of  the  Kidney  occurs  about  once  in  every  thousand 
individuals,  the  organ  being  either  depressed,  so  as  to  lie  over  the  sacro-iliac 
synchondrosis  or  sacral  promontory,  or  raised  above  its  normal  position.  The 
left  kidney  is  more  frequently  affected  in  this  way  than  the  right,  and,  when 
lying  in  the  iliac  fossa,  the  descending  colon  is  usually  displaced  inwards,  so 
that  the  rectum  starts  to  the  right  of  the  middle  line.  The  adrenal  bodies 
retain  their  normal  position,  and  do  not  move  with  the  kidney. 

Cystic  disease,  sarcoma,  and  hydronephrosis  may  also  occur  congenitally, 
and  will  in  turn  be  described  below. 

Floating  and  Moveable  Kidney. — The  term  Floating  Kidney  has 
been  applied  to  a  supposed  congenital  condition  in  which  the  organ 
is  attached  to  the  posterior  abdominal  wall  by  a  meso-nephron  or 
peritoneal  ligament ;  it  is,  however,  more  than  doubtful  whether 
such  an  abnormality  really  exists.  By  Moveable  Kidney  is 
meant  an  acquired  condition  in  which  the  kidney  moves  within 
the  perinephric  fatty  tissue,  which  forms  a  loose  capsule  around 
it.  It  occurs  more  frequently  in  women  than  in  men,  and  more 
often  on  the  right  than  on  the  left  side,  partly  because  the  renal 
vessels  are  longer  on  this  side  than  on  the  other,  and  partly 
because  the  descending  colon  is  more  fixed  than  the  ascending. 

Causes. — Parturition  accounts  for  many  cases  ;  firstly,  because 
of  the  sudden  diminution  of   the  intra-abdominal  pressure,  and 


SURGICAL   AFFECTIONS  OF  THE  KIDNEYS  1051 

secondly,  owing  to  the  resulting  pendulous  and  relaxed  state  of 
the  abdominal  muscles,  especially  if  the  patient  too  early  resumes 
the  erect  posture,  or  undertakes  physical  work  without  efficient 
external  support ;  hence  it  is  more  frequent  among  the  poor  than 
amongst  the  rich.  It  may  also  follow  the  removal  of  large 
abdominal  tumours  or  rapid  emaciation,  whilst  tight-lacing  or 
traumatic  influences  may  be  responsible  for  some  cases.  It  is 
frequently  associated  with  that  form  of  displacement  downwards 
of  the  abdominal  viscera  which  is  known  as  Glenard's  disease, 
or  enteroptosis.  This  is  perhaps  due  to  accumulation  of  faeces 
in  the  transverse  colon,  whereby  the  lesser  omentum  and  other 
peritoneal  ligaments  become  stretched,  and  in  consequence  the 
intestines,  stomach,  and  even  the  liver  may  slip  downwards  and 
become  moveable.  The  right  kidney  participates  freely  in  this 
displacement. 

The  Symptoms  arising  from  a  moveable  kidney  consist  chiefly 
in  pain  referred  to  the  back,  or  perhaps  shooting  along  the  ureter 
to  the  groin,  testis  or  labium  majus  ;  it  is  increased  by  pressure  on 
or  manipulation  of  the  abdomen.  Vomiting  is  a  significant  sign, 
and  the  surgeon  should  never  omit  to  examine  the  loins  in  cases 
of  obstinate  vomiting  with  no  apparent  cause.  Periodical  exacer- 
bations of  these  symptoms,  with  a  temporary  diminution  in  the 
amount  of  urine,  result  from  kinking  of  the  ureter  ;  sudden  relief, 
followed  by  an  increased  flow  of  urine  possibly  containing  some 
muco-pir ,  indicates  that  the  organ  has  returned  to  its  normal 
situation.  On  examining  the  abdomen,  a  moveable  tumour  can 
often  be  observed  with  ease  if  the  abdominal  parietes  are  not 
loaded  with  fat,  and  on  manipulation  pain  and  vomiting  may  be 
induced.  If  the  patient  is  lying  in  the  prone  position  on  a  flat 
couch,  a  distinct  loss  of  resistance  is  noticed  external  to  the 
erector  spinas  on  the  affected  side. 

Treatment  consists  in  wearing  an  abdominal  belt,  suitably 
padded,  or  in  the  operation  of  nephrorrhaphy  (p.  1071). 

Injuries  of  the  Kidney  are  usually  due  to  crushes  of  the  body, 
as  between  the  buffers  of  railway  cars,  or  when  a  cart  passes 
over  the  abdomen,  or  from  blows  or  falls.  Considerable  haemor- 
rhage follows,  both  into  the  substance  of  the  kidney  or  its  pelvis, 
and  into  the  perinephric  fatty  tissue,  and  this  even  when  the 
capsule  has  not  been  torn.  The  integrity  of  this  structure  is  a 
point  of  great  importance,  since  it  limits  to  some  extent  the 
bleeding  and  prevents  urinary  extravasation  ;  the  kidney  may 
be  crushed  to  a  pulp  without  any  external  haemorrhage,  and 
under  these  circumstances  clots  are  likely  to  pass  down  the 
ureter,  and  may  obstruct  it  and  lead  to  its  subsequent  occlusion. 
When  the  anterior  portion  of  the  capsule  is  torn,  the  peritoneum 
may  also  be  involved,  and  then  evidences  of  intraperitoneal 
bleeding  may  manifest  themselves,  and,  indeed,  if  the  kidney  is 


1052  A   MANUAL  OF  SURGERY 


extensively  lacerated,  fatal  haemorrhage  may  result,  though  this 
is  unusual.  Rupture  of  the  posterior  surface  of  the  kidney  opens 
up  the  retroperitoneal  cellular  tissue,  which  becomes  infiltrated 
with  blood  and  urine,  and  suppuration  is  almost  certain  to  follow, 
resulting  in  pyaemia  or  at  a  later  date  in  exhaustion  from  chronic 
septic  poisoning. 

The  Symptoms  produced  consist  in  severe  shock,  combined 
with  pain  in  the  loin,  shooting  down  into  the  testis  or  thigh,  and 
increased  frequency  of  micturition,  the  urine  voided  being  usually 
mixed  with  blood.  The  amount  of  blood  lost  in  this  way  varies 
considerably;  in  the  slighter  cases  the  haematuria  is  of  short 
duration,  but  in  more  extensive  lesions  it  may  be  severe  and 
so  persistent  as  to  threaten  life.  The  passage  of  clots  down  the 
ureter  gives  rise  to  renal  colic,  and  obstruction  of  that  duct  may 
lead  to  total  suppression  of  the  secretion  on  the  affected  side. 
The  bladder  may  in  some  cases  become  greatly  distended  with 
clots,  the  blood  coagulating  after  it  has  entered  the  viscus. 
Haemorrhage  into  the  perinephric  tissues  is  indicated  by  the 
formation  of  a  swelling  in  the  loin,  and  laceration  of  the  peri- 
toneum is  shown  by  distension  of  the  abdomen  and  the  existence 
of  fluid  within  it.  The  development  of  a  perinephritic  abscess  is 
recognised  by  fever,  rigors,  increased  pain  in  the  loin,  and  the 
usual  phenomena  of  deep  suppuration. 

The  Treatment  usually  required  is  to  keep  the  patient  quiet  in 
bed,  with  an  icebag  applied  to  the  loin  ;  pain  may  be  relieved  by 
strapping  the  side  or  by  applying  a  firm  bandage.  Persistent 
haemorrhage  necessitates  the  administration  of  ergot,  tannic  acid,  or 
turpentine  ;  but  if  it  is  threatening  the  patient's  life,  an  exploratory 
incision  is  required,  and,  if  need  be,  removal  of  the  organ,  although 
it  is  sometimes  possible  to  stitch  up  a  limited  rent.  Any  disten- 
sion of  the  bladder  must  be  relieved,  the  clots  being  washed  out 
through  a  large-eyed  catheter.  The  occurrence  of  peritonitis  or 
of  a  perinephritic  abscess  will  call  for  suitable  surgical  measures, 
the  injured  viscus  being  dealt  with  according  to  circumstances. 

Rupture  of  the  Ureter  is  a  rare  accident,  usually  due  to  direct 
violence,  but  occasionally  happening  during  pelvic  operations, 
such  as  removal  of  the  uterus.  When  due  to  a  subcutaneous 
injury,  it  cannot  be  recognised  at  once,  but  extravasation  of  urine 
takes  place,  resulting  in  the  formation  of  a  perinephritic  abscess. 
This  is  incised  sooner  or  later,  and  on  exploring  the  cavity  it  may 
be  possible  to  detect  the  rent  in  the  ureter,  but  more  frequently  its 
situation  cannot  be  found,  and  then  a  doubt  will  necessarily  exist 
as  to  whether  the  lesion  involves  the  ureter  or  the  pelvis  of  the 
kidney.  In  either  case  a  urinary  fistula  in  the  loin  results,  which 
may  possibly  close  after  a  time  ;  if  the  fistula  persists,  nephrectomy 
will  be  required,  and  then  the  sooner  such  an  operation  is  under- 
taken the  better.  In  a  few  favourable  cases  it  has  been  possible 
to  suture  the  rent  in  the  ureter  by  the  following  plan  :    the  lower 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1053 

end  of  the  divided  ureter  is  closed,  the  exposed  mucous  membrane 
being  tucked  in  by  sutures  passing  through  the  muscular  coat ; 
the  upper  end  is  then  implanted  into  a  longitudinal  opening  made  in 
the  side  of  the  lower  segment,  and  accurately  stitched  in  position. 

We  have  recently  had  two  cases  probably  of  this  nature  under  treatment  at 
hospital.  Both  occurred  in  young  boys,  and  both  were  due  to  cab  accidents. 
In  the  first,  after  the  preliminary  shock  had  passed  off,  nothing  special  was 
noted  for  about  ten  days,  when  on  sitting  up  sharp  pain  was  experienced  in 
the  side,  and  this  was  followed  by  a  retroperitoneal  collection  of  fluid  together 
with  some  amount  of  fever.  On  incision  a  large  quantity  of  limpid  urine 
escaped,  with  but  very  little  pus — an  interesting  illustra'ion  of  the  fact  that 
healthy  urine  does  comparatively  little  damage  to  tissues  into  which  it  is 
extravasated.  The  finger  introduced  into  the  wound  passed  beyond  the 
middle  line,  and  the  ureter  could  be  felt  traversing  the  cavity ;  but  the  rent 
could  not  be  found.  Drainage  was  provided,  and  for  a  time  a  urinary  fistula 
persisted  ;  finally,  the  wound  healed  completely.  In  the  second  case  the 
inflammatory  phenomena  were  more  marked,  but  an  incision  was  not  made 
until  the  twelfth  day  ;  here  also  the  lesion  could  not  be  found,  and  drainage 
was  resorted  to,  but  without  avail,  nephrectomy  being  subsequently  required. 
Both  cases  recovered. 

Hydronephrosis  is  a  condition  characterized  by  distension  of 
the  pelvis  and  calyces  with  urine,  as  a  result  of  some  obstruction 
to  its  exit. 

Causes. — (i.)  It  may  be,  though  very  rarely,  congenital  in  origin. 
It  must  be  borne  in  mind  that  the  body  of  the  kidney  is  developed 
from  the  metanephros,  and  that  the  ureter  unites  subsequently 
with  it  to  form  its  excretory  duct ;  such  union  is  occasionally 
defective  at  the  upper  end,  well-marked  obstruction  occurring  at 
the  junction  of  the  ureter  with  the  infundibulum  of  the  pelvis. 
Similar  trouble  sometimes  arises  from  the  ureter  becoming  kinked 
over  an  abnormally  placed  renal  artery.  It  is,  however,  more 
frequently  due  to  an  impervious  condition  of  the  urethra  or  to  the 
existence  of  a  membranous  septum  therein  ;  both  kidneys  are 
then  necessarily  affected.  The  amount  of  distension  in  some  of 
these  cases  is  such  as  to  interfere  seriously  with  parturition  until 
the  abdomen  has  been  tapped.  The  infants  are  often  born  dead, 
or  succumb  shortly  after  birth,  (ii.)  Acquired  forms  of  obstruction 
are  by  no  means  uncommon,  and  may  be  arranged  under  the 
following  headings  :  (a)  Blocks  within  the  urinary  passages  from 
the  presence  of  stenes,  parasites,  foreign  bodies,  or  even  blood-clot ; 
(b)  changes  of  structure  affecting  the  walls  of  the  urinary  passages, 
e.g.,  inflammatory  swelling  of  the  mucosa,  cicatrices,  stenosis,  or 
tumours ;  (c)  kinking  of  the  ureter  in  cases  of  floating  kidney ; 
and  (d)  the  pressure  of  extrinsic  tumours  or  cicatrices,  as  after 
pelvic  cellulitis.  Hydronephrosis  may  be  unilateral  or  bilateral ; 
in  the  former  case  the  obstruction  arises  within  the  ureter,  or 
from  some  vesical  condition  involving  its  entrance  into  the 
bladder  ;  in  the  latter  case  the  cause  is  generally  to  be  looked  for 
below  this  spot. 

It  must  be  clearly  understood  that  a  sudden  and  absolute  block 


io54 


A   MANUAL  OF  SURGERY 


never  leads  to  hydronephrosis.  Should  it  occur  as  the  result  of 
impaction  of  a  calculus  in  one  of  the  ureters,  the  secretion  on  that 
side  is  totally  suppressed  as  soon  as  the  tension  within  the  pelvis 
and  calyces  is  sufficiently  high.  Should,  however,  the  obstruction 
he  intermittent  or  incomplete,  so  that  some  of  the  urine  escapes, 
thereby  relieving  the  pressure,  hydronephrosis  develops.  Sudden 
and  complete  occlusion  of  the  urethra  likewise  results  in  dilatation 
of  the  bladder  and  rupture  either  of  that  viscus  or  of  the  urethra, 
whilst  a  gradually  increasing  obstruction  is  always  likely  to  lead 
to  hydronephrosis. 

Pathological  History. — The  earliest  result  of  obstruction  to  the 
flow  of  urine  consists  in  dilatation  of  the  ureter  and  pelvis,  which 
is  soon  followed  by  expansion  of  the  calyces.  The  pyramids 
are  flattened,  and  the  cortex  expanded  and  thinned,  so  that  the 
whole  kidney  looks  larger 
than  usual.  A  certain  amount 
of  interstitial  infiltration  of 
the  cortex  is  always  present ; 
the  urine  secreted  in  the 
early  stages  is  usually  abun- 
dant and  of  a  low  specific 
gravity. 

If  the  obstruction  con- 
tinues, the  renal  tissue 
becomes  more  and  more 
atrophied,  until  finally  it  dis- 
appears entirely,  the  kidney 
being  represented  by  a  thin- 
walled  multilocular  cyst.  At 
any  stage  septic  phenomena 
may  supervene,  giving  rise 
to  pyonephrosis  {vide  infra). 

The  Clinical  History  varies 
considerably  with  the  method 
of  onset  and  the  cause  of  the 
trouble.  Frequently  all  that 
happens  is  a  painless  en- 
largement of  the  affected  organ ;  if  both  are  involved,  there 
may  be  at  first  some  increase  in  the  amount  of  urine  secreted, 
which  is  pale,  limpid,  and  of  a  low  specific  gravity ;  after  a 
time  the  quantity  diminishes,  and  finally  anuria  and  uraemia 
follow,  especially  if  septic  changes  supervene,  as  is  so  commonly 
the  case.  When  only  one  kidney  is  affected,  the  excretion 
may  remain  normal  in  quantity  and  quality,  owing  to  compen- 
satory hypertrophy  of  its  fellow.  Not  unfrequently  a  fluctuating 
swelling  of  considerable  size  is  produced  by  hydronephrosis ; 
it  presents  all  the  physical  signs  of  a  renal  tumour  (p.  1065), 
and    its    formation    is    often    associated    with     pain,    vomiting, 


Fig.    371. — Hydronephrosis.      (From 
Specimen     in     Bristol     Hospital 

Museum.) 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1055 


and  increased  frequency  of  micturition.  Finally,  a  perinephritic 
abscess  may  develop,  owing  to  ulceration  of  the  pelvis  or  ureter, 
and  the  cyst  may  thus  discharge  through  the  loin.  Occasionally 
the  size  of  the  tumour  varies  considerably  from  time  to  time, 
owing  to  the  obstruction  being  temporarily  overcome  by  the 
pressure  of  retained  urine  behind  it. 

The  Treatment  of  hydronephrosis  should  in  the  first  place  be 
directed  to  removal  of  the  cause,  if  practicable,  and  where  the 
obstruction  exists  in  the  prostate  or  urethra,  no  other  treatment 
is  feasible.  In  some  cases  of  congenital  hydronephrosis  due  to 
malformation  of  the  upper  end  of  the  ureter,  it  is  possible  to 
transplant  it  and  thereby  relieve  the  obstruction.  Unilateral 
hydronephrosis  must  be  dealt  with  by  aspiration  as  a  temporary 
measure  ;  but  this  is  rarely  satisfactory,  and  usually  needs  to  be 
followed  by  an  exploratory  incision  (nephrotomy),  by  means  of 
which  it  may  be  possible  in  a  few  cases  to  reach  and  deal  with 
the  obstruction.  In  the  majority,  however,  the  block  is  situated 
so  low  down  that  it  cannot  be  reached,  and  nephrectomy  must 
then  be  undertaken. 

Inflammation  of  the  Kidney  and  its  Surroundings.  —  It  is  un- 
necessary to  discuss  the  many  varieties  of  inflammation  of  the 
kidney  ;  they  are  dealt  with  in  medical  text-books.  The  following 
conditions  are,  however,  of  surgical  importance  : 

1.  Pyelitis  is  the  term  applied  to  an  inflammation  involving 
the  pelvis  of  the  kidney,  the  calyces,  and  perhaps  the  ureter.  The 
chief  causes  from  which  it  arises  are  :  (a)  The  presence  of  a 
calculus,  or  the  passage  of  uric  acid  crystals  in  gouty  individuals  ; 
(b)  tuberculous  disease,  either  starting  primarily  in  the  kidney," 
or  extending  upwards  from  the  bladder  ;  (c)  extension  of  septic 
inflammation  from  the  bladder  and  urethra  ;  (d)  malignant  disease 
of  the  kidney  ;  (e)  occasionally  in  floating  or  moveable  kidney ; 
(/)  the  ingestion  of  irritating  drugs,  e.g.,  cantharides,  turpentine, 
and  occasionally  cubebs  or  copaiba ;  (g)  the  presence  of  foreign 
bodies,  such  as  needles,  bullets,  and  parasites,  e.g.,  the  Bilharzia 
hamatobia  or  the  Stvongylns  gigas ;  (h)  a  pyaemic  embolus  ;  and 
(i)  possibly  cold. 

Whatever  the  cause,  the  pathological  phenomena  are  the  same, 
consisting  in  the  lining  membrane  becoming  congested  and 
thickened,  and  secreting  a  muco-purulent,  or  even  purulent,  dis- 
charge. Owing  to  the  swelling  of  the  mucous  membrane,  the 
entrance  to  the  ureter  is  encroached  on,  and  a  certain  amount  of 
distension  of  the  pelvis  and  calyces  (hydronephrosis)  follows. 
Where  micro-organisms  are  present,  as  in  cases  due  to  extension 
from  the  bladder,  the  kidney  is  likely  to  be  involved  in  the  process 
(pyelonephritis),  or  the  condition  may  be  followed  by  a  urinary 
abscess  in  the  loin  or  suppurative  perinephritis. 

The  Symptoms  of  pyelitis  consist  of  pain  and  tenderness  over 


1056  A   MANUAL  OF  SURGERY 


the  affected  kidney,  increased  frequency  of  micturition,  and  the 
intermittent  discharge  of  pus  in  acid  urine.  The  intermissions  are 
due  to  the  inflammatory  swelling  of  the  mucous  membrane,  which 
temporarily  blocks  the  upper  entrance  to  the  ureter,  and  necessi- 
tates a  certain  degree  of  pressure  of  the  urine  and  pus  accumulated 
in  the  pelvis  of  the  kidney  in  order  to  overcome  the  obstruction. 
Necessarily,  where  pyelitis  follows  chronic  cystitis,  the  acid  re- 
action of  the  urine  is  neutralized  by  the  changes  occurring  in  the 
bladder ;  in  such  cases  a  nocturnal  elevation  of  temperature  is 
usually  noted. 

The  Treatment  of  pyelitis  is  mainly  directed  to  the  cause. 
Where  such  is  removable,  e.g.,  calculus  or  foreign  bodies,  an 
operation  is  advisable.  In  septic  cases  originating  in  the  bladder, 
treatment  should  first  be  directed  towards  the  latter  viscus.  If 
no  cause  is  evident,  the  patient  is  kept  warm,  his  diet  restricted 
to  the  simplest  solids  and  bland  fluids,  ana  salol,  alkalies,  and 
sedatives  prescribed.  If  these  measures  fail,  the  affected  kidney 
should  be  explored. 

2.  Pyelonephritis,  or  inflammation  of  the  pelvis  of  the  kidney 
together  with  the  renal  parenchyma,  is  almost  invariably  suppura- 
tive in  type  and  commonly  due  to  extension  upwards  from  the 
lower  urinary  organs,  constituting  the  chief  element  in  the  more 
serious  cases  of  what  used  to  be  badly  termed  '  surgical  kidney.' 

This  condition  may  supervene  suddenly  and  with  acute  symp- 
toms, and  then  probably  results  from  some  surgical  operation  or 
simply  from  catheterism  in  a  patient  whose  bladder  is  in  a  highly 
septic  condition.  The  organisms  find  their  way  upwards  along 
the  lymphatics  in  the  mucous  lining  of  the  ureters,  and  soon  infect 
the  pelvis,  giving  rise  to  a  suppurative  pyelitis  ;  the  walls  of  the 
ureters  may  in  such  cases  be  studded  with  miliary  abscesses. 
The  presence  of  septic  matter  in  the  pelvis  always  lights  up  a 
certain  amount  of  irritation  in  the  renal  substance,  constituting  a 
subacute  interstitial  nephritis  ;  but  in  addition  to  this  bacteria 
invade  the  pyramids  and  travel  upwards  along  the  lymphatics  or 
the  renal  tubules,  giving  rise  to  abscesses,  either  scattered  through 
the  connective  tissue  of  the  organ  or  within  its  tubules,  in  either 
case  seriously  damaging  its  excretory  function.  In  both  in- 
stances it  is  possible  for  many  of  these  minute  foci  of  pus  to  run 
together  and  form  a  large  collection,  which  in  time  becomes 
recognisable  from  outside ;  but  more  usually  the  patient  dies  of 
toxaemia  or  uraemia  before  that  stage  is  reached.  Sometimes  the 
condition  develops  more  chronically,  and  then  the  phenomena  of 
pyonephrosis  are  more  prominent. 

The  Clinical  History  of  pyelonephritis  is  a  little  vague.  In 
acute  cases  the  symptoms  probably  commence  with  a  severe  rigor 
shortly  after  the  operation  which  has  called  the  trouble  into 
existence.  This  is  associated  with  pain  in  the  loins  or  back, 
headache,  vomiting,  and  probably  some  amount  of   drowsiness, 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1057 

perhaps  passing  into  a  condition  of  coma.  The  rigor  may  be 
repeated,  or  the  fever  may  remain  high  without  exacerbations. 
The  urine  is  usually  diminished  in  amount,  and,  indeed,  may  be 
suppressed  entirely  ;  if  any  passes,  it  is  high-coloured  and  contains 
albumen  and  perhaps  blood,  together  with  some  amount  of  pus, 
which  is  probably  derived  largely  from  the  lower  portion  of  the 
urinary  track.  The  prognosis  in  these  cases  is  nearly  hopeless, 
the  patient  being  almost  certain  to  die  of  uraemia,  especially  as 
both  kidneys  are  generally  affected,  although  in  the  more  chronic 
type,  if  the  cause  of  obstruction  is  removed,  he  may  recover. 

Treatment. — The  cause  of  the  affection  in  the  lower  urinary 
passages  must  be  attended  to ;  septic  urine  is  drawn  off,  and  if 
need  be  the  bladder  washed  out ;  all  causes  of  obstruction  must 
also  be  removed,  if  practicable.  The  patient  is,  of  course,  kept  in 
bed  ;  the  loins  are  cupped  or  fomented  ;  the  patient  is  encouraged 
to  drink  plenty  of  bland  fluid,  whilst  stimulants  are,  if  possible, 
avoided  entirely,  as  also  opium.  When  the  temperature  remains 
high,  quinine  is  administered. 

3.  Pyonephrosis  is  the  name  applied  to  a  distension  of  the  pelvis 
of  the  kidney  when  associated  with  suppurative  pyelitis.  It  is 
always  secondary,  either  to  pyelitis  or  to  hydronephrosis.  In  the 
former  case,  the  inflammation  of  the  ureter  causes  partial  obstruc- 
tion to  the  flow  of  urine,  and  hence  leads  to  dilatation  ;  in  the 
latter,  suppuration  extends  to  the  previously  dilated  pelvis  from 
the  bladder,  or  as  a  result  of  the  local  cause.  It  is  always  asso- 
ciated with  a  certain  amount  of  pyelonephritis,  from  which  indeed 
it  is  only  distinguished  by  the  greater  degree  of  dilatation. 

Pathological  Conditions. — The  lining  membrane  of  the  pelvis 
is  inflamed,  thickened,  and  perhaps  ulcerated.  A  considerable 
quantity  of  decomposing  urine,  mixed  with  muco-pus,  is  always 
present  in  the  dilated  pelvis  and  calyces,  and  rugged  calculi  or 
tuberculous  masses  may  also  be  found,  giving  rise  to  a  chronic  or 
subacute  interstitial  nephritis,  which  may  run  on  to  suppuration. 
A  certain  amount  of  perinephritis  is  always  associated  with  this 
condition. 

Clinical  Signs. — The  kidney  is  found  to  be  enlarged  and  tender 
on  palpation,  whilst  more  or  less  constant  pain  is  present  in  the 
loin.  The  temperature  is  usually  somewhat  raised,  especially 
at  night,  from  the  absorption  of  septic  products ;  the  patient 
steadily  loses  ground,  and  becomes  emaciated ;  the  tongue  is 
dry,  the  appetite  diminished,  and  nausea  is  sometimes  present. 
The  urine  is  usually  scanty  in  amount,  and  loaded  with  muco-pus, 
which  may  be  constant  or  intermittent.  If  both  kidneys  are 
involved,  the  excretion  of  urine  gradually  diminishes,  leading  to 
a  fatal  issue  from  uraemia,  unless  the  patient  dies  previously  from 
toxaemia  or  pyaemia. 

Treatment. — Where  both  kidneys  are  involved  as  a  result  of 
some  urethral  or  prostatic  affection,  no  special  treatment  directed 

67 


1058  A   MANUAL  OF  SURGERY 

to  the  kidneys  is  feasible ;  but  if  the  condition  is  unilateral,  and 
not  secondary  to  disease  of  the  lower  urinary  organs,  nephrotomy 
should  be  undertaken,  and  any  removable  cause  dealt  with. 
Failing  this,  the  cavity  may  be  drained,  or  even  nephrectomy 
performed. 

4.  Abscess  in  the  Kidney  may  follow  any  of  the  conditions 
already  alluded  to,  in  which  bacteria  gain  access  to  the  organ  from 
below.  It  also  occurs  in  connection  with  pyaemia  and  after  the 
general  infective  fevers,  being  then  more  or  less  of  a  pyaemic  type. 
In  acute  interstitial  nephritis  the  abscesses  are  multiple  and  at 
first  small,  being  located  between  the  tubules  or  sometimes  within 
them  ;  the  pyramids  then  have  a  streaky  white  appearance  due 
to  their  infiltration  with  pus,  and  the  abscesses  form  in  the 
cortical  substance  at  their  base.  Larger  collections  are  caused 
by  the  amalgamation  of  several  of  the  smaller.  In  pyaemia  the 
abscesses  are  preceded  by  infarcts  which  appear  immediately 
beneath  the  capsule  as  wedge-shaped  areas  of  a  chocolate  colour, 
which  turns  to  yellowish  white  as  suppuration  occurs.  Symptoms 
are  not  produced  unless  the  abscess  is  large  enough  to  be  detected 
from  outside ;  the  mere  presence  of  pus  in  the  urine  associated 
with  an  enlarged  and  tender  kidney  is  not  sufficient  evidence  of 
abscess  formation.  When  the  collection  is  large  enough,  the 
organ  can  be  distinctly  felt,  and  perhaps  fluctuation  detected. 
Possibly  pyuria  is  absent,  but  a  perinephritic  abscess  is  very 
likely  to  form.  Treatment  of  an  abscess  of  the  kidney  consists 
in  nephrotomy  for  drainage  purposes,  or  perhaps  nephrectomy. 

The  more  chronic  varieties  are  probably  tuberculous  in  origin, 
and  may  then  attain  considerable  dimensions,  all  that  is  noted 
being  the  lumbar  swelling,  whilst  pyuria  is  not  necessarily 
present. 

5.  Perinephritis  cannot  be  recognised  unless  suppurative  in 
nature,  resulting  either  from  septic  wounds  or  from  ulceration 
involving  the  walls  of  the  pelvis  and  calyces,  or  from  the  trans- 
mission of  micro-organisms  from  the  interior  of  a  suppurating 
kidney  or  pelvis  without  any  breach  of  surface.  A  perinephritic 
abscess  may  also  arise  from  inflammation  spreading  from  the 
intestine,  pleural  cavity,  ribs,  or  elsewhere. 

The  Symptoms  may  be  acute  or  chronic  in  nature.  In  acute 
perinephritis,  signs  of  deep  suppuration  in  the  loin  are  produced, 
viz.,  an  indurated  painful  swelling,  associated  with  fever,  and 
perhaps  preceded  by  rigors.  Fluctuation  may  sometimes  be 
detected  when  pus  has  formed,  but  the  abscess  is  often  so  deeply 
placed  that  it  is  difficult  to  recognise  it  at  first ;  it  tends  to  point 
at  the  side  of  the  erector  spinae,  or  may  burrow  forwards  between 
the  abdominal  muscles,  and  find  an  exit  on  the  anterior  abdominal 
wall.  Occasionally  it  bursts  into  the  peritoneal  or  pleural  cavities, 
or  into  the  intestine.  If  it  comes  to  the  surface,  it  is  preceded  by 
congestion  and  cedema  of  the  skin.     Chronic  perinephritis  gives  rise 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS 


1059 


to  no  characteristic  symptoms  until  an  abscess  forms  which  is 
large  enough  to  be  felt. 

Treatment  in  each  case  consists  in  giving  exit  to  the  pus  through 
an  incision  at  the  outer  border  of  the  erector  spinae ;  the  cavity  is 
then  carefully  examined,  and  the  cause  of  the  suppuration,  if 
possible,  determined,  and  treated  according  to  the  requisites  of 
the  case. 


Tuberculous  Disease  of  the  Kidney  occurs  in  one  of  three 
forms,  (a)  It  may  arise  in  the  course  of  acute  general  tuber- 
culosis, when  miliary  tubercles  are  found  studding  the  organs, 
but  giving  rise  to  no  special  symptoms.  Treatment,  of  course,  is 
impracticable. 

(b)  It  may  extend  upwards  from  a  similar  affection  of  the  bladder, 
and  then  almost  invariably  involves  both  kidneys.     The  mucous 

membrane  of  the  ureter 
becomes  thickened  and 
transformed  into  (Edema- 
tous granulation  tissue 
containing  tubercles,  and 
that  of  the  pelvis  and 
calyces  is  similarly 
affected ;  finally,  the  renal 
parenchyma  itself  be- 
comes infiltrated  with 
tuberculous  tissue  spread- 
ing from  the  pyramids. 
Clinically,  enlargement  of 
both  kidneys  is  noticed, 
arising  partly  from  the 
deposit  of  tubercle  within 
the  organ  and  partly  from 
the  obstruction  within  the 
ureter.  The  symptoms 
caused  by  the  renal  mis- 
chief cannot  at  first  be 
distinguished  from  those 
due  to  the  vesical  trouble. 
Fig.   372.  — Tuberculous    Kidney,    showing  perinephritic   abscess 

Thickening    of     Mucous    Membrane     of  ,,      r  n  j 

Pelvis  and  Ureter.     (From   Specimen  in  occasionally  follows,  and 
College  of  Surgeons'  Museum.)  the  patient  dies  from  ex- 

haustion,   septic    absorp- 
tion, or  uraemia.     Treatment  in  these  cases  is  of  no  avail. 

(c)  Primary  Tuberculosis  of  the  kidney  is  generally  unilateral, 
and  commences  as  a  deposit  of  tubercle  in  the  cortex  or  at  the 
base  of  one  of  the  pyramids.  A  caseous  mass  forms,  which  may 
extend  widely,  causing  disintegration  of  the  kidney  substance,  or 
may  burst  into  the  pelvis  and  infect  that  cavity.     A  tuberculous 


A   MANUAL     OF  SURGERY 


pyonephrosis  follows,  and  the  process  spreads  for  some  distance 
down  the  ureter,  and  even  infects  the  bladder  (Fig.  372).  Sup- 
purative perinephritis  may  also  supervene,  and  give  rise  to  an 
abscess  which  bursts  externally. 

The  Symptoms  are  at  first  indefinite,  the  patient  complaining 
of  increased  frequency  of  micturition,  and  unilateral  pain  in  the 
loin,  neither  of  which  conditions  is  improved  by  rest,  remaining 
the  same  at  night  as  in  the  day.  The  pain  is  generally  of  an 
aching  character,  and  more  or  less  constant,  although  exacerba- 
tions may  occur.  The  urine  usually  contains  a  certain  propor- 
tion of  pus,  in  which  on  examination  the  Bac.  tuberculosis  can  often 
be  detected.  Hematuria  is  not  marked,  even  if  present  at  all. 
On  examination  the  kidney  may  be  found  to  be  slightly  enlarged, 
but  is  not  tender,  except  in  the  later  stages,  when  it  constitutes  a 
tumour  of  considerable  size,  and  may  contain  a  large  quantity 
of  pus. 

The  Diagnosis  of  primary  renal  tuberculosis  is  usually  a  matter 
of  doubt,  if  the  presence  of  bacilli  in  the  urine  cannot  be  demon- 
strated, since  the  symptoms  are  very  similar  to  those  of  renal 
calculus.  The  history  of  the  patient  and  of  his  family  may  be 
of  importance,  but  the  chief  points  of  distinction  are  that  the 
symptoms  are  less  influenced  by  exercise  or  rest,  and  there  is  less 
hematuria  or  renal  colic  than  when  a  calculus  is  present,  whilst 
the  kidney  is  usually  not  so  tender  on  manipulation ;  of  course, 
the  condition  is  much  less  common  than  that  of  stone.  In  doubtful 
cases  the  final  distinction  is  made  by  exploring  the  organ  through 
an  incision  in  the  loin.  The  tuberculous  kidney  is  usually  mottled 
in  colour  and  pallid -looking,  whilst  hard,  scattered,  caseous 
nodules  may  be  felt,  which  become  fluid  on  pressure,  or  on  in- 
cision give  exit  to  caseous  pus.  The  upper  part  of  the  ureter  is 
often  somewhat  thickened  and  indurated.  In  calculus  the  surface 
is  uniformly  even  and  dark  red,  or  if  any  areas  of  softening  are 
present,  they  are  of  a  bluish-red  colour ;  the  pelvis  and  upper  end 
of  the  ureter  are  usually  lax  and  distonded. 

Treatment. — If  on  exploration  of  the  kidney  the  disease  is  found 
to  be  strictly  limited  and  the  pelvis  unaffected,  it  may  be  possible 
to  treat  it  in  the  same  way  as  tuberculous  affections  elsewhere, 
viz.,  by  scraping  away  the  diseased  tissue,  careful  purification  of 
the  cavity  by  liquefied  carbolic  acid,  and  plugging  the  wound 
thus  formed.  In  other  cases  it  may  be  possible  to  excise  wedge- 
shaped  areas  of  the  renal  cortex,  securing  the  wounds  by  sutures. 
In  the  majority  of  instances,  however,  the  disease  will  have  spread 
much  too  extensively  for  such  conservative  treatment,  the  kidney 
practically  consisting  of  a  series  of  cysts  filled  with  offensive 
pus.  If  the  surgeon  is  tolerably  certain  that  the  other  kidney 
is  healthy,  nephrectomy  should  be  performed,  care  being  taken  to 
divide  the  ureter  below  the  farthest  limit  of  the  disease.  The 
occurrence  of  a  perinephritic  abscess  necessitates  an  incision  in 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS 


1061 


the  loin,  and  through  this  opening  the  kidney  can  be  explored 
and,  if  necessary,  removed. 

Renal  Calculus. — Renal  Calculi  are  usually  met  with  in  indi- 
viduals suffering  from  lithiasis,  as  indicated  by  the  passage  of 
sand  or  gravel  in  the  urine.  The  general  causes  of  this  con- 
dition are  detailed  elsewhere  (p.  1088).  All  renal  concretions  are 
primarily  excreted  in  a  crystalline  form  from  the  renal  tubules, 
but  under  ordinary  circumstances  are  sufficiently  small  to  find 
their  way  into  the  pelvis  of  the  kidney,  and  thence  along  the 
ureter  to  the  bladder.  If,  however,  they  are  obstructed  in  their 
onward  course,  either  on  account  of  their  size  or  shape,  or  some 
narrowing  of  the  tubules,  they  may  become  lodged  in  the  kidney 


Fig.  373. — Calculous  Kidney.     (College  of  Surgeons'  Museum.) 

substance  or  in  one  of  the  calyces,  and  by  the  gradual  deposit  of 
the  same  material  increase  in  size  until  large  enough  to  give  rise 
to  symptoms  (Fig.  373).  Renal  calculi  are  not  often  of  great 
bulk,  rarely  exceeding  that  of  a  Barcelona  nut ;  occasionally, 
however,  the  whole  of  the  pelvis,  and  some  of  the  calyces,  may  be 
occupied  by  a  concretion,  which  takes  the  shape  of  the  cavity  in 
which  it  lies.  When  many  calculi  are  present  in  the  pelvis  of  the 
same  kidney,  they  are  usually  faceted.  Chemically  they  consist 
either  of  uric  acid  or  urate  of  ammonium ;  sometimes,  however, 
they  are  composed  of  oxalate  or  acid  phosphate  of  lime. 

The  Pathological  Phenomena  connected  with  renal  calculi  vary 
with   their  size,  shape,  number,  and  position.     If  situated  in  the 


1062  A  MANUAL  OF  SURGERY 

substance  of  the  renal  parenchyma,  they  give  rise  to  but  little 
change,  being  more  or  less  encapsuled  in  a  cavity  lined  by 
granulation  tissue.  When  occupying  the  pelvis  of  the  kidney, 
they  set  up  pyelitis,  and  from  the  obstruction  to  the  flow 
of  urine,  caused  partly  by  the  thickening  of  the  mucous 
membrane,  and  partly  by  the  calculus  engaging  the  orifice  of 
the  ureter,  produce  dilatation  of  the  pelvis  of  the  kidney,  and 
the  phenomena  of  hydro-  or  pyo-nephrosis.  If  on  account  of 
their  shape  or  size  they  become  imprisoned  in  one  of  the  calyces, 
ulceration  of  the  wall  and  suppurative  perinephritis  may  follow ; 
the  calculus  may  even  find  its  way  into  the  abscess  cavity,  and  be 
discharged  spontaneously  or  removed  through  the  loin,  a  urinary 
fistula  often  resulting.  If  the  calculus  passes  down  the  ureter, 
it  gives  rise  to  the  symptoms  of  renal  colic.  When  small  and 
smooth,  it  usually  reaches  the  bladder  without  much  difficulty, 
and  is  then  voided  with  the  urine,  or  remains  as  a  vesical  calculus. 
Occasionally,  owing  to  its  size  or  irregular  shape,  it  becomes 
impacted  in  the  ureter,  usually  at  its  upper  end,  giving  rise  to 
acute  obstruction  and  the  cessation  of  the  urinary  secretion  on 
that  side,  followed  by  disorganization.  If  the  kidney  thus  affected 
is  the  only  one  available  for  excretory  purposes,  the  patient,  if 
unrelieved,  dies  in  a  few  days  from  suppression  of  urine  [calculous 
anuria).  In  other  cases  the  stone  ulcerates  through  the  wall  of 
the  ureter,  giving  rise  to  a  retroperitoneal  urinary  abscess,  or 
possibly  to  suppurative  peritonitis.  If  the  ureter  is  only  partially 
obstructed  by  the  calculus,  the  changes  which  take  place  in  the 
kidney  are  more  gradual,  and  result  in  hydro-  or  pyo-nephrosis. 

The  typical  Symptoms  arising  from  renal  calculus  are  as  follows : 
The  patient  complains  of  pain  in  the  loin,  more  or  less  persistent, 
and  often  paroxysmal  in  nature,  which  is,  however,  always  in- 
creased on  exercise  or  jolting  ;  it  is  frequently  referred  to  distant 
regions,  but  most  commonly  follows  the  course  of  the  genito- 
crural  nerve,  giving  rise  to  pain  in  the  front  of  the  thigh,  accom- 
panied by  retraction  of  the  testicle ;  in  the  female  it  is  also 
experienced  in  the  labium  majus.  Sometimes  it  extends  down 
the  back  of  the  thigh,  and  it  has  even  been  said  that  pain  in  the 
heel  is  pathognomonic !  It  is  almost  invariably  associated  with 
hematuria,  and  often  with  pyuria,  the  amount  of  blood  or  pus 
being  increased  on  exertion.  Frequency  of  micturition  is  a  pro- 
minent symptom,  whilst  if  the  pelvis  is  enlarged  the  kidney  may  be 
tender,  and  distinctly  felt  on  palpation.  If  the  calculus  is  lodged 
in  the  renal  parenchyma,  the  urinary  secretion  may  be  but  little 
influenced,  although  the  characteristic  pain  is  well  marked  ;  the 
patient  also  finds  that  at  night  he  can  only  gain  relief  by  lying 
on  the  affected  side,  and  on  manual  examination  the  kidney, 
though  somewhat  tender,  is  not  much  enlarged.  When  the 
calculus  lies  in  the  pelvis  or  one  of  the  calyces,  the  typical 
phenomena  described  above  are  produced ;  but  it  is  then  noticed 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1063 

that  at  night  the  patient  lies  on  the  sound  side,  since  the  organ  is 
both  enlarged  and  tender.  On  the  other  hand,  it  is  an  undoubted 
fact  that  stones  even  of  large  size  may  exist  for  years  in  the  kidney 
without  giving  rise  to  any  symptoms  whatever. 

The  passage  of  a  calculus  down  the  ureter  is  accompanied 
by  the  symptoms  known  as  Renal  Colic.  They  consist  of 
excruciating  pain  of  a  paroxysmal  nature,  which  comes  on 
suddenly,  and  is  referred  both  to  the  loin  and  along  the  course 
of  the  genito-crural  nerve.  It  is  always  associated  with  vomiting 
and  severe  shock,  the  patient  often  lying  on  the  floor  writhing  in 
agony,  with  cold  perspiration  standing  in  beads  on  his  forehead. 
The  temperature  is  subnormal,  and  the  pulse  weak  and  rapid. 
Strangury  is  usually  present,  the  patient  suffering  from  frequent 
paroxysmal  efforts  to  pass  water,  but  only  succeeding  in  evacuat- 
ing a  small  amount,  and  that  generally  blood-stained.  After 
lasting  for  a  variable  period,  the  pain  suddenly  ceases,  as  a  result 
of  the  passage  of  the  calculus  into  the  bladder,  or  of  its  slipping 
back  into  the  pelvis  of  the  kidney. 

Calculous  anuria  is  the  term  applied  to  a  cessation  of  the 
urinary  secretion  which  results  from  blocking  of  one  or  both 
ureters  with  calculi,  the  opposite  kidney  in  the  former  case  being 
absent,  atrophied  or  diseased.  The  condition  is  usually  lighted 
up  by  some  physical  effort,  which  presumably  dislodges  the 
calculus.  It  is  ushered  in  by  sudden  pain  in  the  loin,  which 
often  passes  away  in  the  course  of  two  or  three  days.  The 
anuria  is  rarely  complete  at  first,  a  few  ounces  of  pale  limpid 
urine  being  passed  at  intervals,  whilst  occasionally  distinct  poly- 
uria is  present.  Sooner  or  later  definite  uraemic  phenomena 
supervene  ;  the  most  usual  period  is  seven  or  eight  days  after  the 
onset,  but  incomplete  obstruction  or  a  pre-existing  condition  of 
hydronephrosis  may  delay  matters.  The  onset  of  uraemia  is 
indicated  by  vomiting,  a  slow,  full  pulse  becoming  irregular, 
contraction  of  the  pupils  and  muscular  tremors.  Coma  and  con- 
vulsions are  rarely  seen,  and  there  is  no  dyspnoea ;  the  tempera- 
ture is  subnormal.  Possibly  the  calculus  can  be  detected  through 
the  rectum  or  vagina  if  it  is  impacted  low  down. 

The  Diagnosis  of  renal  calculus  is  often  a  matter  of  uncertainty 
in  the  absence  of  a  history  of  the  passage  of  gravel  or  of  the 
occurrence  of  renal  colic.  It  is  most  likely  to  be  mistaken  for 
tuberculous  disease ;  the  differential  diagnosis  between  the  two 
conditions  has  already  been  considered  (p.  1060).  Some  assist- 
ance may  perhaps  be  obtained  by  the  use  of  the  X  rays,  and 
Mr.  Henry  Morris  has  pointed  out  that  too  long  an  exposure  is 
undesirable,  since  the  calculi  are  not  very  opaque,  owing  to  their 
containing  so  much  organic  material.  Phosphatic  calculi  are 
more  easily  detected  than  those  consisting  of  oxalate  of  lime, 
whilst  the  uric  acid  stones  are  only  seen  with  difficulty. 

Treatment. — In  the  early  stages  treatment  is  directed  to  the  cure 


1064  A  MANUAL  OF  SURGERY 

of  lithiasis  (see  p.  1088).  The  patient's  diet  and  general  habits 
of  life  must  be  suitably  regulated,  and  he  is  instructed  to  make 
use  of  alkaline  purgatives,  such  as  Carlsbad  or  Vichy  waters,  or 
citrate  of  lithia  and  sulphate  of  soda  may  be  administered  in  a 
mixture.  Plenty  of  bland  fluid  should  be  ordered,  such  as  boiled 
or  distilled  water,  in  the  hope  of  dissolving  the  stone  or  assisting 
its  onward  passage  to  the  bladder.  Sometimes  it  may  become 
encysted,  if  the  patient  is  kept  absolutely  at  rest ;  the  symptoms 
will  then  gradually  ameliorate,  and  finally  disappear. 

Attacks  of  renal  colic  are  treated  by  the  use  of  hot  hip  baths, 
warm  drinks,  and  hypodermic  injections  of  morphia ;  in  the  more 
severe  cases  chloroform  must  be  administered. 

If,  in  spite  of  the  above-mentioned  measures,  the  pain  persists 
or  increases  in  amount,  or  if  one  kidney  is  considerably  enlarged 
and  very  tender,  an  exploratory  operation  is  required,  especially  if 
a  considerable  amount  of  blood  or  pus  is  being  passed  in  the 
urine,  and  the  patient's  temperature  raised.  It  must  also  be 
undertaken  if  a  perinephritic  abscess  forms  or  a  calculus  becomes 
impacted  in  the  ureter.  Pain  in  both  kidneys  is  no  contra- 
indication to  operation,  since  there  is  no  objection  to  exposing 
and  even  removing  calculi  from  both  organs  ;  it  must  not  be 
forgotten,  however,  that  sympathetic  pain  in  a  sound  kidney  may 
be  induced  by  calculi  on  the  opposite  side.  Naturally,  the  organ 
in  which  most  pain  is  complained  of  is  dealt  with  first,  unless  the 
existence  of  a  calculus  in  the  opposite  kidney  is  indicated  by  the 
X  rays.  The  constant  passage  of  gravel,  moreover,  need  not 
deter  one  from  operating,  since  when  once  the  kidney  has  been 
relieved  by  removal  of  the  larger  masses,  the  tendency  to 
recurrence  may  be  checked  by  suitable  diet  or  drugs.  The 
amount  of  urea  excreted  daily  should  always  be  estimated  in 
these  cases,  and  if  it  is  much  diminished  no  operation  should  be 
undertaken.  For  details  of  the  technique  of  nephrolithotomy, 
see  p.  1069. 

Where  the  organ  is  totally  disorganized  nephrectomy  may  be 
required,  but  such  treatment  is  not  always  advisable,  especially 
when  sinuses  have  resulted  from  a  suppurative  perinephritis.  In 
such  cases  the  renal  tissue  has  often  entirely  disappeared,  and 
disintegrating  calculous  material  may  occupy  the  pelvis,  which  is 
surrounded  by  a  mass  of  dense  fibro-cicatricial  tissue,  the  removal 
of  which  is  impracticable  and  even  dangerous.  All  that  should 
be  attempted  is  the  extraction  of  the  stone  and  the  purification  of 
the  cavity ;  the  patient  must  resign  himself  to  the  inconvenience 
of  a  suppurating  sinus  in  the  loin. 

A  diagnosis  of  calculous  anuria  should  always  determine  an 
operation,  as  such  is  the  only  means  of  saving  life.  After  explor- 
ing the  kidney  and  its  pelvis  in  the  usual  way,  the  ureter  is 
exposed  by  prolonging  the  incision  downwards  and  forwards  in 
front  of  the  anterior  superior  iliac  spine,  and  parallel  to  the  outer 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1065 

end  of  Poupart's  ligament.  The  peritoneum  and  its  contents  are 
displaced  forwards,  and  the  ureter  can  then  be  explored  from  end  to 
end,  except  at  its  lower  portion  in  females.  An  impacted  stone  is 
cut  down  on  and  removed  through  a  longitudinal  incision  in  the 
ureteral  wall,  which  is  subsequently  closed  by  a  Lembert's  suture. 
When  the  lower  end  of  the  female  ureter  is  blocked,  the  calculus  can 
often  be  detected  pev  vaginam,  and  may  be  removed  by  that  route. 

Tumours   of    the    Kidney. — The   General   Characters   of    renal 
tumours  are  as  follows  :  A  swelling  is  noticed  in  the  loin,  which  is 


Fig.  374. — Cystic  Disease  of  Kidney.     (King's  College  Museum.) 

shaped  more  or  less  like  the  kidney,  a  notch  being  occasionally 
felt  on  the  inner  border,  and  the  outer  margin  being  rounded.  The 
flank  is  always  dull  on  percussion,  the  note  remaining  unaltered 
whatever  the  patient's  position,  and  intestine  never  finding  its  way 
behind  the  tumour.  The  passage  of  the  colon  in  front  of  the  kidney 
not  unfrequently  gives  rise  to  a  band  of  resonance  over  its  anterior 
surface  ;  the  bowel,  however,  soon  gets  pushed  aside  by  the  growth 
of  the  tumour.     On  the  right  side  it  is  not  unusual  for  the  renal 


io66  A  MANUAL  OF  SURGERY 

dulness  to  be  continuous  with  that  due  to  the  liver.  The  mass 
moves  slightly  on  respiration,  though  less  distinctly  than  the 
liver  or  spleen  ;  and  no  pedicle  can  be  felt  passing  down  towards 
the  pelvis. 

The  different  varieties  of  tumour  which  may  originate  in  the 
kidney  may  be  classified  as  the  simple  and  the  malignant.  Several 
cystic  conditions  also  occur. 

The  Simple  tumours  of  the  kidney  are  : 

i.  Cystic  Disease  (or,  as  it  has  been  termed,  adenoma  of  the 
kidney),  which  may  be  congenital  or  acquired.  It  is  not  unfre- 
quently  bilateral,  especially  when  congenital.  The  kidney  is  en- 
larged and  occupied  by  cysts,  varying  in  size,  but  rarely  exceed- 
ing that  of  a  cherry ;  they  are  lined  with  epithelium,  which  is 
generally  flattened,  and  filled  with  a  limpid  fluid  containing  urea 
and  perhaps  cholesterine.  The  cysts  are  often  very  numerous, 
and  may  project  from  the  surface  of  the  kidney  as  nodular  elastic 
outgrowths.  The  pelvis  remains  unaffected  until  the  later  stages 
of  the  disease  (Fig.  374).  Generally  the  whole  kidney  is  involved, 
and  may  attain  enormous  dimensions ;  but  occasionally  the 
growth  is  limited  to  one  portion  of  the  organ.  The  origin  of  this 
condition  is  uncertain,  but  it  is  supposed  to  be  due  to  the  per- 
sistence of  the  mesonephros  (or  Wolffian  body)  in  the  substance 
of  the  true  kidney  (or  metanephros),  and  its  development  into 
cysts.  The  early  symptoms  are  simply  those  of  pressure,  but  at 
a  later  stage  the  secretion  of  urine  is  interfered  with  to  such  an 
extent  as  to  produce  uraemia.  The  tendency  of  this  affection  to 
affect  both  kidneys  prevents  any  hope  of  benefit  from  operation. 

2.  Papilloma  of  the  renal  pelvis  is  a  rare  condition,  characterized 
by  the  development  within  its  cavity  of  a  villous  mass,  identical 
in  structure  with  that  met  with  in  the  bladder.  It  has  usually 
been  observed  in  elderly  people,  and  the  chief,  if  not  the  only, 
symptom  is  excessive  hematuria.  It  cannot  be  diagnosed  with 
certainty,  but  if  found  in  an  exploratory  operation,  it  can  be 
removed  with  success. 

3.  Occasionally  tumours  of  a  considerable  size  are  found  growing 
from  the  kidney,  similar  in  structure  to  the  zona  fasciculata  of  the 
adrenal  bodies.  They  are  looked  on  as  adenomata  growing  from 
accessory  and  misplaced  adrenals  ;  the  renal  parenchyma  is  normal 
in  texture,  though  stretched  over  the  new  growth.  When 
diagnosed,  they  may  be  removed  together  with  the  kidney,  and 
the  results  are  usually  satisfactory. 

Malignant  tumours  of  the  kidney  may  be  divided  into  : 
1.  The  Sarcomata  of  Infants,  which  are  often  congenital,  but 
may  be  acquired  within  the  first  few  years  of  life.  They  are 
encapsuled,  the  kidney  substance  being  sometimes  spread  over 
them,  and  consist  of  round  or  spindle  cells,  the  latter  often  show- 
ing a  cross-striation,  resembling  that  of  muscular  fibres  (myo-sar- 
comata).     They  grow  to  a  great  size,  and  may  affect  both  organs, 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1067 


but  pain  and  haematuria  are  absent.  Death  results  from  general 
dissemination  or  from  exhaustion,  or  may  follow  mechanical 
obstruction  to  the  circulation,  as  by  the  detachment  of  a  sarco- 
matous embolus,  which  travels  upwards  and  blocks  the  pulmonary 
vessels.  Treatment  by  nephrectomy  has  given  most  unsatisfac- 
tory results,  recurrence  within  a  short  period  occurring  even  in 
those  few  cases  which  escape  death  from  shock.  When  both 
kidneys  are  affected,  nothing  can  be  done. 

2.  The  Sarcomata  of  Adults  occur  between  the  thirtieth  and 
fiftieth  years,  and  are  of  the  spindle-celled  variety.  Only  one 
kidney  is  generally  involved,  giving  rise  to  a  rapidly  growing 
swelling,  associated  with  pain  and  haematuria.  Calculi  are  often 
found  in  the  pelvis  of  such  organs.  Secondary  deposits  form 
in  the  viscera,  and  death  is  usually  due  to  exhaustion.  The 
results  of  nephrectomy  have  not  been  very  encouraging. 

3.  Carcinoma  is  an  uncommon  form  of  tumour  in  the  kidney. 
It  presents  the  same  clinical  features  as  a  sarcoma,  and  can  only 
be  recognised  on  microscopic  examination.  One  symptom,  how- 
ever, requires  special  mention,  since  it  is  extremely  suggestive  of 
the  presence  of  cancer,  viz.,  the  development  of  a  varicocele.  It 
is  due  to  the  pressure  of  enlarged  and  cancerous  lymphatic  glands 
upon  the  roots  of  the  spermatic  veins,  and  hence,  whenever  an 
elderly  person  develops  a  varicocele,  a  careful  examination  of  the 
kidney  on  the  affected  side  should  always  be  instituted. 

Various  Cystic  Conditions  of  the  kidney  must  be  noted  in  addi- 
tion to  the  general  cystic  disease,  already  described. 

(a)  Hydatid  Disease  affects  the  kidney,  as  it  may  involve  any 
other  organ  in  the  body.  It  starts  either  beneath  the  capsule 
or  in  the  glandular  substance ;  in  the  former  case  it  is  likely  to 
form  a  rounded  projection,  which  may  be  detected  on  palpation  of 
the  loin  ;  in  the  latter  it  expands,  or  even  destroys,  the  whole  of 
the  glandular  tissue,  and  may  burst  into  the  renal  pelvis,  the 
cysts  being  passed  along  the  ureter,  accompanied  by  more  or 
less  colic.  Suppuration  may  complicate  matters,  but,  unless  the 
cyst  has  ruptured  into  the  pelvis,  diagnosis  is  scarcely  feasible 
apart  from  an  exploratory  incision. 

Treatment  consists  in  cutting  down  on  the  kidney,  and 
enucleating  the  mass,  if  possible.  Failing  this,  drainage  may  be 
undertaken,  but  in  bad  cases  nephrectomy  is  necessary. 

(b)  Dermoid  Cysts  have  also  been  found. 

(c)  Serous  Cysts  are  occasionally  met  with,  arising  possibly  as 
a  result  of  obstruction  to  some  of  the  ducts.  Rounded  swellings, 
single  or  multiple,  are  produced,  growing  outwards  from  the 
cortex,  and  containing  a  thin  fluid  with  a  small  amount  of 
albumen  and  saline  substances  in  solution.  They  give  rise  to  no 
symptoms  except  from  their  size,  and  rarely  require  treatment 
other  than  simple  aspiration  or  drainage. 

(d)  Not  unfrequently  a  number  of  small  cysts  develop  in  con- 


io68 


A   MANUAL  OF  SURGERY 


nection  with  chronic  granular  nephritis,  but  they  are  of  no  clinical 
importance. 

Operations  on  the  Kidney. 

The  kidneys  are  placed  on  either  side  of  the  middle  line,  and 
extend  from  the  nth  rib  above,  to  midway  between  the  last  rib 
and  the  iliac  crest  below,  the  right  kidney  being  somewhat  lower 
than  the  left,  owing  to  the  presence  of  the  liver.  The  hilus  is 
situated  opposite  the  spinous  process  of  the  first  lumbar  vertebra, 
and  the  upper  ends  of  the  organs  are  nearer  to  the  spine  than  the 
lower. 

The  kidneys  may  be  exposed  by  two  chief  routes,  viz.,  the 
lumbar  and  the  abdominal. 

The  Lumbar  incision  (Fig.  375,  B)  commences  at  a  point  cor- 


Fig.  375. — Diagram  to  Illustrate  Lumbar  Incisions. 
A,  For  lumbar  colotomy  ;  B,  for  exposing  tbe  kidney. 

responding  to  the  outer  border  of  the  erector  spinse,  and  \  inch 
below  the  last  rib,  extending  downwards  and  outwards  in  the 
direction  of  the  fibres  of  the  external  oblique  for  about  4  or  5 
inches  towards  the  anterior  superior  iliac  spine.  The  posterior 
portions  of  the  abdominal  muscles  and  the  fascia  lumborum  are 
divided  seriatim,  and  the  fatty  tissue  surrounding  the  kidney  is 
thus  easily  reached  and  opened. 

The  Abdominal  incision  is  made  along  the  linea  semilunaris, 
which  is  divided,  and  the  peritoneal  cavity  opened.  If  the  colon 
lies  over  the  kidney  it  is  displaced  inwards  and  held  aside,  as  also 
the  other  intestines,  by  cloths  soaked  in  warm  salt  solution  ;  the 
peritoneum  covering  the  posterior  abdominal  wall  is  incised  to  the 
outer  side  of  the  colon,  and  the  organ  thus  exposed. 

A  third  method  has  been  advocated  by  some  surgeons,  known 
as  the  Lateral  or  Lumbo-abdominal.     The  incision  extends  verti- 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1069 

cally  from  the  tip  of  the  last  rib  to  the  iliac  crest,  and,  if  necessary, 
a  cross-cut  is  made  backwards  at  right  angles  to  it.  The  peri- 
toneum is  stripped  forwards  from  the  kidney,  the  operation  being 
thus  retroperitoneal.  The  advantage  over  the  ordinary  lumbar 
incision  has,  however,  yet  to  be  demonstrated. 

The  following  are  the  chief  operations  undertaken  upon  the 
kidney : 

1.  Nephrotomy  consists  in  exposure  of  the  kidney,  exploration 
of  its  substance,  and,  if  need  be,  incision  into  it  for  the  removal 
of  some  abnormal  condition.  It  should  generally  be  undertaken 
through  the  loin.  When  exposed,  the  kidney  is  partially  freed 
from  its  connections,  and  drawn  up  into  the  wound.  Its  sub- 
stance is  then  carefully  palpated  between  the  fingers,  any  abnormal 
softening  or  hardening  being  noted.  It  may  next  be  explored 
with  a  fine  round  needle,  such  as  is  used  for  knitting.  Care 
must  be  taken  not  to  mistake  the  sensation  imparted  to  the 
fingers  by  striking  the  pyramids  with  the  needle  for  a  stone. 
If  nothing  abnormal  is  detected,  an  incision  should  be  made 
through  the  convex  border  of  the  kidney  substance,  a  little  pos- 
terior to  the  mesial  plane  of  the  organ  and  at  the  junction  of  its 
inferior  and  middle  thirds.  Free  haemorrhage  follows  such  a  pro- 
ceeding, but  soon  stops  when  the  finger  is  inserted.  This  incision 
through  the  renal  parenchyma  must  always  be  undertaken  in 
preference  to  one  through  the  pelvis,  since  the  latter  heals  with 
difficulty,  and  is  liable  to  leave  a  fistula.  One  of  the  lower  calyces 
is  opened  by  this  means,  and  the  pelvic  cavity  is  then  carefully 
explored  by  the  finger  or  probe.  The  upper  part  of  the  ureter  is 
best  examined  by  making  a  tiny  hole  in  the  pelvis  through  which 
a  probe  is  introduced,  the  opening  being  subsequently  sutured 
without  difficulty.  Should  a  stone  be  detected,  it  may  be  removed 
by  dressing  forceps  or  a  scoop  through  the  renal  parenchyma,  as 
also  any  foreign  body ;  a  papillomatous  growth  can  be  scraped 
away,  and  the  base  carefully  cauterized,  whilst  if  the  operation  is 
performed  in  order  to  drain  a  suppurating  pelvis,  a  drainage-tube 
is  inserted  into  its  interior.  The  wound  in  the  cortex  is  usually 
secured  by  one  or  more  catgut  sutures  passed  through  its  sub- 
stance, unless  the  condition  of  the  lining  membrane  of  the  pelvis 
renders  such  a  step  inadvisable,  or  unless  permanent  drainage  is 
required.  The  external  wound  may  then  be  closed,  the  muscular 
planes  being  carefully  united  by  a  series  of  buried  sutures. 

2.  Nephrectomy,  or  total  removal  of  the  kidney,  is  performed  for 
the  following  conditions  :  (a)  For  tuberculous  disease,  when  con- 
servative measures  are  impracticable,  or  when  the  pelvis  and 
ureter  are  involved ;  (b)  for  calculous  pyonephrosis,  when  the 
renal  parenchyma  is  disintegrated  ;  (c)  for  hydronephrosis,  when 
palliative  measures  or  drainage  have  failed  to  give  relief ;  (d)  for 
malignant  disease ;  (e)  for  traumatic  lesions,  such  as  disintegra- 
tion or  rupture,  especially  if  complicated  by  laceration  of  the 
peritoneum  ;  and  (/)  for  some  cases  of  ruptured  ureter. 


1070  A  MANUAL  OF  SURGERY 

Before  undertaking  the  excision  of  any  kidney,  however  diseased, 
it  is  essential  that  the  surgeon  should  satisfy  himself  as  to  the 
existence  of  another,  and  also,  if  possible,  ascertain  that  it  is 
capable  of  undertaking  the  increased  duties  which  will  subse- 
quently fall  upon  it.  Many  different  plans  of  doing  this  have 
been  suggested,  but  it  is  often  difficult  to  be  absolutely  certain. 
In  doubtful  cases  the  best  course  is  to  perform  an  exploratory 
laparotomy,  by  means  of  which  not  only  can  the  existence  of  a 
second  kidney  be  determined,  but  also  its  condition  investigated, 
and  the  size  of  the  renal  artery  ascertained.  An  examination  of 
the  diseased  organ  can  also  be  made ;  if  it  is  of  large  size,  the 
operation  may  be  at  once  completed  from  the  front ;  but  if  it  is 
small  enough  to  be  dealt  with  from  the  loin,  the  abdomen  is 
closed,  and  the  nephrectomy  put  off  for  a  week  or  ten  days, 
until  the  first  incision  has  healed.  It  is  sometimes  possible  to 
prove  the  existence  of  a  second  kidney  by  means  of  the  cysto- 
scope,  little  gushes  of  urine  being  seen  to  escape  from  the  ureter ; 
in  females  catheterism  of  the  ureter  is  practicable.  Another 
method  suggested  is  to  compress  the  orifice  of  one  ureter  and 
collect  the  urine  from  the  other ;  but  these  plans  are  difficult  to 
accomplish  and  cannot  be  depended  on. 

Nephrectomy  may  be  undertaken  through  the  abdomen  or 
through  the  loin  ;  but  sundry  combinations  or  modifications  of 
these  operations  have  been  recommended  by  various  authorities. 

The  Abdominal  Operation  is  chiefly  utilized  when  the  organ  is 
much  enlarged,  on  account  of  the  readier  access  obtained,  espe- 
cially to  the  pedicle.  The  main  objection  lies  in  the  fact  that  the 
peritoneum  is  opened,  and  thereby  exposed  to  septic  contamina- 
tion, especially  when  the  pelvis  and  the  upper  part  of  the  ureter 
are  distended  with  decomposing  pus,  as  is  frequently  the  case. 
Moreover,  no  satisfactory  drainage  is  obtained  for  the  cavity  left 
by  the  removal  of  the  organ,  unless  a  counter-opening  is  made 
through  the  loin.  Of  course,  a  great  advantage,  as  before  stated, 
is  that  the  other  kidney  can  be  first  examined,  and  its  condition 
ascertained.  As  to  the  technique  :  after  exposing  the  kidney  in 
the  manner  already  described,  the  organ  is  freed  from  its  adhesions 
to  surrounding  tissues,  the  surgeon  being  careful  to  keep  outside  its 
true  capsule,  but  inside  the  layer  of  condensed  perinephric  tissue. 
Special  precautions  must  be  adopted  in  dealing  with  the  posterior 
aspect  of  the  tumour,  particularly  on  the  right  side,  where  it  is 
occasionally  adherent  to  the  inferior  vena  cava.  The  mass  is  now 
lifted  from  its  bed,  and  its  pedicle,  consisting  of  the  ureter  and 
renal  vessels,  isolated.  These  latter  are  secured  separately  by 
ligature  and  divided,  a  clamp  being  applied  to  the  distal  ends. 
The  ureter  is  dealt  with  in  the  same  way,  small  pieces  of  sponge 
being  packed  round  so  as  to  receive  any  secretion  which  may 
escape;,  the  exposed  mucous  membrane  in  the  portion  which  is 
left   is   carefully   touched   over   with    pure   carbolic   acid.      The 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1071 

kidney  thus  freed  is  removed,  and  the  wound  in  the  posterior 
parietal  layer  of  the  peritoneum  brought  together,  if  possible,  by 
sutures,  provision  for  drainage  having  been  previously  made 
either  through  the  loin  or  by  the  insertion  of  a  gauze  drain  from 
the  front.  The  abdominal  cavity  is  carefully  cleansed  from  all 
blood-clot,  and  closed  in  the  usual  way.  Considerable  shock  is 
always  experienced  from  this  operation,  and  the  death-rate  from 
this  cause  is  somewhat  high. 

The  Lumbar  Method  can  only  be  employed  when  the  kidney  is 
not  much  enlarged.  The  organ  is  exposed  by  the  incision  already 
described,  enucleated  from  its  surroundings,  and  the  pedicle  dealt 
with  as  in  the  abdominal  operation.  If  the  condition  of  the 
opposite  organ  has  not  previously  been  ascertained  by  laparotomy, 
Kocher  recommends  that  the  peritoneum  should  be  incised  at 
the  outer  margin  of  the  wound,  so  as  to  enable  the  hand  to  be 
inserted  across  the  middle  line,  and  thus  allow  an  exploration 
of  the  opposite  loin. 

Should  it  be  desirable  to  include  the  ureter  in  the  scope  of  the 
operation,  the  incision  may  be  prolonged  into  the  groin  in  the 
direction  of  the  fibres  of  the  external  oblique,  and  the  peritoneum 
and  its  contents  pushed  forwards  ;  by  this  means  it  can  be  traced 
down  almost  to  the  bladder. 

3.  Nephrorrhaphy  is  the  title  given  to  the  operation  for  fixing  a 
moveable  kidney.  The  usual  lumbar  incision  is  adopted,  and 
if  the  organ  is  found  to  move  freely  within  its  fatty  capsule,  this 
latter  should  be  always  drawn  into  the  wound,  and  a  considerable 
portion  excised.  Two  or  three  silk  stitches  of  medium  thickness 
are  then  passed  through  the  muscles,  and  also  through  the 
cortical  portion  of  the  kidney,  securing  a  good  hold  of  it.  By 
tying  these  the  kidney  is  fixed  to  the  posterior  abdominal  wall, 
and  the  wound  is  then  closed.  The  results  of  this  operation  have 
not  always  been  satisfactory,  the  symptoms  returning.  It  appears 
from  experiments  that  sutures  passed  through  the  renal  paren- 
chyma are  very  quickly  disintegrated  and  removed ;  and  hence, 
although  the  kidney  may  seem  to  be  efficiently  immobilized  at  the 
completion  of  the  operation,  it  readily  becomes  loose  again.  To 
obviate  this  it  has  been  suggested  to  leave  the  parietal  incision 
open,  merely  stuffing  it  with  gauze,  so  that  a  firm  mass  of  cica- 
tricial tissue  may  develop,  extending  from  the  kidney  to  the  sur- 
face, and  thus  anchoring  it.  Some,  again,  have  recommended 
that  the  true  capsule  should  be  partially  stripped  off  and  stitched 
to  the  abdominal  parietes,  the  raw  surfaces  thus  formed  uniting 
securely,  and  fixing  the  organ  ;  whilst  others  advise  the  isolation 
of  one  of  the  tendons  of  the  spinalis  dorsi,  which  is  passed  from 
above  downwards  under  the  capsule,  as  a  support  on  which  the 
kidney  is  slung.  (See  report  in  Clinical  Journal,  February  5, 
1896.) 


CHAPTER  XXXVII. 

BLADDER    AND    PROSTATE. 

Congenital  Affections   of  the   Bladder. 

I.  Ectopia  Vesica,  or  Extroversion  of  the  Bladder,  is  the  term  given  to 
denote  total  absence  of  the  anterior  wall  of  the  bladder  and  of  the  lower 
portion  of  the  abdominal  parietes,  as  a  result  of  which  the  mucous  membrane 
of  the  posterior  vesical  wall  is  exposed  and  rendered  somewhat  prominent 
by  the  pressure  from  behind  of  the  abdominal  contents  (Fig.  376,  B).  This 
surface   is   usually   irregular,   and   covered    with    papilliform    processes ;  the 


// 


// 


Fig.  376. — Ectopia  Vesica.     (Tillmanns.) 

B,  Exposed  mucous  membrane  of  bladder  ;  U,  U,  orifices  of  ureters; 
H,  H,  projections  of  pubic  rami  on  either  side. 

orifices  of  the  ureters  (U,  U)  are  easily  recognised  below,  urine  being  occa- 
sionally emitted  from  them  in  forcible  jets.  The  condition  is  necessarily  one  ol 
the  greatest  discomfort,  not  only  from  the  constant  dribbling  of  urine  causing 
excoriation  and  eczema  of  the  thighs  and  surrounding  parts,  but  also  from  the 
pain  and  irritation  due  to  friction  of  the  clothes  against  the  exposed  mucous 
membrane.     The  symphysis  pubis  is  always  absent,  and  the  horizontal  ramus 


BLADDER  AND  PROSTATE  1073 

of  the  pubic  arch  terminates  on  either  side  in  the  inguinal  region  (H,  H).  The 
innominate  bones  are  usually  rotated  outwards,  and  the  sacrum  is  convex 
anteriorly  from  side  to  side  instead  of  being  concave.  In  consequence  of  this 
pelvic  malformation,  the  patient's  gait  and  powers  of  progression  are  con- 
siderably impaired.  The  penis  is  cleft,  and  in  a  condition  of  complete 
epispadias ;  it  is  drawn  upwards  and  backwards  over  the  trigone,  so  that  it 
requires  pulling  down  (as  seen  in  the  illustration)  to  expose  the  ureteral 
orifices.  The  testes  are  often  found  in  the  inguinal  canal,  or,  if  in  the 
scrotum,  are  accompanied  by  congenital  herniae.  No  umbilicus  is  present. 
The  condition  is  due  to  impaired  development  of  the  anterior  wall  of  the 
allantois  and  the  lower  segment  of  the  abdominal  parietes.  At  birth  the 
lower  portion  of  the  umbilical  cord  is  expanded  over  the  raw  surface,  con- 
stituting the  anterior  vesical  wall.  When  the  cord  separates,  the  posterior 
vesical  wall  is  necessarily  exposed. 

The  Treatment  of  this  distressing  malformation  is  most  unsatisfactory. 
The  majority  of  the  cases  are  treated  by  the  application  of  a  urinal,  but, 
unfortunately,  the  instruments  hitherto  devised  are  not  particularly  efficient. 
Various  operative  measures  have  also  been  practised  with  the  object  of 
covering  the  exposed  surface,  and  forming,  if  possible,  a  reservoir  in  which 
the  urine  may  be  retained,  (a)  Trendelenburg's  operation  consists  in  division 
of  the  sacro-iliac  ligaments  from  behind,  so  as  to  enable  the  lateral  halves  of 
the  pelvis  to  be  compressed  together.  By  this  means  the  posterior  vesical 
wall  is  thrown  backwards  and  its  tendency  to  protrude  lessened.  The 
wounds  are  allowed  to  granulate,  and,  if  successful,  the  bladder  wall  finally 
lies  at  the  bottom  of  a  sulcus,  which  can  usually  be  covered  over  by  a  plastic 
operation  without  much  difficulty.  The  main  objections  to  this  method  are 
that  it  involves  a  very  severe  operation,  and  also  leads  to  a  further  weakening 
of  the  pelvic  arch,  the  integrity  of  which  is  already  much  impaired  by  the 
absence  of  the  pubic  symphysis  (b)  Plastic  operations  without  interfering 
with  the  pelvis  have  been  introduced  and  practised  by  the  late  Professor  John 
Wood,  Thiersch,  and  others.  For  full  details,  we  must  refer  to  larger  text- 
books. Suffice  it  here  to  state  that  a  skin  flap  is  turned  down  from  the 
anterior  abdominal  wall  above  the  breach  of  surface,  and  sutured  on  either 
side  to  the  margins  of  the  defect.  The  cutaneous  surface  of  this  flap  con- 
stitutes the  anterior  wall  of  the  newly-formed  bladder,  if  such  it  can  be 
called,  whilst  its  raw  outer  surface  is  covered  in  either  by  flaps  derived  from 
either  side,  or  by  undercutting  the  neighbouring  skin  and  sliding  it  upwards 
to  the  middle  line,  where  it  is  united  by  sutures,  as  suggested  and  successfully 
carried  out  by  Mr.  Boyce  Barrow.  The  after-treatment  is  always  prolonged 
and  tedious,  and  the  patients  are  likely  to  experience  much  subsequent 
inconvenience  owing  to  the  growth  from  the  under  surface  of  the  abdominal 
flap  of  hairs,  which  become  encrusted  with  phosphates. 

2.  An  Umbilical  Urinary  Fistula  is  sometimes  met  with  as  a  result  of 
imperfect  closure  of  the  urachus. 

3.  Occasionally  in  cases  of  malformation  of  the  rectum  the  Primitive 
Cloacal  Condition  may  in  part  persist  (see  p.  1025). 

Traumatic  Affections  of  the  Bladder. 

Rupture  of  the  Bladder  may  be  produced  in  several  ways : 
(1)  It  may  be  due  to  direct  violence  applied  to  the  lower  part  of 
the  abdomen,  especially  when  the  viscus  is  distended.  (2)  It 
may  complicate  a  fracture  of  the  pelvis,  either  as  a  direct  result  of 
the  violence,  or  from  penetration  of  a  spicule  of  bone  from  the  os 
pubis.  (3)  The  bladder  may  be  opened  by  a  penetrating  wound. 
(4)  Apart  from  traumatic  lesions,  rupture  may  occur  from  simple 
over-distension,  especially  if  destructive  ulceration  of  its  walls  is 

68 


to74  A  MANUAL  OF  SURGERY 


present ;  or  it  may  follow  ulceration  of  a  saccule  if  it  contains  a 
phosphatic  concretion. 

Rupture  of  the  bladder  is  divided  into  two  main  classes,  accord- 
ing to  whether  or  not  the  peritoneal  cavity  is  opened.  The 
peritoneum  covers  the  upper  and  back  part  of  the  viscus,  being 
reflected  anteriorly  along  the  urachus,  laterally  along  the  ob- 
literated hypogastric  arteries,  and  posteriorly  on  to  the  rectum. 

Intraperitoneal  Rupture  involves  the  posterior  or  superior  por- 
tions of  the  viscus,  and  is  the  variety  most  frequently  met  with. 
The  symptoms  produced  are  severe  shock,  associated  with  hypo- 
gastric pain  of  a  burning  nature.  The  patient  experiences  a  con- 
stant desire  to  micturate,  but,  as  a  rule,  nothing  is  passed,  except 
perhaps  a  little  blood.  Peritonitis  soon  follows,  running  a  rapidly 
fatal  course,  especially  if  efficient  treatment  is  not  adopted.  On 
passing  a  catheter  the  bladder  is  usually  found  empty,  or  possibly 
a  little  blood-stained  urine  may  be  withdrawn  ;  if,  however,  the 
instrument  is  insinuated  through  the  rupture  into  the  peritoneal 
cavity,  a  considerable  quantity  of  blood-stained  urine  can  be 
drawn  off  and  the  point  of  the  catheter  may  be  felt  under  the 
anterior  abdominal  wall.  A  useful  diagnostic  sign  consists  in 
injecting  a  measured  amount  of  boric  acid  lotion  into  the  bladder, 
and  noting  how  much  of  it  returns  ;  when  a  rupture  exists,  some 
considerable  discrepancy  will  probably  be  noted  between  the  two 
quantities. 

The  Treatment  of  these  cases  consists  in  immediate  laparotomy  ; 
the  fluid  within  the  peritoneal  sac  is  removed  by  sponges,  and 
the  wound  in  the  bladder  clearly  demonstrated,  preferably  with 
the  patient  in  the  Trendelenburg  position  (p.  1105),  which  must 
not,  however,  be  adopted  until  the  urine  and  inflammatory  effusions 
have  been  removed.  The  rent  is  carefully  closed  by  means  of  a 
row  of  Lembert's  sutures,  which  should  always  extend  a  little 
beyond  each  extremity  of  the  wound.  Possibly  a  drainage-wick 
or  a  Keith's  tube  may  need  to  be  inserted  for  a  few  hours,  so  as 
to  remove  any  exudation.  The  abdominal  wall  is  then  closed  in 
the  usual  way,  and  the  patient  put  back  to  bed.  The  urine  is 
either  drawn  off  at  regular  intervals,  or  a  cathether  may  be  tied 
in  the  bladder,  the  urine  being  syphoned  by  an  attached  rubber 
tube  into  a  vessel  placed  beneath  the  bed. 

Extraperitoneal  Rupture  of  the  bladder  involves  its  anterior 
wall  or  base.  The  urine  finds  its  way  into  the  pelvic  cellular 
tissue,  and,  if  unhealthy,  at  once  gives  rise  to  a  most  virulent 
form  of  suppurative  pelvic  cellulitis,  which  is  usually  fatal  from 
toxaemia  or  pyaemia.  Abscesses  tend  to  point  either  above  the 
pelvic  brim  or  in  the  perineum.  The  treatment  consists  in  free 
incisions  through  the  perineum,  or  above  the  brim  of  the  pelvis. 
If  the  urine  is  healthy  and  uncontaminated  with  bacteria,  and  is 
not  allowed  to  remain  long  in  contact  with  the  tissues,  the  pros- 
pects of  recovery  are  good. 


BLADDER  AND  PROSTATE  1075 

Foreign  Bodies  introduced  into  the  bladder  from  without  are  of 
various  natures,  such  as  portions  of  catheters  or  bougies,  pins, 
etc.  They  give  rise  to  symptoms  of  chronic  cystitis  and  usually 
become  encased  with  phosphatic  deposit.  They  should  be 
removed  as  early  as  possible  with  a  lithotrite,  but  if  of  large  size 
or  thickly  covered  with  phosphates,  must  be  treated  by  perineal 
or  suprapubic  cystotomy.  In  the  female  digital  dilatation  of  the 
urethra  is  the  best  means  of  gaining  access  to  the  interior  of  the 
viscus. 

Methods  of  Examining  the  Bladder. 

When  a  patient  presents  himself  complaining  of  increased  frequency  of 
micturition  and  other  evidences  suggestive  of  chronic  disease  of  the  bladder, 
a  systematic  examination  of  the  individual  and  his  urinary  passages  must 
always  be  instituted.  .  The  history  of  the  case,  the  character  of  the  symptoms, 
and  the  condition  of  the  urine  are  carefully  gone  into.  At  the  first  interview 
it  is  advisable  to  ask  the  patient  to  void  his  urine,  after  which,  providing  no 
tight  stricture  exists,  a  medium-sized  catheter-a-boule,  or  one  of  rubber,  should 
be  gently  introduced,  and  the  amount,  if  any,  of  the  residual  urine  estimated 

d 


Fig.  377. — Leiter's  Electric  Cystoscope.     (Tillmanns.) 

a,  Electric  lamp  in  beak  ;  b,  glass  window  for  illumination  purposes ; 
c  d,  switch  for  opening  or  closing  current. 

and  tested.  Having  gained  all  the  information  possible  from  this  source,  an 
examination  of  the  bladder  should  then  be  made,  or  perhaps  at  a  subsequent 
visit.  (1)  The  patient  is  laid  on  a  couch,  and  the  lower  part  of  the  abdomen 
uncovered.  The  hypogastrium  is  then  examined  by  inspection,  palpation,  and 
percussion,  so  as  to  ascertain  whether  or  not  the  bladder  is  distended,  or  if 
any  abnormal  resistance  can  be  felt,  either  from  thickening  of  the  wall  or  the 
presence  of  a  tumour.  (2)  A  sound  is  then  passed  according  to  the  method 
described  at  p.  1097,  and  the  interior  of  the  viscus  explored;  by  this  means  a 
calculus  may  be  detected,  and  even  sometimes  a  tumour,  as  also  a  rough  and 
irregular  condition  of  the  mucous  membrane.  (3)  The  finger  is  inserted  into 
the  rectum,  or,  in  the  female,  into  the  vagina,  before  the  sound  is  withdrawn, 
so  as  to  enable  the  condition  of  the  posterior  vesical  wall  to  be  investigated 
between  the  point  of  the  finger  and  the  sound.  Enlargement  of  the  prostate  or 
of  the  vesiculae  seminales  can  also  be  detected  in  this  way.  (4)  As  mentioned 
elsewhere,  Bigelow's  evacuator  is  useful,  not  only  to  wash  out  the  bladder,  but 
also  to  detect  the  presence  of  very  small  calculi  which  the  sound  may  have 
missed.  (5)  Of  recent  years  a  new  means  of  examining  the  interior  of  the 
bladder  has  been  introduced  in  the  shape  of  the  cystoscope  (Fig.  377).  This 
consists  of  a  straight  tube  with  a  short  end  bent  at  an  angle,  in  which  an 
electric  lamp  is  placed,  the  wires  leading  to  it  being  carried  within  the  tube. 
A  small  window  covered  with  glass  is  situated  close  to  the  angle,  and  a  prism 
is  here  inserted  in  such  a  manner  that,  when  the  surgeon  looks  through 
an  eyepiece  placed  at  the  end  of  the  instrument,  he  is  able  to  see  the  portion  cf 
the  vesical  wall  illuminated  by  the  electric  lamp.     To  use  it  the  bladder  must 


io?6  A  MANUAL  OF  SURGERY 

be  previously  washed  out,  and  the  patient  anaesthetized.  About  six  ounces  of 
boric  acid  lotion  should  be  present  in  the  bladder,  so  as  to  prevent  the  vesical 
wall  from  being  injured  by  the  instrument,  which  always  becomes  hot  after 
the  lamp  has  been  used  for  some  time.  Different  ends  are  supplied  to  enable 
the  anterior  and  posterior  walls  to  be  examined.  Considerable  practice  is 
needed  for  any  useful  information  to  be  gained  by  the  aid  of  this  instrument, 
but  in  skilled  hands  much  may  be  learnt  as  to  the  condition  of  the  mucous 
membrane.  (6)  Finally,  in  cases  where  great  irritability  of  the  bladder  exists 
in  spite  of  treatment,  and  its  presence  cannot  be  explained,  an  exploratory 
cystotomy,  either  suprapubic  or  perineal,  is  justifiable. 

Inflammation  of  the  Bladder. 

Acute  Cystitis,  or.  inflammation  of  the  bladder  wall,  results 
from :  (i.)  Cold  in  gouty  subjects ;  in  fact,  there  are  certain 
individuals  who  often  '  take  cold  '  in  their  bladders,  instead  of 
developing  a  bronchial  or  nasal  catarrh,  (ii.)  It  is  sometimes 
due  to  traumatic  causes,  e.g.,  the  presence  of  foreign  bodies,  or 
injury  to  the  viscus  during  operation,  (iii.)  It  occurs  most  fre- 
quently as  a  complication  of  gonorrhoea,  owing  to  an  upward 
extension  of  the  inflammation,  and  in  such  cases  the  symptoms 
are  often  very  severe,  (iv.)  It  may  result  from  the  absorption  of 
irritating  poisons,  such  as  cantharides.  (v.)  Septic  cystitis  may 
supervene  if  a  dirty  instrument  is  introduced,  and  there  can  be 
but  little  doubt  that  this  was  a  most  prolific  source  of  the  mis- 
chief in  times  past ;  it  is  very  likely  to  occur  when  the  bladder 
is  paralyzed  in  cases  of  spinal  injury.  Under  these  circum- 
stances infection  may  supervene  even  when  sterilized  instru- 
ments are  employed,  owing  to  the  presence  of  mucus  in  the 
urethra,  along  which  cocci  are  able  to  find  their  way.  The  im- 
portance of  sterilizing  the  penis  and  urethra,  and  guarding  the 
external  meatus  by  an  antiseptic  dressing  in  these  cases  has 
already  been  referred  to  (p.  634). 

The  Bacteriology  of  cystitis  has  not  been  very  satisfactorily  worked  out,  but 
that  bacteria  are  present  and  play  an  important  part  in  its  production  cannot 
for  a  moment  be  doubted.  The  Bacillus  colt  is  one  of  the  most  common 
microbes  found,  and  may  be  unaccompanied  by  other  organisms,  the  urine 
remaining  acid,  though  stale  and  objectionable  to  the  smell.  How  it  reaches 
the  bladder  is  somewhat  uncertain,  but  probably  in  girls — in  whom  this 
variety  of  cystitis  is  not  unfrequent — it  may  reach  the  urinary  organs  by 
direct  infection  from  the  rectum  to  the  vulva,  a  vulvo-vaginitis  being  some- 
times associated  with  it.  It  has  also  been  shown  that  any  wound  of  the 
rectal  mucosa  is  liaHe  to  be  followed  by  migration  of  bacilli  into  neighbouring 
organs. 

More  commonly  the  urine  is  alkaline  and  ammoniacal ;  in  such  cases 
organisms  which  have  the  property  of  decomposing  urea  are  fo.md,  such  as 
the  Proteus  Hauseri,  the  Diplococcus  urea  liquefaciens,  ordinary  pyogenic  cocci, 
etc.,  with  or  without  the  Bacillus  coli. 

The  Symptoms  of  acute  cystitis  consist  in  pain  referred  to  the 
perineum  and  hypogastrium,  together  with  tenderness  on  pressure 
over  the  symphysis  pubis.  This  is  accompanied  by  extreme 
irritability  of  the  bladder,  frequent  efforts  of  a  painful  and  spas- 


BLADDER  AND  PROSTATE  1077 


modic  nature  being  made  to  pass  water  (strangury) ;  but  little 
urine  is  voided  at  a  time,  for  as  soon  as  any  amount  has  collected 
it  is  ejected  forcibly.  It  generally  contains  blood  and  pus,  soon 
becoming  alkaline,  and  teeming  with  bacteria.  Some  amount  of 
fever  is  usually  noted,  as  also  vomiting,  whilst  tenesmus  may  be 
induced  as  a  result  of  the  proximity  of  the  rectum  to  the  inflamed 
bladder.  The  usual  termination  of  the  case  is  in  resolution,  but 
sometimes  chronic  irritability  may  persist.  In  rare  instances  the 
inflammation  is  of  such  a  virulent  nature  as  to  cause  death.  The 
urine  in  these  cases  is  often  exceedingly  foul,  and  the  fatal  issue 
is  due  to  exhaustion,  peritonitis,  suppurative  pyonephrosis,  or 
even  acute  toxaemia  ;  occasionally  the  whole  mucous  lining  of  the 
viscus  may  slough.  In  some  patients,  however,  when  the  inflam- 
mation is  concentrated  at  the  neck  of  the  bladder,  retention,  dis- 
tension, and  atony  may  ensue. 

Treatment. — The  patient  should  be  kept  in  a  warm  atmosphere, 
and  preferably  in  bed,  and  fomentations  applied  to  the  lower  part 
of  the  abdomen  ;  hot  hip-baths  twice  daily,  maintained  for  some 
time,  are  very  advantageous.  The  diet  should  be  restricted 
to  fluid,  and  the  patient  encouraged  to  partake  freely  of  barley- 
water  and  other  bland  liquids.  Alkalies  and  henbane  may  be 
administered,  and  morphia  and  belladonna  suppositories  are  use- 
ful to  allay  the  pain  and  irritability.  As  a  rule,  no  instrument 
should  be  passed  during  the  acute  stage,  unless  retention  is 
present  ;  but  if  the  urine  becomes  very  foul,  the  bladder  may  be 
gently  washed  out.  In  the  worst  cases  urotropine  (5  to  10  grains) 
salol  (10  to  20  grains),  and  boric  acid  (15  to  20  grains),  adminis- 
tered by  mouth,  may  do  good. 

Chronic  Cystitis  is  much  more  common  than  the  acute  variety. 
The  usual  cause  is  some  irritation  of  the  walls  of  the  viscus,  as 
from  calculi,  tumours,  foreign  bodies,  tuberculous  ulceration,  or 
retention  and  decomposition  of  urine,  especially  if  associated  with 
obstruction  to  the  outflow,  as  by  a  stricture  or  enlarged  prostate. 
It  may  also  follow  acute  cystitis,  whilst  impairment  of  the  nervous 
mechanism,  as  in  various  forms  of  injury  or  disease  of  the  spinal 
cord,  may  induce  trophic  changes  and  predispose  to  its  occurrence. 

The  Symptoms  are  those  of  irritability  of  the  bladder,  the  patient 
constantly  desiring  to  pass  water,  and  having  to  rise  at  night, 
perhaps  several  times,  for  this  purpose.  The  urine  becomes 
turbid,  and  on  standing  deposits  a  variable  amount  of  mucus 
or  muco-pus,  mixed  with  epithelial  cells,  crystals  of  triple  phos- 
phate, and  a  granular  sediment  of  phosphate  of  lime.  It  is 
usually  alkaline,  perhaps  foul-smelling  and  ammoniacal,  con- 
taining an  abundance  of  micro-organisms.  There  is  often  but 
little  pain,  though  when  a  calculus  exists,  or  the  neck  of  the 
bladder  is  ulcerated,  this  may  become  a  prominent  symptom.  The 
patient's  general  health  is  not  at  first  affected,  but  if  the  symptoms 


1078  A  MANUAL  OF  SURGERY 


persist  it  soon  becomes  impaired,  partly  from  the  absorption  of 
septic  products  from  the  bladder,  and  partly  from  the  want  of 
rest  and  sleep  arising  from  nocturnal  disturbance,  and  this  may 
be  so  marked  as  to  lead  to  fatal  exhaustion.  In  other  cases  the 
inflammation  may  spread  from  the  bladder  along  the  ureters  to 
the  kidneys,  and  the  phenomena  of  septic  pyelonephritis  manifest 
themselves  (p.  1056). 

Pathological  Anatomy. — The  mucous  membrane  is  thickened  and 
congested,  the  superficial  veins  dilated  and  even  varicose,  whilst 
ulceration  is  not  uncommon.  The  continued  repetition  of  the 
acts  of  micturition  leads  to  hypertrophy  of  the  bladder  wall,  which 
becomes  thickened  and  fasciculated ;  this  effect  is  of  course  most 
marked  when  the  cystitis  is  associated  with  obstruction  to  the 
outflow  of  urine.  The  mucous  membrane  may  protrude  outwards 
between  the  muscular  fasciculi,  giving  rise  to  pouch-like  saccules, 
in  which  phosphatic  concretions  are  sometimes  formed,  and  the 
retained  urine  undergoes  decomposition.  Perforative  ulceration 
occasionally  follows,  originating  a  fatal  peritonitis  or  pelvic  cellu- 
litis from  extravasation  of  urine.  The  contracted  state  of  the 
bladder  and  the  overgrowth  of  its  muscular  substance  lead  to 
compression  of  the  openings  of  the  ureters,  hydronephrosis  being 
thus  induced.  A  plug  of  viscid  mucus  often  finds  its  way  into  the 
ureteral  orifice,  and  by  becoming  infected  with  bacteria  causes  an 
extension  of  the  septic  mischief  to  the  kidney. 

The  Diagnosis  of  chronic  cystitis  is  readily  made  from  the 
characteristic  symptoms  of  irritation  of  the  bladder  and  the 
condition  of  the  urine ;  but  considerable  difficulty  may  be  ex- 
perienced in  determining  its  cause.  In  investigating  a  case,  not 
only  must  the  character  of  its  onset  be  considered,  but  also  the 
general  history  of  the  patient,  whilst  a  thorough  examination  of 
the  lower  urinary  passages  must  be  instituted,  and  the  urine 
examined  microscopically.  The  passage  of  a  catheter  or  sound 
will  generally  detect  any  obstruction  located  in  the  urethra,  whilst 
the  bladder  is  also  examined  by  the  different  methods  described 
at  p.  1075. 

The  Treatment  of  chronic  cystitis  is  naturally  directed  towards 
its  cause,  if  such  can  be  discovered  ;  thus,  calculi  or  foreign  bodies 
should  be  removed,  and  strictures  dilated.  In  most  cases,  even 
where  the  cause  is  not  apparent,  great  benefit  will  be  derived 
from  washing  out  the  bladder.  Catheters  and  other  instruments 
should  always  be  sterilized  before  use,  and  lubricated  with  some 
antiseptic  preparation,  such  as  carbolic  oil  (1  in  20) ;  for  it  is  all- 
important  to  remember  that  sepsis,  if  not  already  existent,  is 
easily  induced,  and  that  its  presence  renders  the  case  much  more 
difficult  to  cure. 

The  bladder  is  best  irrigated  by  passing  a  soft  rubber  instru- 
ment, to  the  end  of  which  is  attached  a  portion  of  drainage-tube 
about  3  feet  long,  and  beyond  this  a  glass  funnel,  into  which  the 


BLADDER  AND  PROSTATE  1079 


material  employed  is  poured.  By  raising  the  funnel  the  fluid  runs 
into  the  bladder,  whilst  on  depressing  it  below  the  bed  or  couch 
the  fluid  returns  on  the  syphon  principle.  The  patient's  sensa- 
tions must  guide  the  surgeon  as  to  how  much  fluid  can  be  borne 
in  any  particular  case.  Various  solutions  are  employed  for  this 
purpose,  but  perhaps  the  most  useful  are  weak  Condy's  fluid, 
sanitas  (1  in  10),  boric  acid  (20  grains  to  1  ounce),  perchloride  of 
mercury  (1  in  2,000),  or  a  neutral  solution  of  quinine  (2  grains  to 
1  ounce),  and  they  may  be  used  alternately  with  advantage. 
The  frequency  with  which  the  injections  are  made  must  vary 
with  the  severity  of  the  symptoms  ;  it  is  not  often  necessary  to 
perform  the  operation  more  than  once  ur  twice  a  day. 

At  the  same  time  that  this  local  treatment  is  being  adopted, 
the  patient's  general  habits  of  life  must  be  regulated.  The  diet 
should  be  bland  and  unstimulating  ;  alcohol  is  better  avoided, 
but  if  essential  for  other  reasons,  well-diluted  gin  or  whisky  may 
be  given.  Tea  and  coffee  should  be  prohibited,  whilst  a  milk 
diet  is  perhaps  the  best  which  can  be  employed.  As  to  medicines, 
there  are  none  which  can  alter  the  reaction  of  the  urine  from 
alkaline  to  acid,  but  perhaps  salol,  boric  acid,  or  benzoic  acid 
may  be  of  some  assistance.  Urotropine  is  useful,  acting  by  setting 
free  formalin  in  the  bladder.  Hot  infusions  of  buchu,  uva  ursi, 
and  triticum  repens,  act  as  mild  diuretics,  and  as  alteratives  to 
the  vesical  mucous  membrane  ;  full  doses,  however,  such  as  a 
pint  or  a  pint  and  a  half  in  the  course  of  the  day,  are  needed. 
Where  much  muco-pus  is  excreted,  copaiba,  cubebs,  turpentine, 
or  sandal-wood  oil  may  be  given,  whilst  injections  of  dilute 
astringents  have  been  advised,  but  must  be  used  with  caution. 

In  cases  which  do  not  improve,  and  if  the  patient  is  becoming 
exhausted  from  the  constant  interference  with  his  rest,  etc.,  the 
only  means  of  treatment  left  is  that  of  opening  the  bladder  through 
a  perineal  incision.  Perineal  Cystotomy  is  undertaken  not  only  for 
the  draining  of  a  chronically  inflamed  bladder,  but  also  to  explore 
the  mucous  lining  of  the  viscus,  to  remove  growths  and  foreign 
bodies,  as  also  sometimes  to  deal  with  prostatic  enlargements  and 
calculi.  The  bladder  is  first  thoroughly  washed  out,  a  few  ounces 
of  antiseptic  solution  being  left  within  it.  After  anaesthesia  has 
been  induced,  a  staff  with  a  median  groove  is  passed  into  the 
bladder,  and  then  the  patient  is  placed  in  the  lithotomy  position, 
and  the  perineum  shaved.  An  incision  is  made  in  the  middle 
line  of  the  perineum,  from  a  point  n\  inches  in  front  of  the  anus 
to  about  1  inch  from  that  opening.  The  knife  divides  the  deeper 
structures  of  the  perineum,  and,  guided  by  the  left  index-finger  in 
the  wound,  is  made  to  enter  the  groove  in  the  staff  at  a  point 
corresponding  to  the  membranous  portion  of  the  urethra.  It  is 
then  carried  upwards  and  backwards  along  the  groove,  incising 
the  prostate  and  entering  the  bladder.  The  knife  is  carefully 
withdrawn,    the   finger    gently   inserted    into    the    bladder,    and 


ioSo  A   MANUAL  OF  SURGERY 


the  staff  removed.  After  digital  exploration  of  the  bladder,  a 
full-sized  gum-elastic  catheter  (No.  16  or  18)  is  passed  in  through 
the  wound  and  fixed,  a  long  piece  of  rubber  tubing  being  attached 
to  allow  of  the  constant  escape  of  the  urine,  as  well  as  to  permit 
of  occasional  irrigation.  The  catheter  is  removed  and  changed 
at  the  end  of  forty-eight  hours,  and  in  favourable  cases  may  be 
discontinued  altogether  at  the  end  of  a  week ;  in  severer  cases  a 
permanent  opening  may  have  to  be  maintained. 

Tuberculous  Disease  of  the  Bladder  may  be  primary  or  secondary, 
the  latter  being  the  more  usual  and  extending  from  the  kidney, 
prostate,  or  testicle.  It  is  much  more  common  in  men  than  in 
women,  and  is  most  frequently  seen  in  young  adults.  It  com- 
mences in  the  submucous  tissue  as  a  deposit  of  miliary  tubercle, 
which  caseates  and  suppurates,  breaking  down,  and  giving  rise  to 
ulcers  with  undermined  edges  ;  these  are  rarely  of  large  size  at 
first,  are  usually  multiple,  and  situated  in  or  near  the  trigone. 
The  Symptoms  are  those  of  chronic  cystitis  and  hsematuria,  the 
irritability  of  the  viscus  being  very  marked.  The  diagnosis  is 
made  by  demonstrating  the  bacillus  of  tubercle  in  the  urine,  and 
by  the  cystoscope.  The  course  of  the  case  is  unfavourable,  the 
ulcers  increasing  in  size,  and  death  resulting  from  exhaustion, 
general  infection,  phthisis,  or  extension  to  the  kidneys. 

Treatment. — The  case  is  usually  treated  for  some  time  as  one 
of  chronic  cystitis  before  its  nature  as  a  tuberculous  affection  is 
ascertained.  In  the  milder  cases  it  may  suffice  to  attend  to  the 
general  health  and  hygiene  of  the  individual,  and  to  wash  out  the 
bladder  with  some  antiseptic  two  or  three  times  a  week,  leaving 
a  drachm  or  two  of  a  10  per  cent,  solution  of  iodoform  in  olive 
oil  or  glycerine  within  the  viscus.  In  more  advanced  cases 
cystotomy  has  been  undertaken  by  the  suprapubic  method,  and 
the  ulcerated  surfaces  scraped  and  disinfected  by  applying  the 
galvano-cautery  or  pure  carbolic  acid.  To  effect  this  the  method 
suggested  by  Mr.  Hurry  Fenwick,  of  using  a  suitable  speculum 
as  a  caisson  through  which  to  work,  is  especially  to  be  recom- 
mended. It  is  doubtful,  however,  whether  such  practice  is  of 
much  ultimate  value.  When  the  primary  lesion  in  kidney  or  testis 
is  efficiently  treated,  a  secondary  bladder  trouble  often  improves. 

Very  similar  Symptoms  may  be  induced  by  the  presence  of  a 
Simple  Ulcer  of  the  Bladder,  which,  according  to  Fenwick,  occurs 
not  unfrequently.  It  is  usually  single,  and  situated  near  the  neck 
or  trigone,  giving  rise  to  great  irritability  of  the  viscus  and  haema- 
turia,  although  the  urine  remains  clear.  The  diagnosis  is  best 
made  by  the  cystoscope.  Phosphatic  deposits  sometimes  form 
over  the  ulcerated  surface,  and  may  suggest  the  existence  of  a 
stone.  Treatment  consists  in  washing  out  the  bladder  with  lactic 
acid  (^  to  3  per  cent.),  or  in  scraping  and  cauterizing  the  base  of 
the  sore  through  a  suprapubic  incision. 


BLADDER  AND  PROSTATE 


ioSr 


Tumours  of  the  Bladder. 

New  growths  from  the  vesical  wall  are  not  very  uncommon ; 
they  may  be  simple  or  malignant. 

Simple  Tumours  occur  in  the  form  of  fibroma  and  myxoma,  but 
that  most  often  seen  is  the  Papillomatous  or  Villous  Tumour, 
which  appears  as  a  soft  flocculent  mass,  usually  situated  near  the 

trigone,  and  close  to  the  open- 
ing of  one  of  the  ureters 
(Fig.  378).  The  floating  tufts 
or  villous  processes  consist  of 
an  extremely  delicate  con- 
nective tissue,  covered  with 
a  layer  or  two  of  epithelium 
similar  to  that  lining  the 
bladder,  and  traversed  by 
bloodvessels.  Occasionally  the 
growths  have  a  narrow  base, 
and  are  pedunculated,  but 
more  frequently  are  sessile. 
They  may  be  single,  or  may 
multiply  rapidly,  and  spread 
all  over  the  bladder  by  in- 
fection from  the  primary 
growth. 

The  Symptoms  are  those 
of  recurrent  haemorrhage,  the 
blood  being  of  a  bright  red 
colour,  followed  later  on  by  irritability  of  the  bladder.  At  first 
the  haemorrhage  is  intermittent,  considerable  intervals  occurring 
between  the  attacks ;  but  subsequently  it  becomes  more  con- 
tinuous. The  irritability  of  the  bladder  is  generally  induced  by 
chronic  cystitis,  and  when  the  urine  has  undergone  alkaline 
changes,  there  is  a  copious  exudation  of  ropy  mucus  which, 
mixing  with  the  urine,  causes  considerable  difficulty  in  mic- 
turition, leading  in  some  cases  to  strangury.  On  standing,  this 
deposit  becomes  so  tenacious  and  jelly-like  as  to  be  poured  with 
difficulty  from  one  vessel  to  another.  The  urine  may  also  contain 
portions  of  the  tumour  which  have  been  set  free,  and  occasionally, 
if  situated  near  the  neck  of  the  bladder,  some  of  the  fimbriated 
ends  may  be  swept  into  the  urethral  orifice,  and  interfere  with 
micturition.  In  the  same  way  the  opening  of  one  or  both  ureters 
may  be  encroached  upon,  leading  to  hydronephrosis.  On  examina- 
tion of  the  bladder  with  a  sound,  nothing  definite  can  be  detected, 
unless  the  surface  of  the  growth  becomes  encrusted  with  phos- 
phates, and  no  abnormality  is  noticed  on  rectal  examination. 
Occasionally  a  small  portion  of  the  growth  may  be  caught  in  the 
eye  of  a  catheter. 


Fig.  378. — Villous  Tumour  of  the 
Bladder.  (From  King's  College 
Museum.) 


1082 


A   MANUAL  OF  SURGERY 


The  Prognosis  of  the  case  is  unsatisfactory,  since,  although  the 
growth  is  not  at  first  malignant,  it  often  becomes  so,  and  leads  to 
a  fatal  termination  through  exhaustion,  haemorrhage,  or  septic 
complications. 

Sarcoma  of  the  bladder  is  an  unusual  disease,  more  often  seen 
in  children  than  in  adults.  In  the  former  it  gives  rise  to  multiple 
polypoid  growths,  in  the  latter  it  is  usually  single  and  sessile. 
The  tumour  grows  rapidly  and  may  attain  considerable  dimensions, 
spreading  outside  the  bladder  and  even  invading  the  pelvic  bones. 
Lymphatic  glands  are  often  implicated  at  an  early  date. 

Cancer  of  the  bladder  may  originate  in  that  viscus,  or  may 


Fig.  379. —  Cancer  of  Bladder.     (Royal  College  of  Surgeons'  Museum.) 


spread  to  it  from  the  rectum  or  neighbouring  organs.  In  the 
former  case,  a  squamous  epithelioma  is  the  usual  type ;  in  the 
latter,  the  nature  of  the  growth  is,  of  course,  similar  to  that  of 
the  primary  disease  ;  thus,  when  secondary  to  rectal  cancer,  the 
tumour  is  of  a  columnar  type.  Most  frequently  the  affection 
commences  in  the  posterior  wall  above  the  trigone,  extending 
forwards  to  the  neck  of  the  bladder.  The  growth  is  sometimes 
superficial,  projecting  into  the  vesical  cavity  as  a  soft  spongy 
mass,  which  does  not  ulcerate  early,  or  invade  the  muscular 
walls  till  late  ;  but  more  frequently  the  neoplasm  extends  into 
and  infiltrates  the  walls,  whilst  marked  ulceration  is  also  present 


BLADDER  AND  PROSTATE  1083 

(Fig.  379),  the  raw  surface  often  becoming  coated  in  places  with 
a  phosphatic  deposit.  A  cancerous  growth  in  the  bladder  is 
always  more  or  less  likely  to  become  papillated.  The  disease  is 
much  more  common  in  men  than  in  women. 

The  Symptoms  vary  somewhat  in  these  two  forms,  although 
the  conspicuous  features  of  each  are  haematuria  and  irritability 
of  the  bladder.  In  the  slowly  growing  superficial  variety,  the 
tumour  often  attains  a  considerable  size  before  causing  any 
trouble,  beyond  possibly  some  slight  irritability  of  the  bladder. 
A  severe  attack  of  haematuria,  unaccompanied  by  pain,  is  usually 
the  first  symptom  of  importance,  and  may  be  induced  by  some 
injury  which  causes  a  crack  or  fissure  in  the  growth.  This  pain- 
less haematuria  closely  simulates  the  early  symptoms  of  a  simple 
villous  tumour,  but  is  more  persistent,  and  yields  less  readily  to 
treatment.  After  one  or  more  of  such  prolonged  attacks,  cystitis 
follows,  and  the  subsequent  history  resembles  that  of  the  harder 
and  more  rapidly  growing  infiltrating  tumours.  In  such  the 
symptoms  of  vesical  irritability  precede  those  of  haematuria. 
Dysuria  and  severe  pain  referred  to  the  bladder  and  perineum 
are  complained  of,  and  the  urine  early  becomes  alkaline  and 
putrescent ;  shreds  of  the  growth  may  also  be  found  in  the  urine 
on  microscopic  examination.  If  the  tumour  involves  the  internal 
meatus,  micturition  may  be  considerably  impaired,  whilst  if  the 
orifices  of  the  ureters  are  obstructed,  hydronephrosis  results. 
On  passing  a  sound,  the  tumour  can  be  detected  as  an  irregular 
mass  projecting  into  the  bladder,  whilst  the  posterior  vesical  wall 
may  be  felt  per  rectum  to  be  hard  and  resistant ;  its  ulcerated 
surface  may  also  be  seen  with  the  cystoscope. 

The  course  of  the  case  is  similar  to  that  of  a  somewhat  rapidly 
growing  carcinoma,  leading  to  early  and  marked  cachexia,  in- 
creased by  the  sleeplessness  resulting  from  the  vesical  irritation  ; 
secondary  deposits  are  found  in  the  viscera  and  lumbar  glands, 
whilst  perforation  of  the  wall  may  occasionally  follow,  causing 
urinary  extravasation,  septic  cellulitis,  and  death.  Another  most 
distressing  complication  is  the  establishment  of  a  recto-vesical 
fistula,  through  which  the  urine  makes  its  way  into  the  rectum, 
thus  intensifying  the  sufferings  of  the  patient. 

The  Diagnosis  of  a  vesical  tumour  can  only  be  made  with 
certainty  by  the  cystoscope,  or  by  discovering  fragments  of  its 
substance  in  the  urine,  though  in  the  female  it  is  easy  to  dilate 
the  urethra,  and  explore  the  bladder  with  the  finger.  Whenever 
haemorrhage  is  associated  with  marked  vesical  irritability,  and 
cannot  otherwise  be  explained,  a  tumour  of  the  bladder  may  be 
suspected.  The  question  as  to  whether  or  not  it  is  malignant 
can  only  be  determined  by  a  careful  examination  of  the  symptoms. 
In  simple  papilloma,  and  the  superficial  type  of  epithelioma, 
haemorrhage  precedes  the  irritability ;  but  whilst  it  is  usually  im- 
possible to  detect  the  villous  growth  either  by  examination  with 


1084  A   MANUAL  OF  SURGERY 

the  sound  or  from  the  rectum,  a  fungating  malignant  growth  may 
sometimes  be  recognised  by  the  sound.  In  the  infiltrating  type 
of  malignant  disease,  on  the  other  hand,  pain  and  dysuria  always 
precede  the  bleeding  for  a  considerable  interval,  whilst  definite 
evidence  of  the  existence  of  the  growth  can  usually  be  made  out, 
both  by  the  sound  and  on  rectal  examination.  A  worn  and 
exhausted  appearance  must  not  be  looked  on  as  necessarily  the 
outcome  of  advanced  cancerous  cachexia,  since  the  loss  of  rest 
and  sleep  due  to  chronic  vesical  irritability  can  of  itself  lead  to  a 
somewhat  similar  condition. 

Treatment  of  Tumours  of  the  Bladder.  —  In  the  early  stages, 
when  the  diagnosis  of  a  tumour  has  not  been  confirmed,  the 
haematuria  may  be  treated  with  ordinary  haemostatic  remedies, 
such  as  a  mixture  containing  dilute  sulphuric  acid  and  ergot,  or 
turpentine  administered  in  capsules  (10  minims  three  times  a  day). 
When  once  a  diagnosis  has  been  established,  removal  by  operation 
is  the  only  plan  which  holds  out  any  hope  to  the  patient,  and  such 
can  only  be  undertaken  with  any  prospect  of  success  in  benign 
growths,  or  in  the  very  earliest  stages  of  the  superficial  form  of 
malignant  disease.  The  bladder  is  laid  open  either  by  perineal 
or  suprapubic  cystotomy,  and  the  growth  removed  by  the  curette. 
The  suprapubic  operation  is  certainly  preferable,  in  that  it  gives 
one  the  opportunity  of  definitely  seeing  the  interior  of  the  bladder. 
The  plan  already  mentioned  of  employing  an  expanding  speculum 
as  a  caisson  will  be  found  useful ;  when  all  moisture  has  been 
sponged  away  or  sucked  up,  the  vesical  wall  is  seen  at  the  bottom 
of  this  tube  by  means  of  an  electric  lamp  fitted  to  the  surgeon's 
head.  In  default  of  a  better  instrument,  a  Fergusson's  speculum 
can  be  utilized.  Growths  may  be  removed  by  means  of  long- 
handled  instruments  specially  adapted  for  the  purpose,  and  the 
base  from  which  they  spring  must  be  carefully  cauterized. 

When  removal  is  impracticable,  it  only  remains  to  ease  the 
patient's  sufferings  by  means  of  morphia,  the  bladder  also  being 
occasionally  washed  out ;  but  if  the  irritability  is  very  great,  a 
permanent  suprapubic  or  perineal  opening  may  be  established. 

Functional  Derangements  of  the  Bladder. 

Incontinence  of  Urine. — -A  patient  is  said  to  be  suffering  from 
incontinence  when  the  urine  escapes  involuntarily,  dribbling  away 
either  constantly  or  intermittently  from  the  urethra. 

i.  Active  Incontinence  is  often  present  in  young  children,  mostly 
boys.  It  results  from  some  condition  of  increased  excitability  of 
the  urinary  apparatus,  and  is  looked  on  by  some  as  of  a  choreic 
nature ;  in  other  instances,  it  is  probably  due  to  weakness  of  the 
sphincter  vesicae,  which  is  unable  to  resist  the  pressure  induced 
by  even  a  small  amount  of  urine.  The  chief  sources  of  irritation 
are  phimosis,  ascarides  in  the  rectum,  a  rectal  polypus,  or  urine 


BLADDER  AND  PROSTATE  1085 


of  high  specific  gravity,  containing  uric  acid  crystals  in  suspen- 
sion. The  affection  is  most  obvious  at  night,  and,  indeed,  may 
only  occur  during  sleep ;  it  has  been  known  to  persist  till  adult 
life  is  reached.  Somewhat  similar  in  nature  to  this  is  the  irrita- 
bility of  the  bladder  induced  by  calculus,  inflammation,  or  ulcera- 
tion, where  frequent  calls  to  micturition  are  experienced ;  to  this, 
however,  the  term  '  irritability  of  the  bladder '  is  applied,  '  incon- 
tinence '  being  only  used  where  no  active  disease  of  the  viscus  is 
present. 

Treatment  of  the  nocturnal  incontinence  consists  in  the  removal 
of  all  sources  of  irritation,  such  as  a  tight  foreskin,  whilst  the 
child  is  waked  from  sleep  at  regular  intervals  in  order  to  pass 
water,  so  as  to  break  him  of  the  bad  habit.  Tonics,  e.g.,  iron, 
arsenic,  and  quinine,  may  be  administered,  and  tincture  of  bella- 
donna should  also  be  given  in  full  doses.  Instruments  have  been 
used  for  compressing  the  urethra  at  night,  and  are  stated  in  some 
cases  to  have  effected  a  cure. 

2.  Passive  Incontinence  is  said  to  be  present  when  the  neck  of 
the  bladder  is  relaxed,  so  that  as  soon  as  any  urine  is  secreted,  it 
flows  out  of  the  urethra,  the  bladder  in  this  way  never  becoming 
distended.  It  arises  mainly  from  two  causes  :  (a)  Paralysis  of 
the  sphincter  vesicae,  as  a  result  of  some  injury  or  disease  of  the 
spinal  cord,  which  may  either  temporarily  or  permanently  impair 
its  function.  Thus,  in  severe  shock,  the  bladder  is  unconsciously 
evacuated  from  relaxation  of  the  sphincter ;  but  if  the  lumbar 
cord  is  not  compressed  or  destroyed,  the  function  is  soon  regained. 
Any  lesion  involving  the  centre  for  the  sphincter  necessarily 
destroys  its  future  utility,  and  results  in  permanent  incontinence. 
It  is  quite  possible  for  the  detrusor  centre  to  be  damaged  without 
injury  to  the  sphincter,  and  in  such  a  case  distension  of  the  bladder 
with  subsequent  overflow  supervenes.  Paralytic  incontinence 
occasionally  follows  overdistension  of  the  female  urethra  for  the 
removal  of  a  calculus.  Nothing  can  be  done  for  either  of  these 
conditions,  if  permanent,  beyond  the  application  of  a  suitable 
urinal,  (b)  Mechanical  Incontinence  sometimes  results  from  the 
impaction  of  a  calculus  in  the  internal  meatus,  or  from  its 
dilatation  by  a  pedunculated  growth  from  the  prostate. 

3.  False  Incontinence,  or  Distension  with  Overflow,  is  due  to 
any  condition  in  which  the  outflow  of  urine  is  impeded  to  such 
an  extent  as  to  lead  to  a  certain  quantity  being  left  in  the  bladder 
after  every  act  of  micturition,  although  the  patient  imagines  that 
the  organ  has  been  completely  emptied.  This  so-called  residual 
urine  gradually  increases  in  amount  until  the  bladder  becomes 
filled,  and  then  some  of  it  dribbles  away  involuntarily  so  as  to 
wet  the  patient's  clothes.  In  old-standing  cases  the  bladder  can 
be  detected  as  a  tense,  rounded  swelling  in  the  hypogastrium. 
This  condition  is  usually  met  with  in  patients  with  neglected 
stricture  or  enlargement  of  the  prostate,  and  in  the  latter  case  the 


io86  A  MANUAL  OF  SURGERY 


bladder  may  be  so  distended  as  to  contain  several  pints  of  urine. 
Very  much  the  same  state  of  things  obtains  in  paralysis  due  to 
spinal  mischief  (p.  643).  Treatment  must  be  directed  to  keeping 
the  bladder  emptied  by  the  regular  use  of  the  catheter,  but  it 
often  remains  in  an  atonic  state  for  some  time. 

Atony  of  the  Bladder  is  the  term  applied  to  a  condition  in  which 
the  patient  is  unable  to  expel  its  contents,  not  in  consequence  of 
any  true  paralysis  of  the  muscular  walls,  but  simply  from  loss  of 
tone.  The  most  usual  causes  are:  (1)  Chronic  overdistension,  the 
result  of  obstruction  to  the  outflow,  owing  to  enlarged  prostate  or 
stricture,  as  just  described  :  (2)  a  single  prolonged  voluntary  or 
involuntary  overdistension  ;  for  instance,  owing  to  the  oversight 
of  a  house-surgeon,  a  patient  suffering  from  retention  after  an 
operation  for  varicocele  was  left  unrelieved  for  more  than  twenty- 
four  hours,  whereby  atony  was  induced.  (3)  It  occasionally 
follows  cystitis,  especially  that  associated  with  gonorrhoea.  (4)  In 
old  age  atony  is  sometimes  due  to  simple  loss  of  nerve  tone,  a 
condition  very  similar  to  that  which  occurs  after  or  in  the  course 
of  infective  fevers,  such  as  typhus,  and  is  even  met  with  after 
influenza. 

In  the  slighter  cases  all  that  is  noticed  is  some  hesitation  or 
difficulty  in  commencing  the  act  of  micturition,  whilst  the  flow 
of  urine  is  weak,  and  cannot  be  efficiently  completed,  a  few  drops 
dribbling  away  afterwards.  In  worse  cases  a  considerable  amount 
of  residual  urine  may  be  left  in  the  bladder,  and  this  may  lead 
to  chronic  distension  with  overflow,  and  by  its  decomposition  to 
chronic  cystitis.  In  other  cases  actual  retention  may  be  induced. 
The  Treatment  should  be  directed  to  removing  any  source  of 
obstruction  which  exists,  whilst  regular  catheterism  two  or  three 
times  a  day  will  prevent  any  distension  of  the  bladder,  and  the 
administration  of  strychnine,  phosphoric  acid,  and  other  tonics, 
will  improve  the  expulsive  power  of  the  viscus.  The  passage  of 
a  constant  current  of  electricity  may  also  be  employed  two  or 
three  times  a  week,  to  stimulate  the  muscular  fibres  ;  one  elec- 
trode is  inserted  into  the  bladder,  and  the  other  placed  over  the 
hypogastrium. 

Retention  of  Urine. — When  a  person  is  unable  to  expel  the 
contents  of  the  bladder,  so  that  it  becomes  distended,  retention 
is  said  to  be  present.  It  results  from  a  variety  of  conditions, 
classified  as  follows  :  (1)  Penile  and  urethral  causes,  e.g.,  phimosis, 
or  congenital  occlusion  of  the  urethra,  a  ligature  or  ring  placed 
around  the  penis,  impacted  calculus,  the  so-called  congestive  or 
spasmodic  stricture,  organic  stricture,  urethral  or  perineal  abscess, 
ruptured  urethra,  etc. :  (2)  Prostatic  causes,  e.g.,  inflammation, 
abscess,  tumour,  hypertrophy,  calculus :  (3)  Vesical  causes,  e.g., 
atony,  paralysis,  calculus,  tumours,  etc. :  (4)  Reflex  irritation, 
such  as  occurs  after  operations  on  the  rectum  and  anus,  or  in- 
volving  the   spermatic   cord  :     (5)    Hysteria :    (6)    Pressure    from 


BLADDER  AND  PROSTATE  10S7 

neighbouring  organs  or  external  tumours,  e.g.,  uterine  fibroids, 
or  retroversion  of  the  gravid  uterus.  In  investigating  any 
particular  case,  the  age  and  condition  of  the  patient  must  be 
taken  into  consideration,  and  also  the  character  of  any  preceding 
urinary  symptoms,  whilst  a  careful  examination  should  be  made. 
Speaking  generally,  one  may  state  that  the  most  common  cause 
of  retention  in  infants  is  phimosis  ;  in  children,  impacted  calculus, 
or  a  ligature  around  the  penis  :  in  young  men,  gonorrhoea  or 
one  "of  its  complications;  in  young  women,  hysteria,  or  foreign 
bodies  in  the  bladder  ;  in  adult  men,  stricture  ;  in  adult  women 
some  uterine  condition  ;  and,  in  old  men,  hypertrophy  of  the 
prostate. 

If  left  unrelieved,  the  urine  accumulates  and  the  bladder 
becomes  distended,  giving  rise  to  much  pain  and  discomfort.  One 
of  two  conditions  is  certain  to  follow  :  (a)  In  cases  of  retention 
from  stricture  the  dilated  urethra  behind  the  seat  of  obstruction 
gives  way,  resulting  in  extravasation  of  urine.  If,  however,  the 
bladder  wall  is  weakened  by  the  presence  of  sacculation,  rupture 
of  a  saccule  may  follow,  causing  pelvic  extravasation,  (b)  When 
the  retention  arises  from  atony  or  paralysis,  or  from  some  ob- 
struction which  can  be  to  some  extent  overcome,  distension  with 
overflow  is  produced. 

Inasmuch  as  retention  is  merely  a  symptom,  the  treatment 
necessarily  varies  with  the  cause. 

Abnormal  Conditions  of  the  Urine. 

1.  Urinary  Deposits. — Uric  or  lithic  acid  is  eliminated  in  the 
form  of  '  cayenne-pepper '  granules,  usually  known  as  gravel. 
On  microscopic  examination,  the  granules  are  found  to  consist 
of  flat  rhomboidal,  lozenge-shaped  plates,  or  masses  of  acicular 
crystals  (Fig.  380).  They  are  of  a  dusky  brownish-red  colour,  due 
to'  the  absorption  of  urobilin,  the  normal  pigment  of  the  urine. 
The  secretion  in  these  cases  is  always  acid,  and  usually  of  high 
specific  gravity.  The  deposit  is  not  soluble  in  boiling  water,  but 
readily  so  in  alkaline  fluids ;  and  on  reacidulating  such  a  solu- 
tion, the  uric  acid  is  precipitated  in  the  shape  of  white  needle- 
shaped  crystals. 

Urates  or  lithates  of  potassium,  sodium,  or  ammonium  are  of 
frequent  occurrence  in  the  urine,  appearing  as  a  deposit  of 
amorphous  granules  of  variable  colour,  according  to  the  amount 
of  urinary  pigment  present,  and  this  is  often  known  as  a  '  lateri- 
tious,'  or  brick-dust  sediment.  The  ammonium  salt  is  sometimes 
found  in  the  shape  of  spiculated  globular  bodies  (Fig.  381). 
Urates  always  occur  in  acid  urine  of  high  specific  gravity,  and 
are  freely  soluble  in  boiling  water ;  on  the  addition  of  dilute 
hydrochloric  acid  the  uric  acid  is  precipitated.  The  muvexide  test 
may  be  applied  either  for  uric  acid  or  its  salts  ;    it  consists  in 


A   MANUAL  OF  SURGERY 


mixing  the  substance  to  be  tested  with  a  little  nitric  acid,  and 
evaporating  to  dryness,  when  an  orange-red  discoloration  is  pro- 
duced, which  on  the  addition  of  liquor  ammonia?  changes  to  a  deep 
purple-red. 

A  deposit  of  uric  acid  or  urates  is  either  a  temporary  condition 
dependent  on  some  trivial  derangement  of  the  system,  or  is  a 
phenomenon  constantly  recurring  and  due  to  too  great  an  in- 
dulgence in  nitrogenous  food,  too  little  fresh  air  and  exercise,  or 
imperfect  digestion,  the  result  of  some  hepatic  disturbance.  It 
is  also  noted  in  conditions  where  great  tissue  change  is  occurring, 
as  after  violent  exercise  or  in  fevers.  Under  these  circumstances 
the  materials  which  should  be  changed  into  urea  are  transformed 
into  uric  acid  or  its  salts.     When  such  a  tendency  is  continually 


i£*>.to 


r 


'  jp'-' 


j# 


Fig.  380 — Uric  Aciu  Crystals. 


Fig.  381. — Urate  of  Ammonium 
in  Amorphous  Granules  and 
Hedgehog-shaped  Bodies. 


present,  the  patient  is  often  said  to  be  suffering  from  Lithiasis  or 
Lithsemia.  Should  the  individual  be  incapable  of  eliminating  the 
material  thus  formed,  an  attack  of  gout  or  rheumatism  is  likely 
to  supervene,  whilst  it  must  always  be  borne  in  mind  that  the 
formation  of  a  uric  acid  calculus  is  merely  a  manifestation  of  the 
same  diathesis,  which  needs  careful  treatment  after  the  removal 
of  the  stone,  if  a  recurrence  of  this  painful  affection  is  to  be 
prevented. 

The  Treatment  of  lithsemia  or  lithiasis  consists  mainly  in  atten- 
tion to  the  personal  hygiene.  The  patient's  diet  is  regulated,  all 
sweets,  pastry,  and  alcoholic  stimulants  (with  the  exception, 
perhaps,  of  a  little  whisky  well  diluted  with  lithia  or  potash 
water)  being  avoided.  Regular  habits  are  enforced,  and  plenty 
of  outdoor  exercise  recommended.  The  hepatic  secretion  is 
stimulated,  and  the  bowels  regulated  by  the  administration  of 
saline  purgatives,  especially  natural  mineral  waters,  e.g.,  Fried- 
richshall,  Carlsbad,  or  Hunyadi  Janos,  whilst  an  occasional 
dose  of  blue  pill  or  podophyllin  is  advisable.  Lithia  salts  and 
piperazine  have  also  been  employed  with  advantage. 

Oxalate  of  lime  usually  occurs  in  the  urine  of  dyspeptic  and 
hypochondriacal  patients,  who  are  pale,  nervous,  and  irritable. 


BLADDER  AND  PROSTATE 


1089 


It  is  supposed  to  arise  from  the  incomplete  oxidation  of  carbo- 
hydrate foods.  The  urine  is  of  low  specific  gravity,  pale  and 
abundant  in  quantity,  and  slightly  acid  in  reaction  ;  an  excess  of 
mucus  is  usually  present,  causing  the  crystals  to  adhere  to  any 
irregularities  in  a  test  glass.  On  microscopic  examination  they 
are  found  to  be  regular  octahedra,  or  in  the  shape  of  dumb-bells 
(Fig.  382).     The  tve.atment  of  oxaluria  consists  in  regulation  of 


Fig   382. — Oxalate  of  Lime  in  Octahedral  Crystals  and  Dumb-bell- 
shaped  Masses. 

the  diet,  which  must  be  light  and  nourishing,  all  heavy  food 
being  avoided,  as  also  rhubarb,  which  contains  large  quantities  of 
oxalates,  and  the  patient  is  directed  to  drink  only  boiled  or  dis- 
tilled water.  Tonics,  such  as  mineral  acids,  iron,  and  quinine, 
may  be  ordered,  but  the  best  treatment  consists  in  change  of  air 
and  removal,  if  possible,  from  causes  of  anxiety  and  worry. 

Phosphatic  deposits  in  the  urine  occur  in  three  forms :  (i.)  The 
triple  phosphate,  or  ammonio-magnesic,  is  found  in  alkaline  or 


4^ 


Fig.  383. — Crystals  of  Triple  Phosphate  in  Urine. 

decomposing  urine,  and  is  always  vesical  in  origin.  It  exists  in 
the  form  of  hexagonal  prisms,  three  of  the  sides,  however,  being 
very  narrow  ;  the  ends  also  are  bevelled  off,  so  that  the  appear- 
ance of  a  '  knife-rest '  is  produced  (Fig.  383).  (ii.)  The  amorphous 
phosphate  of  lime  is  exceedingly  common,  forming  the  main 
mass  of  any  phosphatic  sediment.  It  is  always  present  in  chronic 
cystitis,  and  is  not  unfrequently  met  with  a  few  hours  after  a 
meal,  constituting  what  is  known  as  the  'alkaline  tide.'  This 
condition  is  often  observed  about  twelve  o'clock  in  the  morning, 
especially  if  an  alkaline  saline  purgative  has  been  taken  before 
breakfast.  The  phosphatic  material  is  voided  at  the  end  of  the 
act   of   micturition,  and   may  give  rise  to  considerable   anxiety 

69 


logo  A   MANUAL  OF  SURGERY 


on  the  part  of  the  patient,  who  mistakes  it  for  seminal  fluid, 
(iii.)  The  most  usual  condition  in  which  phosphates  are  met  with 
in  urine  is  a  mixture  of  the  two  varieties  described  above.  Which- 
ever form  is  present,  the  deposit  becomes  more  evident  on  boiling, 
disappearing,  however,  on  the  addition  of  a  few  drops  of  acid. 
The  treatment  of  phosphaturia  is  always  directed  to  the  vesical 
condition,  except  in  those  unusual  cases  where  it  is  due  to  some 
constitutional  error. 

2.  Hematuria,  or  the  admixture  of  blood  with  the  urine,  is 
best  described  according  to  the  source  from  which  the  blood 
is  derived. 

(a)  Renal  hematuria  results  from  acute  inflammation,  conges- 
tion, calculus,  tumours,  or  injuries  of  the  kidney.  The  urine  is 
sometimes  deeply  coloured  with  the  blood,  and  may  be  as  dark 
as  porter.  Blood  casts  of  the  renal  tubules  are  often  observed, 
and  even  long  sinuous  clots,  corresponding  to  the  shape  of  the 
ureter. 

(b)  Vesical  haematuria  is  due  to  injury,  calculus,  tumours,  ulcera- 
tion, simple  congestion  of  the  bladder  with  varicosity  of  the 
vesical  veins,  or  the  presence  of  the  Bilharzia  luematobia.  The 
blood  is  intimately  mixed  with  the  urine,  but  is  more  abundant 
at  the  end  of  micturition,  and  clots  are  often  present. 

The  Bilharzia  is  a  parasite  which  inhabits  some  of  the  rivers 
and  pools  of  South  Africa.  It  is  taken  into  the  system  by  the 
mouth,  and  may  develop  either  in  the  urinary  track,  or  sometimes 
in  the  lower  bowel  (p.  1027).  The  adult  worms  are  found  in  the 
body  inhabiting  the  radicals  of  the  portal  and  vesical  veins,  and 
discharge  their  ova  through  the  mucous  membrane  of  the  bowel 
or  bladder,  giving  rise  to  haemorrhage.  By  an  extension  to  the 
kidney,  pyonephrosis  may  be  induced.  No  specific  treatment 
has  at  present  been  discovered,  but  in  most  cases  the  disease 
after  a  time  disappears  spontaneously. 

(c)  Prostatic  haematuria  may  be  caused  by  congestion,  calculus, 
ulceration,  or  malignant  disease ;  the  blood  passes  back  into  the 
bladder,  and  hence  the  phenomena  simulate  the  vesical  condition. 
Examination  of  the  prostate  from  the  rectum  may,  however,  give 
a  clue  to  the  source  of  the  mischief. 

(d)  Urethral  haematuria  arises  from  acute  gonorrhoea,  laceration, 
or  instrumentation.  The  blood  often  flows  from  the  urethra  in- 
dependently of  micturition,  whilst  the  first  few  drops  of  the  stream 
are  also  coloured. 

(e)  Haematuria  is  occasionally  of  constitutional  origin,  arising 
from  purpura,  scurvy,  or  haemophilia ;  other  evidences  of  these 
diseases  will  be  observed,  and  render  the  diagnosis  evident. 

Microscopical  examination  of  the  urine  should  always  be  made 
to  ascertain  whether  or  not  blood  corpuscles  are  present,  since 
the  condition  may  be  simulated  by  that  known  as  '  paroxysmal 
haemoglobinuria,'   in   which    corpuscles   are   absent.     The   latter 


BLADDER  AND  PROSTATE  109 1 

condition  is  supposed  to  be  due  to  vaso-motor  spasm  of  the  renal 
vessels,  and  is  not  uncommonly  associated  with  Raynaud's  disease. 

The  only  certain  test  for  the  presence  of  blood  is  by  spectrum 
analysis ;  but  that  most  usually  relied  on  consists  in  mixing 
together  equal  parts  of  tincture  of  guaiacum  and  ozonic  ether. 
The  suspected  urine  is  subsequently  added,  and  sinks  to  the 
bottom  of  the  test-glass ;  a  copious  precipitate  forms  at  the  line 
of  junction  of  the  two  fluids,  which  on  standing  becomes  a  bright 
blue  colour  if  blood  is  present. 

The  investigation  of  a  case  of  haematuria  in  order  to  ascertain 
its  origin  should  be  conducted  in  the  following  way  :  (a)  The 
history  of  the  patient  and  of  his  urinary  trouble  should  be  taken. 

(b)  The  character  of  the  urine  should  be  investigated,  noting  its 
colour,  and  whether  or  not  the  blood  is  intimately  mixed  with  it. 

(c)  The  relation  of  the  passage  of  the  blood  to  the  act  of  micturi- 
tion should  be  noted  by  making  the  patient  pass  the  first  and  last 
portions  of  the  urine  into  separate  vessels  from  that  in  which  he 
passes  the  bulk ;  if  the  urine  in  all  three  vessels  is  equally  dis- 
coloured, the  haemorrhage  usually  comes  from  the  kidneys ;  if 
most  of  the  blood  is  in  the  first  vessel,  it  comes  from  the  urethra 
or  prostate,  whilst  if  the  bulk  of  it  is  contained  in  the  last  vessel, 
it  is  probably  derived  from  the  bladder,  (d)  Microscopical  ex- 
amination of  the  urine  may  lead  to  the  discovery  of  shreds  of 
tumour,  epithelial  cells,  or  blood-casts,  which  could  be  alone 
derived  from  some  special  part  of  the  urinary  track.  By  these 
means  the  source  of  the  haemorrhage,  whether  from  kidney, 
bladder,  prostate,  or  urethra,  may  be  detected,  and  an  opinion 
formed  as  to  the  nature  of  the  disease. 

3.  Pyuria  is  the  term  applied  to  the  admixture  of  pus  or  muco- 
pus  with  the  urine.  It  always  results  from  inflammatory  affec- 
tions of  the  mucous  membrane  lining  the  urinary  passages,  and 
may  be  renal,  vesical,  prostatic,  or  urethral  in  origin  ;  the  methods 
of  investigation,  in  order  to  ascertain  its  exact  source,  are  the 
same  as  for  haematuria. 

Pus  in  urine  is  mainly  recognised  by  the  microscope,  whilst  on 
the  addition  of  liquor  potassae  it  becomes  ropy. 

4.  Chyluria  arises  from  distension  or  rupture  of  the  lymphatic 
vessels  in  the  vesical  mucous  membrane,  and  is  usually  due  to 
the  presence  of  the  Filavia  sanguinis  hominis  (p.  316).  The  urine 
is  milky  in  colour,  and  on  microscopical  examination  this  is  found 
to  be  due  to  the  presence  of  an  emulsion  of  fat. 

5.  Albuminuria,  or  the  escape  of  some  of  the  albuminous 
contents  of  the  blood  with  the  urine,  is  a  condition  of  such 
frequent  occurrence,  and  so  important  in  its  results,  that  the 
precaution  should  always  be  adopted  of  testing  the  urine  of  every 
patient  before  attempting  any  operative  proceedings  ;  and  this  is 
the  more  essential  because  it  is  well  known  that  this  condition 
often  exists  quite  unexpectedly  and  entirely  apart  from  symptoms. 


1092  A   MANUAL  OF  SURGERY 


Tests. — Many  different  methods  have  been  adopted  for  detect- 
ing the  presence  of  albuminuria.  The  following  are,  however, 
the  chief:  (i)  On  simply  boiling  the  urine  a  milky  white  deposit 
forms,  similar  to  that  which  is  caused  by  an  excess  of  phosphates  ; 
the  latter,  however,  disappears  entirely  on  the  addition  of  a  single 
drop  of  dilute  acetic  acid,  whilst  the  former  persists.  (2)  Nitric 
acid  gives  a  white  cloud  or  light-brown  flocculent  precipitate. 
The  urine  should  first  be  boiled,  and  the  acid  added,  but  not  in 
excess,  as  the  deposit  may  be  re-dissolved.  A  more  delicate  test 
consists  in  pouring  the  cold  urine  into  a  test-tube,  and  carefully 
adding  the  acid,  so  as  to  form  a  stratum  below  the  urine ;  at  the 
line  of  junction  of  the  two,  a  white  film  is  formed,  if  albumen  is 
present.  (3)  With  picric  acid  a  yellowish-white  precipitate  is 
thrown  down,  increased  by  boiling.  If  the  urine  is  neutral  or 
alkaline,  it  must  first  be  rendered  slightly  acid  by  the  addition  of 
a  few  drops  of  acetic  acid. 

When  once  the  existence  of  albumen  in  the  urine  has  been 
ascertained,  its  source  and  its  significance  must  be  investigated. 
A  careful  microscopical  examination  of  the  sediment  is  made,  so 
as  to  determine  whether  casts  or  pus  cells  are  present.  The  con- 
dition of  the  peripheral  bloodvessels  in  the  limbs  and  the  character 
of  the  pulse  should  be  noted,  as  also  the  previous  history  of  the 
patient. 

Albuminuria  arises  from  a  variety  of  sources,  and  its  significance 
necessarily  turns  on  the  origin  of  the  affection.  (1)  When  it 
occurs  in  the  course  of  some  disease  involving  long-standing  sup- 
puration, such  as  septic  affections  of  bones  or  joints,  it  is  probably 
due  to  lardaceous  change  in  the  kidneys.  If  the  urine  is  of  low 
specific  gravity  and  light  in  colour,  and  with  but  few  casts,  only 
an  early  stage  of  the  condition  is  present,  and  conservative 
measures  directed  to  the  treatment  of  the  primary  lesion  will 
probably  suffice  ;  if,  however,  the  urine  is  scanty  and  of  high 
specific  gravity  with  much  albumen  and  many  casts,  the  affection 
has  probably  progressed  some  way,  and  radical  treatment,  such 
as  amputation,  should  be  undertaken  to  save  the  patient's  life. 
The  surgeon  must  be  careful  to  prevent  any  undue  absorption  of 
carbolic  acid  in  the  operation,  as  thereby  acute  nephritis  may 
be  lighted  up,  and  even  a  fatal  issue  determined.  (2)  Albu- 
minuria may  be  intermittent,  and  is  then  due  to  some  temporary 
functional  disturbance ;  this  can  only  be  ascertained  by  testing 
the  urine  from  time  to  time.  In  such  cases  operation  is  not 
contra-indicated,  the  albumen  usually  disappearing  with  rest  and 
careful  diet.  (3)  When  caused  by  chronic  Bright's  disease,  the 
concurrent  phenomena  of  that  affection  will  also  be  present  in  the 
shape  of  thickened  arteries  and  high  pulse  tension,  whilst  possibly 
a  certain  amount  of  anasarca  may  be  noted,  or  the  history  of  such 
at  an  earlier  date.  If  there  is  but  little  albumen,  and  a  fair 
amount  of  urea  is  being  passed,  it  is  possible  by  rest  and  suitable 


BLADDER  AND  PROSTATE  1093 


diet  so  to  diminish  it  as  to  warrant  the  performance  of  slight 
operations ;  but  where  the  condition  is  at  all  advanced,  all 
operations  de  complaisance  are  absolutely  contra-indicated,  and  only 
the  chief  surgical  emergencies  should  be  knowingly  dealt  with, 
viz.,  haemorrhage,  asphyxia,  intestinal  obstruction  or  strangula- 
tion and  retention  of  urine.  In  cases  of  severe  injuries,  amputa- 
tion is  generally  indicated  under  circumstances  where  in  a  healthy 
individual  conservative  measures  would  be  adopted.  Operation 
for  malignant  disease  may  be  undertaken  at  the  express  wish  of 
the  patient,  if  the  increased  risks  associated  with  it  have  been  ex- 
plained to  him.  The  importance  of  not  operating  on  these  patients 
depends  on  the  facts  that  they  tolerate  an  anaesthetic  badly,  that 
the  tissues  are  in  a  condition  of  lowered  vitality,  and  hence  the 
process  of  repair  is  hindered,  septic  inflammations  and  erysipelas 
are  very  prone  to  develop,  whilst  secondary  haemorrhage  is  likely 
to  follow,  owing  to  the  high  pulse  tension.  Again,  boils  and 
carbuncles  are  very  common  in  these  patients,  and  where  such 
conditions  are  met  with,  and  especially  if  they  recur,  the  urine 
should  always  be  examined.  (4)  Albuminuria  may  arise  by 
extension  of  inflammation  to  the  kidneys  from  surgical  affections 
of  the  lower  urinary  organs,  and  a  fatal  result  from  shock  or  sup- 
pression of  urine  may  be  induced  by  operations  under  these  con- 
ditions. (5)  It  is  occasionally  the  result  of  cardiac  disease,  owing 
to  valvular  incompetence  and  regurgitation  into  the  systemic 
veins,  and  it  is  then  advisable  to  delay  all  operative  measures 
until  digitalis  has  been  administered  in  sufficient  doses  to  alleviate 
the  urgent  symptoms. 

6.  Diabetes. — The  presence  of  sugar  in  the  urine  is  also  a  matter 
of  the  greatest  importance  from  a  surgical  standpoint,  and  its 
existence  or  not  should  always  be  carefully  ascertained.  The 
chief  tests  employed  are  as  follows  :  (1)  Equal  parts  of  liquor 
potassae  and  solution  of  copper  sulphate  are  boiled  together,  and 
then  a  few  drops  of  the  suspected  urine  added  ;  if  sugar  is  present, 
a  yellowish-red  precipitate  forms  by  the  reduction  of  the  cupric 
salt  to  cuprous  oxide.  (2)  The  same  result  follows  the  use  of 
Fehling's  solution.  It  is  better  to  keep  the  copper  solution 
separate  from  the  potash ;  equal  parts  of  them  are  boiled 
together,  and  a  few  drops  of  the  urine  added  ;  if  sugar  is  present, 
a  red  deposit  occurs.  (3)  Picric  acid  and  liquor  potassae  are 
mixed  and  boiled,  and  the  urine  added  ;  the  presence  of  sugar  is 
indicated  by  the  solution  turning  to  a  dark,  blackish-red  colour. 
The  admixture  of  2  grains  of  sugar  to  the  ounce  is  sufficient  to 
determine  this  discoloration  to  such  an  extent  as  to  render  the 
fluid  quite  opaque. 

The  effect  of  diabetes  is  very  similar  to  that  of  albuminuria,  in 
that  it  leads  to  diminished  vitality  of  the  tissues,  and  consequently 
predisposes  to  the  occurrence  of  sepsis,  and  of  such  infective 
inflammations  as  boils  and  carbuncles.     Peripheral  neuritis  and 


ICQ4 


A   MANUAL  OF  SURGERY 


sclerosis  of  the  smaller  vessels  are  also  induced  by  this  disease 
in  the  later  stages,  and  hence  gangrene  of  the  extremities  is  likely 
to  occur,  especially  in  chronic  cases  and  in  elderly  people.  The 
essential  cause  of  trouble,  however,  is  sepsis,  and  hence  if  the 
most  rigid  aseptic  precautions  are  taken  there  is  no  reason  why 
operative  proceedings  should  not  be  undertaken  in  conditions  of 
danger  and  urgency.  Thus  several  cases  have  been  reported 
lately  in  which  such  serious  proceedings  as  total  removal  of  the 
breast  and  axillary  contents  for  scirrhus,  or  appendicectomy,  have 
been  safely  undertaken  in  confirmed  diabetics. 

Stone  in  the  Bladder. 

Varieties. — A  vesical  calculus  may  be  formed  of  almost  any  of 
the  urinary  deposits  commonly  met  with,  and  each  has  its  own 
special  characteristics. 

(a)  The  uric  add  calculus  (Fig.  384)  is  usually  an  oval,  flattened 


J£<I-   ■-■■ 


Fig.   36 


. — Uric  Acid  Calculus  in 
Section. 


Fig.  385. —  Oxalate  of  Lime 
Calculus  from  Outside  and 
on  Section. 


body  of  considerable  density,  with  a  smooth  or  slightly  nodular 
surface,  and  of  a  nut-brown  colour.  On  section  it  is  distinctly 
laminated,  and  it  may  be  surrounded  by  a  crust  of  phosphatic 
material. 

(b)  The  urate  of  -ammonium  calculus  is  of  very  similar  structure, 
but  of  a  lighter  colour,  and  the  lamination  is  less  distinct. 

(c)  The  oxalate  of  lime  or  mulberry  calculus  (Fig.  385,  A  and  B) 
is  a  rough,  irregular  body,  sometimes  evenly  nodular,  but  not 
unfrequently  tuberculated,  or  even  spiculated.  It  is  extremely 
hard  and  dense,  laminated,  and  of  a  dark  red-brown  colour,  or 


BLADDER  AND  PROSTATE  1095 


sometimes  black,  owing  to  admixture  with  blood.  It  is  rarely  of 
great  size,  on  account  of  the  irritation  caused  by  its  presence,  and 
its  slowness  of  growth. 

(d)  A  pure  phosphatic  calculus  is  very  uncommon,  but  any  stone 
or  foreign  body  is  certain  to  become  coated  with  a  phosphatic 
deposit  when  chronic  cystitis  has  resulted  in  alkaline  decomposition 
of  the  urine.  Occasionally  concretions  of  a  similar  nature  form 
spontaneously  in  saccules  of  the  bladder  ;  such  bodies  are  white 
and  chalky  in  appearance,  friable  in  consistency,  with  no  evidence, 
or  but  little,  of  lamination,  and  on  removal  are  exceedingly 
offensive.  These  concretions  consist  of  a  mixture  of  the  triple 
phosphate  and  phosphate  of  lime.  Less  commonly  an  excess  of 
the  triple  phosphate  is  present ;  if  in  the  proportion  of  two  parts 
of  the  latter  to  one  of  phosphate  of  lime,  a  laminated  and  some- 
what denser  calculus  is  produced,  which  is  sometimes  termed  a 
fusible  calculus,  owing  to  the  fact  that  it  fuses  to  a  bead  under  the 
blowpipe  flame.  Occasionally  a  phosphate  of  lime  calculus  occurs 
in  the  upper  urinary  passages,  e.g.,  the  pelvis  of  the  kidney,  and 
has  a  crystalline  appearance  on  drying. 

(e)  Cystine  forms  the  basis  of  a  rare  calculus  which  is  of  a 
yellowish-green  colour  and  waxy  appearance. 

(/)  Xanthine,  or  xanthic  oxide,  occurs  very  exceptionally  as  a 
calculus  of  a  reddish  colour. 

Structure  of  a  Calculus. — A  calculus  usually  consists  of  the 
following  parts  :  1.  The  nucleus,  which  may  be  formed  by  a  portion 
of  blood-clot,  inspissated  mucus,  a  renal  calculus,  or  some  foreign 
substance  introduced  from  without.  2.  The  body,  which  consists 
of  superposed  layers  of  uric  acid  or  oxalate  of  lime,  or  of  whatever 
substance  the  stone  is  composed ;  not  unfrequently  the  composi- 
tion of  adjacent  laminae  differs,  leading  to  what  is  known  as  an 
alternating  calculus.  Each  lamina  consists  of  myriads  of  minute 
crystals,  held  together  by  vesical  mucus,  with  wdiich  a  certain 
amount  of  phosphatic  material  is  often  mixed,  whilst  layers  of  pure 
phosphatic  deposit  may  be  interposed.  3.  The  crust  consists  of  a 
variable  amount  of  soft,  friable  phosphatic  material,  the  quantity 
of  which  is  the  measure  of  the  degree  of  chronic  cystitis  originated 
by  the  calculus  ;  in  some  cases  it  is  entirely  absent. 

The  Number  of  calculi  present  in  a  bladder  varies  greatly. 
Sometimes  there  is  only  one,  but  a  considerable  number,  counted 
perhaps  by  hundreds,  may  exist  ;  in  such  circumstances  they  are 
never  of  great  size.  Multiple  calculi  are  not  unfrequently  faceted 
as  a  result  of  mutual  friction. 

The  Causes  of  vesical  calculus  must  be  looked  for  in  some  of 
those  constitutional  conditions  already  described  as  predisposing 
to  lithiasis  or  oxaluria.  They  are  very  common  in  children  during 
the  first  decade  of  life,  especially  amongst  the  lower  classes,  the 
children  of  the  rich  rarely  suffering  from  stone.  It  diminishes  in 
frequency  from    childhood  to  the  age   of  twenty-five,  and   then 


IC96  A  MANUAL  OF  SURGERY 


gradually  increases  until  it  is  fairly  common  in  elderly  men. 
The  condition  is  comparatively  rare  in  women,  owing  to 
the  fact  that  the  shortness  and  large  size  of  the  urethra  allow 
small  calculi  to  be  much  more  readily  passed.  Possibly  the 
character  of  the  drinking  water,  or  the  amount  imbibed,  is  a 
matter  of  importance,  as  indicated  by  the  fact  that  the  occurrence 
of  calculus  is  very  unequally  distributed  in  different  parts  of  the 
country  ;  thus,  it  is  most  frequently  met  with  in  the  Eastern 
counties.  It  is  also  very  common  in  India  and  Arabia,  a  fact 
which  may  be  explained  by  the  large  amount  of  fluid  withdrawn 
from  the  body  by  perspiration. 

Symptoms. — The  effects  produced  by  vesical  calculi  vary  in 
different  individuals,  according  to  the  shape  of  the  stone,  and 
the  tolerance  of  the  mucous  membrane.  In  children  and  young 
adults,  where  the  parts  are  very  sensitive,  even  a  smooth  calculus 
gives  rise  to  severe  symptoms,  whilst  old  men  often  tolerate  a 
large  stone  without  much  inconvenience  ;  ceteris  paribus,  an  oxalate 
of  lime  calculus  is  always  more  irritating  than  one  composed  of 
uric  acid.  The  classical  symptoms  of  a  vesical  calculus  may  be 
preceded  by  a  history  of  the  patient  having  passed  '  gravel '  for 
a  long  time,  on  the  cessation  of  which  the  calculous  symptoms 
commenced.  They  consist  of  pain  in  the  perineum  and  neck 
of  the  bladder,  which  radiates  to  the  back  and  down  the  thighs, 
but  is  especially  noticed  at  the  end  of  the  penis  immediately  after 
micturition.  The  stone  is  then  pressed  down  against  the  sensitive 
neck  of  the  bladder  by  the  contraction  of  its  muscular  walls. 
Increased  frequency  of  micturition  is  also  present,  and  perhaps 
haematuria  of  a  vesical  type,  though  this  is  not  a  prominent 
feature.  All  these  phenomena  are  increased  in  severity  by  jolting, 
jumping,  or  any  form  of  exercise,  and  hence  are  more  marked 
during  the  day  than  at  night.  Occasionally  the  patient  complains 
that  the  flow  of  urine  suddenly  ceases  before  the  bladder  has  been 
completely  emptied,  and  that  some  change  in  the  position  of  the 
body  is  needed  in  order  to  allow  him  to  complete  the  act.  In 
addition  to  these  characteristic  symptoms,  he  may  suffer  from 
various  phenomena  secondary  to  the  irritability  of  the  bladder, 
and  depending  on  the  straining  induced  by  the  calculus.  Thus, 
tenesmus,  followed  by  piles  or  prolapsus  ani,  may  be  produced 
by  sympathetic  irritability  of  the  rectum,  especially  in  children  ; 
whilst  a  hernia  may  also  be  caused,  and  not  unfrequently 
priapism. 

The  symptoms  are  somewhat  modified  in  children,  leading  to 
irritability  of  the  bladder,  as  evidenced  by  wetting  of  their  clothes 
and  of  their  beds  at  night,  and  pulling  at  the  prepuce  and  penis. 
These  manifestations  are  very  similar  to  those  caused  by  a  tight 
foreskin,  with  which  condition,  indeed,  a  stone  is  often  associated ; 
hence,  it  is  important  always  to  sound  Ihe  bladder  of  a  child  after 
circumcision  for  phimosis. 


BLADDER  AND  PROSTATE  1097 

The  actual  Diagnosis  of  vesical  calculus  can  only  be  made  by 
sounding.  In  order  to  accomplish  this,  the  patient  is  laid  on  a 
couch  with  the  head  low,  and  the  buttocks  raised  on  a  pillow 
placed  beneath  them.  The  bladder  should  always  contain  a  few 
ounces  of  fluid,  so  as  to  obliterate  any  folds  produced  by  laxity 
of  the  mucous  membrane,  as  well  as  to  facilitate  the  introduction 
of  the  instrument.  A  sound  of  suitable  size,  warmed  and  lubri- 
cated by  some  antiseptic  oil  or  ointment,  is  then  gently  passed 
along  the  urethra,  and  depressed  between  the  separated  legs  so  as 
to  enable  it  to  enter  the  bladder.  The  handle  of  the  instrument, 
which  should  be  cylindrical  in  shape  and  fluted,  with  the  maker's 
name  or  some  mark  to  indicate  the  direction  of  the  beak,  is  then 
lightly  grasped  between  the  index-finger  and  thumb,  and  rotated 
from  side  to  side,  whilst  at  the  same  time  the  whole  instrument 
13  drawn  forwards  or  backwards  in  the  urethra.  Each  side  of 
the  bladder  is  thus  carefully  investigated,  and,  finally,  if  no  stone 
is  detected,  the  beak  is  turned  directly  downwards,  so  as  to 
examine  the  pouch  which  often  forms  behind  a  slightly  enlarged 
prostate.  The  presence  of  a  stone  is  recognised  by  a  metallic 
click,  which  can  be  felt,  and  even  heard,  when  the  end  of  the 
instrument  taps  it.  The  character  of  the  click  is  some  guide  to 
the  size  and  density  of  the  stone.  The  presence  of  two  or  more 
calculi  is  indicated  by  the  surgeon  being  able  to  touch  them  on 
rotating  the  instrument  alternately  to  each  side  of  the  middle  line, 
or  by  seizing  one  stone  with  a  lithotrite,  and  using  it  as  a  sound 
for  the  other.  In  doubtful  cases,  a  still  more  delicate  test  than  the 
sound  is  obtained  by  passing  a  medium-sized  tube  of  a  Bigelow's 
evacuator,  and  washing  out  the  bladder.  The  calculi  may  by 
this  means  be  washed  out  even  from  sacculi,  and  be  felt  to  rattle 
against  the  end  of  the  instrument  when  the  pressure  upon  the 
indiarubber  bulb  is  relaxed.  When  the  calculi  are  multiple 
and  of  small  size,  they  may  be  even  removed  in  this  way  by 
an  examination  which  was  only  intended  to  be  diagnostic  in 
character.  The  surgeon  must  not  forget  that  a  hypertrophied 
bladder  with  projecting  fasciculi  may  somewhat  resemble  a  cal- 
culus, especially  when  coated  with  phosphatic  material.  In 
some  rare  instances  a  calculus  may  be  so  completely  hidden  in 
one  of  the  saccules  as  to  render  its  detection  impossible  by  these 
means. 

Course  of  the  Case. — A  patient  suffering  from  vesical  calculus  is 
certain,  sooner  or  later,  to  develop  symptoms  of  chronic  cystitis, 
and  septic  changes  in  the  urine  are  equally  sure  to  follow- 
possibly  as  a  natural  sequence,  but  more  probably  as  the  result 
of  the  introduction  of  septic  instruments.  The  bladder  is  hyper- 
trophied, and  if  the  stone  is  not  removed,  the  mucous  mem- 
brane becomes  ulcerated,  and  the  inflammation  extends  to  the 
kidneys  ;  the  patient's  life  is  thus  destroyed  partly  by  exhaustion, 
and  partly  by  septic  or  uraemic  poisoning.    Occasionally  a  calculus 


iog8 


A   MANUAL  OF  SURGERY 


becomes  encysted  in  the  saccule  of  a  dilated  bladder  ;  it  increases 
in   size  only  on  that  part  of  the  stone  which   is  exposed  at  the 
mouth  of  the  saccule,  and  hence  may  become   ( — 
more  or  less  mushroom-shaped.     It    is   recog- 
nised   by  the  sound   always  striking  it  in  the 
same  situation. 

The  Treatment  of  vesical  calculus  is  a  matter 
which  has  exercised  the  judgment  and  manipu- 
lative dexterity  of  surgeons  for  many  generations. 
A  large  number  of  operations  have  been  made 
use  of,  but  at  the  present  day  only  three  are 
employed,  viz.,  lithotrity,  lateral  lithotomy,  and 
suprapubic  cystotomy. 

Lithotrity  was  formerly  conducted  at  several 
sittings,  the  stone  being  crushed,  and  the  patient 
allowed  to  pass  the  debris  subsequently ;  this 
process  was  repeated  at  intervals  of  a  few 
days,  until  the  bladder  was  clear.  Such  a 
proceeding  took  a  considerable  time,  and  was 
exceedingly  painful,  irksome,  and  dangerous  to 
the  patient.  The  introduction  of  Bigelow's 
evacuator  completely  revolutionized  this  opera- 
tion, and  enables  it  to  be  completed  at  one 
sitting,  constituting  the  proceeding  sometimes 
termed  Litholapaxy. 

Operation. — The  patient  is  carefully  prepared 
by  keeping  him  under  observation  for  a  few 
days,  regulating  the  bowels,  and,  if  possible, 
reducing  any  inflammation  of  the  bladder  by 
suitable  diet  and  drugs,  and  by  washing  it  out. 
On  the  preceding  night  a  dose  of  castor-oil  is 
administered,  and  an  efficient  enema  a  few  hours 
before  the  operation.  The  patient  should  be 
warmly  clad,  and  the  legs  enclosed  in  thick 
worsted  stockings  reaching  nearly  to  the  groins. 
After  anaesthesia  has  been  induced,  the  head  is 
kept  low,  and  a  pillow  placed  beneath  the 
buttocks,  so  as  to  slightly  raise  the  pelvis.  The 
bladder  is  carefully  washed  out  with  some  bland 
antiseptic,  such  as  a  solution  of  boric  acid,  and 
about  6  ounces  of  lotion  left  within  it,  in  order 
not  only  to  obliterate  all  folds  of  mucous  mem- 
brane, but  also  to  facilitate  the  seizure  of  the 
stone,  and  to  prevent  injury  of  the  walls  during 
the  operation. 

The  lithotrite  is  then  introduced.  The  best  instrument  to 
employ  is  Thompson's  modification  of  Civiale's  (Fig.  386),  the 
male  blade  of  which  is  solid,  and  the  female  fenestrated.     Other 


"CSSS?"'"' 


BLADDER  AND  PROSTATE 


io<59 


forms  are  sometimes  used  in  which  the  female  blade  is  solid,  and 
is  either  the  same  size  or  larger  than  the  male,  in  order  to  protect 
the  walls  of  the  bladder  from  injury.  The  male  blade  slides 
easily  up  and  down  a  groove  in  the  stem  of  the  female  blade,  and 
after  the  stone  has  been  seized,  the  blades  are  forcibly  pressed 
together  by  a  screw  action,  brought  into  play  by  the  mechanism 
in  the  handle,  which  can  be  put  in  and  out  of  gear  at  will.  It  is 
absolutely  essential  that  the  instrument  should  be  made  of  well- 
tempered  steel,  so  as  to  prevent  any  risk  of  breaking  during  the 
operation.  To  introduce  it  some  skill  is  needed,  since  the  curved 
end  is  short,  and  consequently  the  handle  must  be  well  depressed 
between  the  legs,  in  order  that  the  beak  may  pass  under  the 
pubic  arch.      The  position  of  the  stone  is  next  ascertained   by 


Fig.  387. — Evacuator  in  Position  in  the  Bladder 


rotating  the  instrument ;  the  blades  are  opened,  and  the  stone 
caused  to  roll  between  them  by  a  slight  jerk  of  the  handle.  This 
is  better  than  attempting  to  pick  up  the  calculus  by  inverting 
the  blades,  and  is  less  likely  to  injure  the  mucous  membrane. 
If  fairly  grasped,  the  blades  when  screwed  up  crush  it  into 
several  fragments,  each  of  which  is  subsequently  dealt  with  in  a 
similar  fashion.  If  only  the  margin  of  the  stone  is  gripped,  the 
application  of  screw  pressure  may  cause  it  to  slip  away,  and  the 
manoeuvre  must  then  be  carefully  repeated.  When  the  surgeon 
is  satisfied  that  the  fragments  are  sufficiently  small,  the  largest 
evacuator-tube  that  can  be  safely  introduced  is  passed  into  the 
bladder.  To  effect  this,  it  is  sometimes  necessary  to  incise  the 
urethral  orifice  with  a  bistoury  in  a  downward  direction.  The 
evacuator  is  attached  to  the  tube,  and  the  bladder  thoroughly 
washed  out  by  alternate  pressure  upon,  and  relaxation  of,  the 
rubber  bottle.      By  this  means  the  fragments  of  the  stone  are 


A   MANUAL  OF  SURGERY 


collected  in  the  glass  receptacle  which  forms  part  of  the  appar- 
atus. The  washing  is  continued  until  no  more  fragments  are 
heard  or  felt  to  rattle  against  the  end  of  the  tube.  It  is  often 
necessary  to  reintroduce  the  lithotrite  in  order  to  crush  some 
larger  portions  of  the  calculus  still  remaining ;  the  old  practice 
of  withdrawing  small  fragments  within  the  grasp  of  a  lithotrite 
is  to  be  condemned.  It  is  scarcely  necessary  to  re-sound  the 
bladder  after  the  efficient  use  of  the  evacuator.  A  certain  amount 
of  bleeding  is  indispensable  from  these  manipulations,  but  it  is 
not  excessive  in  careful  hands.  Should,  however,  considerable 
bleeding  follow,  the  bladder  is  likely  to  become  subsequently  dis- 
tended with  clots,  necessitating  the  use  of  a  large-eyed  catheter 
for  their  removal. 

After-Treatment. — The  patient  is  placed  in  bed  as  soon  as  the 
operation  is  completed,  and  kept  warm  and  quiet,  and  suitable 
measures  must  be  taken  to  combat  shock.  The  diet  is  restricted 
to  fluids  for  a  few  days,  whilst  pain,  if  complained  of,  may  be 
relieved  by  a  little  morphia.  If  all  goes  well,  he  may  be  allowed 
to  get  up  at  the  end  of  the  week. 

Various  Secruelse  may  follow  this  operation.  Cystitis  results 
partly  from  mechanical  causes,  but  more  frequently  from  imper- 
fect asepsis.  The  symptoms  are  usually  subacute  in  character, 
and  may  pass  away  after  a  few  days ;  but  if  due  to  sepsis, 
considerable  constitutional  disturbance  arises,  and  a  large  amount 
of  viscid  muco-pus  is  excreted,  whilst  the  urine  frecomes  alkaline 
and  ammoniacal.  In  such  a  case  it  is  absolutely  essential  to 
wash  out  the  bladder  once  or  twice  a  day,  as  if  left  to  itself 
the  condition  is  very  liable  to  spread  up  to  the  ureters,  and  may 
destroy  the  patient's  life  by  suppurative  pyelonephritis.  Atony  of 
the  bladder  is  occasionally  induced,  either  by  the  operation  or  by 
a  consequent  cystitis,  and  is  especially  common  in  elderly  indi- 
viduals. It  must  be  treated  by  regular  and  aseptic  catheterism. 
When  the  patient's  kidneys  are  already  affected  prior  to  the 
operation,  any  of  the  conditions  described  under  urinary  fever 
(p.  1126)  may  be  originated  by  it,  even  including  suppression  of 
urine. 

Lateral  Lithotomy  is  an  operation  which  has  always  been  of 
great  interest  to  the  surgeon,  although  at  the  present  day  it  is 
comparatively  seldom  performed.  The  patient,  having  been  suit- 
ably prepared,  is  anaesthetized,  and  the  perineum  shaved.  A 
sound  is  passed  so  as  to  make  certain  of  the  presence  of  the 
calculus,  and  the  bladder  washed  out,  about  6  or  7  ounces  of  an 
antiseptic  solution  being  left  in.  A  fully  curved  staff,  grooved 
on  the  left  side,  is  introduced  and  handed  over  to  the  care  of  a 
trustworthy  assistant.  The  patient  is  then,  and  not  till  then, 
placed  in  the  lithotomy  position,  i.e.,  his  hands  and  ankles  are 
approximated  and  held  together  by  bandages  or  suitable  shackles ; 
a  Clover's  crutch   is  useful  when   the   surgeon    has   not   plenr.y 


BLADDER  AND  PROSTATE 


of  help.  The  staff  is  held  in  the  assistant's  right  hand,  the  left 
hand  being  used  to  support  the  scrotum ;  the  operator  usually 
prefers  the  staff  to  be  held  well  up  under  the  arch  of  the  pubes. 
As  a  final  preparation  before  commencing,  the  left  index-finger  is 
inserted  into  the  rectum,  partly  in  order  to  ascertain  the  depth 
of  the  perineum,  and  partly  to  see  that  the  bowel  is  empty,  and 
to  induce  contraction  of  its  walls,  and  thus  minimize  the  risk 
of  injury  by  the  knife.  Of  course  the  finger  is  afterwards  care- 
fully purified  before  placing  it  in  the  wound. 

The  superficial  incision  (Fig.  389)  commences  at  a  point   iA 


Fig. 


. — Knife,  Staff  and  Forceps  used  in  Lateral  Lithotomy. 
(Down  Brothers.) 


inches  in  front  of  the  anus,  a  little  to  the  left  of  the  central  raphe, 
and  extends  downwards  and  outwards  to  a  spot  just  external  to 
the  middle  of  a  line  from  the  anus  to  the  tuber  ischii,  being 
deeper  behind  than  in  front,  and  dividing  the  skin,  subcutaneous 
tissue,  and  inferior  haemorrhoidal  vessels  and  nerves.  The  in- 
cision is  carefully  deepened  by  the  section  of  any  resisting  bands 
until  the  transverse  perineal  nerves  and  vessels  are  cut  through, 
as  also  the  deeper  layer  of  superficial  fascia  and  anterior  layer  of 
the  triangular  ligament,  which  are  continuous  around  the  trans- 
versa perinei  muscle.  The  left  index-finger  is  then  pushed  on 
into  the  wound,  so  as  to  ascertain  the  position  of  the  staff,  and 
the  knife  is  carried  on  towards  it,  and  made  to  enter  the  groove 
at  a  point  corresponding  to  the  membranous  portion  of  the 
urethra  (Fig.  390).     When   once  the  knife  is  felt  to  be  well  in 


A   MANUAL  OF  SURGERY 


the  groove  it  is  pushed  on  into  the  bladder,  the  handle  being 
depressed,  and  the  blade  somewhat  lateralized.  It  is  most 
important  that  the  point  and  back  of  the  knife  should  never  leave 
the  groove  in  the  staff,  or  the  rectum  is  likely  to  be  wounded  ; 


Fig.  389. — Superficial   Incision   in    Lateral   Lithotomy.     (Fergusson  ) 

as  it  is  passed  onwards,  the  membranous  portion  of  the  urethra, 
together  with  the  deep  constrictor,  is  divided,  as  also  the  capsule 
of  the  prostate,  whilst  the  left  lateral  lobe  of  that  organ  is  freely 
notched.     The    knife    is    then    carefully   withdrawn.     The   left 


Fig.  390. — Deep  Incision  in  Lateral  Lithotomy.     (Fergusson.) 

index-finger  may  now  be  inserted  along  the  urethra  into  the 
bladder,  keeping  the  finger-nail  in  the  groove.  The  opening  in 
the  prostate  is  enlarged  by  twisting  the  finger  once  or  twice  as 
it  lies  in  the  wound.     If  possible,  the  surgeon  feels  the  calculus 


BLADDER  AND  PROSTATE  iioj 


with  the  tip  of  the  finger,  or,  at  any  rate,  satisfies  himself  that 
he  has  entered  the  bladder  before  the  staff  is  withdrawn.  After 
its  removal  the  wound  is  still  further  dilated  by  rotation  of  the 
finger,  so  as  to  facilitate  the  entrance  of  the  lithotomy  forceps, 
which  is  the  next  step  in  the  proceeding.  These  are  inserted  by 
sliding  them  along  the  back  of  the  index-finger,  and  when  once 
introduced  the  finger  may  be  withdrawn,  being  usually  followed 
by  a  gush  of  lotion,  which  may  carry  the  calculus  into  the  grasp 
of  the  forceps.  As  a  rale,  however,  it  is  necessary  to  feel  for 
the  stone,  and  grasp  it  by  opening  and  closing  the  blades.  The 
surgeon  must  then  endeavour  to  manipulate  the  calculus,  so  as 
to  have  its  shortest  diameter  presenting.  The  forceps,  with  the 
stone  in  its  grasp,  is  then  gently  withdrawn  by  pulling  well 
down  along  the  axis  of  the  pelvic  outlet.  Great  care  must  be 
exercised  not  to  use  any  undue  violence,  for  fear  of  bruising  and 
lacerating  the  neck  of  the  bladder ;  gentle  side-to-side  move- 
ment is  perhaps  the  best  to  employ.  Should  the  calculus  be 
larger  than  was  at  first  expected,  the  urethra  and  prostate  may 
be  notched  with  a  probe-pointed  bistoury  on  the  right  side,  so 


zjswms^ 


Fig.  391; — Lithotomy  Scoop,  and  Position  of  Finger  in 
extracting  stone. 

as  to  enlarge  the  aperture,  or  the  tissues  may  be  gently  pushed 
back  with  the  index-finger,  whilst  steady  traction  is  exercised. 
If  the  calculus  breaks  into  several  pieces  or  if  many  calculi  are 
present,  the  fragments  may  be  removed  by  means  of  the  finger 
and  lithotomy  scoop  (Fig.  391).  The  bladder  is  now  once  more 
thoroughly  searched,  washed  out  with  an  antiseptic,  and  all  evident 
haemorrhage  stopped.  In  most  cases  it  is  advisable  to  introduce 
through  the  wound  a  gum-elastic  vaginal  tube  or  a  large  catheter, 
which  is  left  in  position  for  a  few  days. 

The  After-Treatment  consists  in  keeping  the  patient  quiet,  with 
his  legs  tied  together,  a  pad  of  wool  being  placed  against  the 
perineal  wound,  which  is  syringed  out  once  or  twice  a  day 
through  the  tube.  When  the  wound  begins  to  granulate,  the 
tube  may  be  removed  ;  the  urine  escapes  for  a  time  through  the 
perineal  opening,  which,  however,  contracts  gradually,  and  closes 
in  most  instances  in  the  course  of  two  or  three  weeks.  The 
patient  should  be  kept  on  a  light  non-stimulating  diet,  with  plenty 
of  diluent  drinks,  such  as  barley-water. 

Complications  and  Dangers  of  Lateral  Lithotomy. — (1)  Hamor- 
rliage  may  arise  from  three  sources :  the  superficial  arteries  of  the 


1 104  A   MANUAL  OF  SURGERY 


perineum,  the  deep  branches  of  the  pudic,  especially  that  which 
passes  to  the  bulb,  and  the  veins  of  the  prostatic  plexus.  The  first 
of  these  are  divided  in  the  superficial  incision,  and  may  be  readily 
secured,  if  necessary,  by  forceps  and  ligature.  The  artery  to  the 
bulb  is  not  likely  to  be  wounded  if  the  incision  is  limited  anteriorly 
according  to  the  directions  given  above  ;  if,  however,  this  trunk 
or  its  branches  in  the  bulb  are  cut,  free  arterial  haemorrhage 
follows,  which  is  usually  stopped  without  difficulty  by  opening 
up  the  wound  and  seizing  the  bleeding-points  with  forceps.  The 
internal  pudic  artery  runs  but  little  risk  of  injury  except  in  those 
cases  where  it  follows  an  abnormal  course ;  it  is  readily  treated 
on  general  principles.  Venous  haemorrhage  from  the  prostate  is 
a  more  serious  matter,  and  is  especially  prone  to  occur  in  elderly 
persons  with  prostatic  hypertrophy.  It  is  recognised  by  venous 
blood  welling  up  from  the  depths  of  the  wound,  or  possibly,  if 
not  evident  at  the  time  of  the  operation,  by  the  bladder  becoming 
distended  with  clot,  considerable  pain  being  thereby  induced.  If 
noticed  during  the  operation,  it  is  treated  by  syringing  out  the 
wound  with  iced  lotion,  and  the  insertion  of  an  air  tampon  or 
a  petticoated  tube.  The  former  contrivance  consists  of  a  gum- 
elastic  catheter,  the  deep  portion  of  which  is  surrounded  by  an 
indiarubber  bag,  which  can  be  inflated  with  air  through  a  small 
tube  fitted  with  a  stop-cock,  to  which  a  force-pump  can  be 
attached.  The  petticoated  tube  is  used  when  the  latter  is  not 
obtainable  or  fails  to  act ;  it  is  made  by  tying  a  petticoat  of  lint  or 
gauze  around  the  distal  end  of  a  vaginal  tube ;  this  is  then  passed 
into  the  bladder,  and  the  space  between  the  petticoat  and  the  tube 
packed  with  gauze.  If  the  bladder  becomes  filled  with  blood- 
clot,  this  must  be  broken  up  and  removed  by  syringing  with  hot 
water  through  a  large-eyed  catheter,  and  the  wound  subsequently 
plugged  around  a  catheter.  (2)  A  Wound  of  the  Rectum  may  be 
caused  by  carrying  the  superficial  incision  too  far  backwards,  or 
by  keeping  it  too  near  the  middle  line  behind ;  or  it  may  occur 
later  in  the  operation  by  not  maintaining  the  point  of  the  knife 
strictly  in  the  groove.  It  is  more  liable  to  happen,  however,  whilst 
withdrawing  the  knife,  the  point  being  swept  backwards,  thus 
opening  the  bowel ;  it  most  frequently  happens  to  boys.  It  is 
often  not  recognised  until  flatus  and  faeces  are  passed  through 
the  wound  at  a  later  date.  If  of  small  size  and  situated  low 
down,  it  will  probably  close  by  cicatrization  without  special  treat- 
ment ;  but  when  high  up  and  more  extensive,  a  recto-vesical 
fistula  is  likely  to  follow.  The  treatment  usually  recommended 
in  such  a  case  is  to  divide  the  sphincter,  and  thus  lay  the  lower 
end  of  the  rectum  and  the  lithotomy  wound  into  one  cavity,  the 
communication  being  sometimes  closed  by  the  contraction  of  the 
granulation  tissue  which  fills  up  the  wound.  In  suitable  cases  it 
may  be  possible  to  stitch  up  the  opening  from  the  rectum  after 
paring  its  edges.     (3)  Pelvic  Cellulitis  is  caused  by  cutting  beyond 


BLADDER  AND  PROSTATE  1105 

the  limits  of  the  prostate,  and  thus  opening  up  the  recto-vesical 
fascia,  or  by  bruising  and  over-distension  of  the  neck  of  the 
bladder  by  dragging  through  it  too  large  a  stone.  In  either 
case  urinary  extravasation  and  diffuse  septic,  inflammation  are 
iikely  to  follow,  resulting  in  grave  constitutional  disturbance  of 
a  septic  nature,  and  possibly  in  the  death  of  the  patient.  The 
treatment  suggested  is  to  support  the  general  health  by  suitable 
diet  and  stimulants,  whilst  local  tension  is  relieved  by  extending 
the  wound  backwards,  even  into  the  rectum.  (4)  Septic  Cystitis, 
and  extension  of  the  inflammation  to  the  kidneys,  occasionally 
supervenes,  whilst  life  may  be  also  destroyed  by  shock,  suppres- 
sion of  urine,  or  pyaemia. 

Lateral  Lithotomy  in  Boys  was  formerly  considered  one  of  the 
most  successful  major  operations  in  surgery,  but  at  the  present 
time  it  has  been  proved  that  lithotrity  can  be  equally  well  prac- 
tised, provided  suitable  instruments  are  employed  and  the  external 
meatus  is  incised.  Should  a  cutting  operation  be  required,  the 
high  position  of  the  bladder  lends  itself  most  favourably  to  the 
suprapubic  method,  which  is  now  extensively  practised.  The 
chief  peculiarities  of  lateral  lithotomy  in  boys  consist  in  the  rudi- 
mentary nature  of  the  parts  involved,  and  in  the  fact  that  the 
bladder  is  an  abdominal  rather  than  a  pelvic  viscus.  Hence  the 
deep  incision  always  travels  beyond  the  limits  of  the  prostate, 
whilst  the  knife  has  to  pass  relatively  higher  than  usual  in  order 
to  reach  the  bladder.  Considerable  difficulty  is  also  experienced 
in  touching  the  stone  with  the  finger,  and  if  much  force  is  used, 
the  neck  of  the  bladder  may  be  torn  through,  and  fatal  cellulitis 
ensue.  Atrophy  of  the  left  testis  has  happened  as  a  sequela  of 
this  operation  owing  to  section  of  the  ejaculatory  duct  in  the 
prostate. 

Suprapubic  Cystotomy  is  an  operation  which  has  been  exten- 
sively practised  of  recent  years,  and  with  considerable  success. 
The  chief  difficulty  consists  in  displacing  the  anterior  reflection 
of  the  peritoneum,  so  as  to  expose  the  bladder  without  injuring 
it.  This  is,  however,  readily  accomplished  by  the  use  of  Trendelen- 
burg's position.  The  bladder  is  washed  out,  and  8  or  10  ounces  of 
lotion  left  within  it  ;  the  patient  is  then  placed  with  the  pelvis 
raised  well  above  the  head,  the  intestines  being  thus  allowed  to 
gravitate  to  the  postero-superior  part  of  the  abdomen  ;  as  soon  as 
the  abdominal  parietes  are  opened,  air  rushes  into  the  connective 
tissue  behind  the  symphysis  (cavum  Retzii),  and  the  peritoneum 
is  thus  pressed  back. 

Operation. — The  pubes  having  been  previously  shaved,  and  the 
hypogastrium  purified,  an  incision  is  made  in  the  median  line 
reaching  from  the  top  of  the  symphysis  upwards  for  about  2  or 
3  inches ;  the  lower  part  of  the  linea  alba  is  divided,  and  the 
retro-pubic   cellular  tissue  opened    up.     The  entrance  of  atmo- 

70 


no6  A   MANUAL  OF  SURGERY 


spheric  air  into  this  cavity  further  assists  in  the  depression  of  the 
peritoneum.  The  tense  rounded  outline  of  the  bladder  can  now 
be  readily  detected  with  the  finger,  and  a  couple  of  lateral  silk 
sutures  or  slings  are  passed  through  its  walls  so  as  to  steady  it 
and  prevent  its  subsequent  retraction.  An  opening  is  then  made 
into  it  in  the  middle  line,  through  which  the  index-finger  is  passed 
and  the  stone  examined.  Suitably  curved  lithotomy  forceps  are 
introduced,  and  the  stone  grasped  and  withdrawn.  The  after- 
treatment  of  the  wound  is  a  point  on  which  much  difference  of 
opinion  has  been  expressed.  Some  leave  it  open,  allowing  it  to 
heal  by  granulation  ;  this  is  especially  advisable  if  much  cystitis 
is  present.  When,  however,  the  bladder  is  tolerably  healthy,  it 
may  be  closed  by  sutures,  which  only  pass  through  the  muscular 
and  submucous  coats,  and  thus  when  tied  do  not  project  into  its 
cavity.  The  external  wound  may  then  be  left  open  or  closed, 
except  at  the  spot  where  a  drainage-tube  or  gauze  wick  is  passed 
down  to  the  vesical  wound,  so  as  to  allow  exit  to  any  urine  which 
may  accidentally  become  extravasated.  The  urine  is  either 
drawn  off  by  a  catheter  at  regular  intervals,  certainly  not  less 
than  three  or  four  times  daily,  or  the  bladder  is  drained  by  tying 
in  a  catheter. 

Choice  of  Operation  for  Vesical  Calculus. — At  the  present  day 
lithotrity  has  been  brought  to  such  a  standard  of  excellence  that 
there  is  no  doubt  as  to  the  general  rule  which  should  be  followed, 
viz.,  that  unless  some  contra-indication  is  present,  all  cases  of  vesical 
calculus  should  be  treated  by  lithotrity. 

The  Contra-indications  to  Lithotrity  are  as  follow  :  (i)  Conditions 
of  the  Stone.  If  the  calculus  exceeds  i^  inches  in  diameter,  it  is 
not  advisable  to  attempt  lithotrity  on  account  of  the  damage 
which  may  be  inflicted  on  the  vesical  wall.  Moreover,  some 
stones,  especially  those  consisting  of  oxalate  of  lime,  are  so  hard 
that  no  lithotrite  can  crush  them.  Phosphatic  concretions,  on 
the  other  hand,  are  so  soft  that  a  lithotrite  becomes  clogged, 
and  crushing  is  impracticable.  An  encysted  stone  will  also  pre- 
clude lithotrity  on  account  of  its  fixed  position.  There  is  no 
objection  to  dealing  with  multiple  calculi  by  this  means,  but  if 
only  of  small  size,  they  may  be  removed  by  simply  using  the 
evacuator.  (2)  Conditions  of  the  Urethra.  The  existence  of  an 
organic  stricture,  or  an  enlarged  prostate,  may  render  lithotrity 
impracticable  from  the  impossibility  of  passing  large  enough 
instruments,  whilst  false  passages  may  make  it  exceedingly 
difficult.  Excessive  irritability  of  the  urethra,  as  evidenced  by 
the  occurrence  of  severe  rigors  after  instrumentation,  may  alsG 
render  the  operation  unadvisable.  (3)  Conditions  of  the  Bladder. 
The  existence  of  severe  cystitis  or  the  presence  of  sacculi,  as 
indicated  by  the  cystoscope,  will  usually  suggest  the  performance 
of  lithotomy ;  whilst  a  contracted  bladder,  which  will  only  hold  a 


BLADDER  AND  PROSTATE  1107 


few  ounces  of  urine,  materially  increases  the  dangers  and  diffi- 
culties of  lithotrity. 

Having  thus  described  the  conditions  which  contra-indicate 
lithotrity,  a  choice  must  be  made  between  entering  the  bladder 
from  the  perineum  or  above  the  pubes. 

Indications  for  Lateral  Lithotomy. — (1)  Where  cystitis  and 
great  irritability  of  the  bladder  are  present,  the  incision  facilitating 
the  process  of  draining  and  washing  it  out ;  (2)  the  presence  of  a 
phosphatic  concretion  ;  (3)  a  contracted  and  hypertrophied  con- 
dition of  the  bladder. 

Suprapubic  Lithotomy  should  be  undertaken  under  the  following 
conditions  :  (1)  Where  the  stone  is  too  large  to  be  dealt  with  by 
crushing ;  (2)  where  the  stone  is  encysted ;  (3)  where  a  stricture 
or  enlarged  prostate  is  present  ;  (4)  where  lateral  lithotomy  is 
rendered  impracticable  on  account  of  pelvic  conditions,  such  as 
rachitic  contraction  or  the  existence  of  a  tumour,  or  where  the 
left  hip-joint  is  ankylosed,  preventing  the  patient  from  assuming 
the  lithotomy  position.  Suprapubic  cystotomy  is  only  absolutely 
contra-indicated  by  two  conditions,  viz.,  severe  septic  cystitis  and 
contraction  of  the  bladder. 

Calculus  in  the  Female. — As  already  mentioned,  vesical  calculus 
is  very  rare  amongst  women,  owing  to  th«  shortness  and  greater 
size  of  the  urethra,  so  that  small  stones  passing  downwards  from 
the  kidneys  are  easily  voided.  Phosphatic  concretions  are  not 
uncommon,  and  are  then  formed  around  a  foreign  body  usually 
introduced  by  the  patient.  Many  of  the  symptoms  are  very 
similar  to  those  in  the  male. 

Treatment. — If  the  calculus  does  not  exceed  ^  to  f  inch  in 
diameter,  it  can  usually  be  extracted  by  dilating  the  urethra  with 
the  finger,  the  sphincter  being  also  nicked  in  two  or  three  places 
if  necessary.  It  is  never  wise  to  totally  divide  the  sphincter,  as 
incontinence  is  almost  certain  to  follow.  For  a  somewhat  larger 
stone  lithotrity  can  be  undertaken,  whilst  for  those  of  really  large 
size  suprapubic  cystotomy  is  the  best  procedure.  It  has  been 
recommended  to  open  the  bladder  through  the  anterior  vaginal 
wall,  and  thus  remove  a  stone  ;  but  this  is  scarcely  desirable,  for 
fear  of  the  persistence  of  a  vesico-vaginal  fistula. 

Affections  of  the  Prostate. 

Acute  Prostatitis  arises  most  usually  as  a  sequela  of  gonorrhcea, 
either  in  its  acute  or  chronic  stage,  by  direct  extension  backwards 
of  the  inflammatory  process  ;  it  is  also  occasionally  met  with  as 
a  result  of  stricture  arising  from  the  irritation  of  retained  and 
decomposing  urine,  or  from  the  passage  of  instruments.  It  is 
also  said  to  be  induced  by  the  application  of  cold  or  damp  to  the 
perineum,  as  by  sitting  on  cold  stones  or  damp  grass,  but  probably 


noS  A  MANUAL  OF  SURGERY 

this  has  been  preceded  by  bacterial  invasion  of  the  posterior  part 
of  the  urethra.  Suppuration  follows  in  not  a  few  cases,  being  due 
to  the  infection  of  the  prostatic  follicles  with  pyogenic  organisms. 
Sometimes  merely  one  or  two  follicles  are  enlarged,  causing  what 
is  termed  a  follicular  abscess;  occasionally  the  mischief  extends 
much  more  widely,  involving  the  whole  of  one  lobe,  or  perhaps 
the  whole  organ,  and  constituting  a  parenchymatous  abscess. 

The  Symptoms  consist  of  deep-seated  pain  referred  to  the  neck 
of  the  bladder,  with  perhaps  a  sense  of  weight  and  fulness  about 
the  perineum.  Micturition  becomes  frequent  and  painful,  and 
defalcation  may  cause  considerable  distress.  As  the  organ 
increases  in  size,  the  pain  becomes  more  and  more  severe,  and  all 
movements  of  the  body,  as  also  the  act  of  sitting,  are  increasingly 
difficult.  On  rectal  examination  the  organ  can  be  felt  enlarged, 
hot,  and  tender.  Suppuration  is  likely  to  follow,  and  retention  of 
urine  may  be  thereby  induced.  A  follicular  abscess  bursts  into  the 
urethra  spontaneously,  or  is  ruptured  by  the  passage  of  a  catheter 
for  the  relief  of  retention  ;  the  opening,  however,  is  often  of  a 
valvular  nature,  and  only  a  small  portion  of  the  pus  escapes. 
The  process  may  then  continue  to  spread,  and  the  pus  may  find 
its  way  into  the  rectum,  or  come  to  the  surface  through  the 
perineum.  In  either  of  the  latter  conditions,  a  rectal  or  perineal 
fistula  is  liable  to  result.  Considerable  constitutional  disturbance 
is  usually  associated  with  this  affection,  whether  suppuration 
occurs  or  not.  The  formation  of  a  parenchymatous  abscess  is 
always  attended  with  much  more  acute  symptoms,  both  general 
and  local.  The  organ  is  larger  and  produces  more  rectal  irrita- 
tion ;  a  considerable  quantity  of  pus  may  form,  and  suppuration 
may  extend  beyond  the  capsule  into  surrounding  parts. 

Treatment. — The  patient  should  be  kept  in  bed  on  a  restricted 
diet,  and  the  bowels  freely  opened  by  saline  purges,  combined 
with  small  doses  of  antimony,  and  perhaps  full  doses  of  hyoscyamus. 
Local  depletion  may  be  undertaken  by  cupping  the  perineum,  or 
by  applying  ten  or  twelve  leeches  to  it.  Hot  hip-baths  are  also 
very  valuable,  and  linseed-meal  poultices  may  be  placed  on  the 
perineum  after  the  leeches  have  been  removed.  Extreme  pain 
should  be  relieved  by  the  use  of  morphia  suppositories,  and  if  the 
urine  needs  to  be  drawn  off,  a  soft  rubber  catheter  of  small  size 
should  be  used.  If  an  abscess  forms  and  is  not  opened  by  the 
passage  of  a  catheter,  or  if  the  natural  opening  is  of  a  valvular 
character,  so  that  the  cavity  cannot  completely  empty  itself,  an 
incision  must  be  made  into  it  through  the  middle  line  of  the 
perineum,  being  guided  by  a  finger  placed  in  the  rectum ;  pus 
may  not  be  reached  until  the  knife  has  entered  to  a  depth  of 
about  2  inches.  Urine  will  sometimes  escape  from  this  opening, 
and  may  continue  to  do  so  for  some  considerable  time.  If 
gonorrhoea  is  also  present,  suitable  treatment  must  be  adopted  in 
order  to  check  the  discharge. 


BLADDER  AND  PROSTATE  1109 


Chronic  Prostatitis  is  perhaps  one  of  the  most  common  causes 
of  chronic  gleet  after  gonorrhoea.  It  is  sometimes  left  as  a 
sequela  of  an  acute  attack,  or  may  arise  as  a  result  of  stricture. 

The  Symptoms  produced  by  it  are  a  sense  of  weight  and  fulness 
about  the  perineum,  combined  with  irritability  of  the  bladder, 
and  pain  referred  to  the  extremity  of  the  penis  at  the  end  of 
micturition,  owing  to  the  bladder  contracting  upon  the  hyperaemic 
and  sensitive  organ.  A  glairy  discharge  of  viscid  material, 
similar  in  appearance  to  uncooked  white  of  egg  (prostatorrhaa), 
is  often  present,  whilst  fine  threads  of  mucus  are  usually  seen 
floating  in  the  urine,  being  due  to  the  formation  of  mucous  casts 
of  the  prostatic  ducts.  On  examination  through  the  rectum,  the 
organ  can  be  felt  enlarged  and  tender,  and  the  vesiculae  are 
usually  in  the  same  condition.  Chronic  suppuration  may  follow, 
the  abscess  bursting  into  the  urethra  or  rectum,  or  pointing  in 
the  perineum. 

The  Diagnosis  from  tuberculous  disease  can  usually  be  made 
by  careful  attention  to  the  history  and  physical  signs, 

Treatment  consists  in  counter-irritation  of  the  surface  of  the 
perineum,  as  by  blisters  or  iodine  paint,  care  being  taken  that 
the  reagent  employed  does  not  extend  either  to  the  anus  or 
scrotum.  Belladonna  suppositories  may  be  of  value,  whilst  the 
occasional  passage  of  a  cold  metal  bougie  may  do  good.  In 
suitable  cases,  where  a  long-standing  gleet  is  present  with  no 
suspicion  of  suppuration,  a  cure  may  occasionally  be  brought 
about  by  the  administration  of  iodide  of  potassium,  or  of  the  liq. 
ferri  perchloridi  (IT^xv.  or  more,  t.d.s.),  combined  with  sulphate 
of  magnesia.  The  local  application  of  a  solution  of  nitrate  of 
silver  by  a  porte-caustique  is  also  sometimes  recommended,  but 
we  are  not  much  in  favour  of  such  a  proceeding.  Probably  the 
best  treatment  consists  in  forcible  dilatation  of  the  prostatic 
urethra,  as  suggested  by  Oberlander,  the  follicles  being  thereby 
emptied  of  their  secretion ;  massage  of  the  prostate  per  vecium 
against  a  sound  held  in  position  may  also  be  useful.  Should  an 
abscess  form,  it  is  incised  through  the  perineum. 

Tuberculous  Disease  of  the  Prostate  is  usually  met  with  as  a 
result  of  extension  from  similar  disease  in  the  epididymis,  the 
seminal  vesicles  being  also  invaded  ;  occasionally,  however,  it 
may  arise  as  a  primary  affection.  In  either  case,  it  rapidly 
spreads  to  the  bladder,  and  thence  to  the  ureters  and  kidneys. 
The  prostate  is  found  to  contain  caseous  masses  in  the  early 
stages,  but  later  on  these  break  down,  leading  to  extensive  ulcera- 
tion, and  sometimes  the  organ  is  riddled  with  ragged  cavities. 
The  symptoms  are  those  of  irritability  of  the  neck  of  the  bladder, 
combined  with  pain  referred,  perhaps,  to  the  end  of  the  penis, 
or  mainly  noticed  in  the  back  or  perineum,  Hematuria  is  occa- 
sionally produced,  whilst  pyuria  is  almost  constant      The  urine 


A   MANUAL  OF  SURGERY 


is  feebly  acid  or  neutral,  and,  on  examination  of  the  pus  which 
is  deposited  on  standing,  the  tubercle  bacillus  may  be  detected. 
Rectal  examination  will  demonstrate  an  irregular  enlargement  of 
the  organ,  whilst  if  the  vesiculae  are  invaded,  they  can  also  be  felt. 
Treatment  consists  in  attending  to  the  general  health,  and 
the  administration  of  tonics.  Possibly,  if  the  disease  is  not  too 
extensive,  benefit  may  be  derived  from  scraping  the  tuberculous 
tissue  away  through  a  perineal  incision. 

Prostatic  Calculi  are  of  unfrequent  occurrence,  being  usually 
met  with  in  cases  of  chronic  prostatitis,  especially  that  resulting 
from  stricture  of  the  urethra  or  previous  attacks  of  gonorrhoea. 
They  are  generally  multiple,  and  of  small  size,  consisting  mainly 
of  carbonate  of  lime.  They  develop  primarily  in  the  glandular 
crypts,  and  may  remain  embedded  in  the  organ,  giving  rise  to 

but  little  inconveni- 
ence. When  large  and 
protruding  from  the 
gland  into  the  urethra, 
symptoms  of  obstruc- 
tion to  the  flow  of 
urine  are  produced, 
whilst  on  passing  a 
catheter  or  sound  a 
distinct  click  or  grating 
may  be  noticed.  In 
the  latter  case,  great 
irritability  of  the  neck 
of  the  bladder  is  in- 
duced. Sometimes  a 
number  of  them  are 
found  in  a  pouch  or 
pocket,  formed  by  the 
amalgamation  of 
several  of  the  crypts. 
It  is  in  some  instances 
possible  to  remove  the 
calculi      through      the 

_  _  _  „  urethra,  but  more  fre- 

Fig.  392. — Enlarged  Prostate  ;  Middle  Lobe  .  .... 

replaced  by  Enormous  Fibro-myoma.    (From  quently  a  perineal  mci- 
College  of  Surgeons'  Museum.)  sion  is  required. 


Hypertrophy  of  the  Prostate  is  a  condition  rarely  met  with, 
except  in  patients  over  fifty  years  of  age.  There  is  a  general 
enlargement  of  the  tissues  of  the  part,  involving  either  the 
glandular  and  the  muscular  elements  equally,  or  especially  limit- 
ing itself  to  one  or  other  of  these  tissues  ;  more  frequently  the 
glandular  element  is  considerably  in  excess.  Another  variety  is 
due  to   the   development  of  localized  tumours  in,  or  outgrowths 


BLADDER  AND  PROSTATE 


from,  the  organ,  which  are  usually  fibro-myomatous  in  nature, 
particularly  if  embedded  in  the  prostatic  substance  ;  when  of  this 
type  they  are  almost  exactly  analogous  to  the  so-called  fibroid 
tumours  of  the  uterus,  since  they  originate  in  the  walls  of  the 
sinus  pocularis,  the  male  analogue  of  that  organ.  These  tumours 
are  rather  denser  than  ordinary  prostatic  tissue,  and  are  often 
completely  encapsuled.  They  are  primarily  developed  in  the 
substance  of  the  prostate,  but  may  project  backwards,  when 
large,  towards  the  rectum,  or  grow  upwards  into  the  bladder 
(Fig.  392),  or  may  even  become  pedunculated,  constituting  a 
polypus  in  the  dilated  urethra.  Not  uncommonly  these  new 
growths  consist  mainly  of  glandular  tissue  with  distinct  ducts,  and 
possibly  concretions  may  be  found  in  the  tubules.    There  are  thus, 


Fig.  393.— Effect  of  Enlargement  of  the  Middle  Lobe  of  the 
Prostate  on  the  course  of  the  Urethra.     (Diagrammatic.) 

The  left-hand  figure  represents  the  normal  curve  of  the  urethra ;  that  on  the 
right  side  the  barrier  caused  by  an  enlarged  middle  lobe. 

pathologically  speaking,  three  main  forms  of  the  so-called  'chronic 
hypertrophy  of  the  prostate ':  the  diffuse  enlargement,  the  fibro- 
myomata,  and  the  adenomata,  but  they  are  often  combined  one 
with  the  other. 

The  changes  produced  in  the  prostatic  urethra  and  neck  of  the 
bladder  vary  considerably  according  to  the  character  of  the  out- 
growth in  any  particular  case.  A  certain  amount  of  obstruction 
is  always  present,  except  in  a  few  instances  in  which  the  internal 
meatus  becomes  unduly  patent,  possibly  from  a  tumour  in  the 
median  portion  being  wedged  in  between  the  two  lateral  lobes. 
The  prostatic  urethra  is  increased  in  length  in  all  cases  of 
this  disease.  When  the  lateral  lobes  are  enlarged,  the  lumen 
of  the  urethra  is  diminished  from  side  to  side,  being  narrow 
or  chink-like  instead  of  circular  ;  its  vertical  measurements  are, 
however,  increased.  The  urethra  is,  moreover,  rendered  more 
or  less  tortuous,  owing  to  irregular  enlargement  of  the  various 


A  MANUAL  OF  SURGERY 


portions.  Thus,  if  the  median  lobe  is  especially  prominent, 
a  rounded  barrier  extends  across  the  urethra,  which  becomes 
almost  S-shaped  (Fig.  393,  B).  If  one  lateral  lobe  is  enlarged 
more  than  the  other,  the  urethra  is  pushed  over  towards  the 
unaffected  side.  The  shape  of  the  internal  meatus  is  also  considerably 
modified  :  when  the  median  lobe  is  enlarged,  it  becomes  crescentic, 
the  convexity  looking  upwards  and  forwards ;  when  one  lateral 
lobe  is  of  larger  size  than  the  other,  the  orifice  is  also  crescentic, 
the  convexity  being  directed  towards  the  smaller  lobe;  when  all 
three  lobes  are  affected,  the  entrance  to  the  bladder  may  be 
Y-shaped,  the  limbs  of  the  Y  passing  on  either  side  of  the  median 
lobe.  Not  unfrequently  the  prostate  may  project  into  the  bladder 
as  a  rounded,  collar-like  elevation,  encircling  the  meatus.  There 
is  an  abundant  blood  supply  to  the  organ,  the  veins  in  the  capsule 
being  notably  enlarged. 

The  Symptoms  vary  somewhat  with  the  nature  and  position 
of  the  enlargement.  The  patient  at  first  finds  some  difficulty  in 
micturition,  especially  at  the  commencement  of  the  act ;  straining 
often  hinders  rather  than  assists.  The  stream  is  not  necessarily 
smaller  than  formerly,  but  is  projected  with  less  force.  Gradu- 
ally irritability  of  the  bladder  ensues,  and  the  patient  has  to  pass 
water  very  frequently,  a  trouble  especially  noticed  during  the 
night.  Some  degree  of  pain  and  a  sense  of  weight  and  fulness 
about  the  perineum  are  also  experienced,  whilst  tenesmus,  and 
even  hernia,  may  be  subsequently  induced  by  the  straining. 
Intermittent  attacks  of  increased  pain  and  difficulty  in  micturition 
occur  from  time  to  time,  being  generally  induced  by  exposure  to 
cold  and  wet,  and  presumably  due  to  congestion  of  the  prostate. 
After  lasting  for  a  few  days  the  more  acute  symptoms  slowly 
disappear,  if  judiciously  treated. 

As  the  obstruction  increases,  a  certain  amount  of  residual  urine 
remains  within  the  bladder  after  each  act  of  micturition,  the 
vesical  muscles  gradually  losing  power  and  becoming  atonic. 
Gradually  well-marked  distension  and  atony  of  the  bladder  ensue 
in  neglected  cases,  the  urine  dribbling  away  and  wetting  the 
clothes,  whilst  decomposition  of  the  retained  fluid  follows,  and 
causes  cystitis  with  increasing  vesical  irritation  and  muscular 
spasm.  The  urine  becomes  alkaline  after  a  time,  containing 
muco-pus  and  phosphates,  the  result  of  chronic  cystitis.  This,  if 
neglected,  is  certain  to  lead  to  hydronephrosis  and  pyelonephritis. 
The  general  health  of  the  patient  is  slowly  undermined  by  the 
constant  irritation  produced  by  this  process,  as  also  by  septic 
absorption,  and  the  final  chapter  may  be  ushered  in  by  symptoms 
of  uraemia  from  the  mischief  inflicted  on  the  kidneys. 

Occasionally  the  early  symptoms  may  pass  unnoticed  for  a 
considerable  time,  the  patient  imagining  that  the  frequent  calls  to 
pass  water  are  good  signs  rather  than  evidences  of  disease.  In 
such  cases  the  bladder  may  become  over-distended,  and  the  con- 
dition unsuspected  until,  owing  possibly  to  some  exposure  to  cold 


BLADDER  AND  PROSTATE  1113 

or  over-indulgence  in  alcohol,  complete  retention  is  induced,  and 
then,  to  the  surprise  of  the  patient,  an  enormous  amount  of  urine 
is  withdrawn  on  the  passage  of  a  catheter.  Priapism  is  some- 
times a  troublesome  condition,  and  the  effect  of  this  on  the  moral 
sense  may  be  very  serious,  and  leads  in  some  cases  to  acts  of 
gross  indecency. 

The  Diagnosis  of  enlarged  prostate  is  made  partly  by  a  con- 
sideration of  the  symptoms  complained  of,  but  mainly  by  an 
examination  of  the  urethra  and  rectum.  The  age  of -the  patient, 
the  increasing  irritability  of  the  bladder,  by  night  and  day,  the 
fact  that  straining  hinders  rather  than  helps  the  expulsive  act, 
together  with  evidence  of  vesical  distension — all  these  facts  indi- 
cate that  the  seat  of  obstruction  lies  in  the  prostate.  A  rectal 
examination  is  then  instituted,  and  some  idea  gained  of  the  size 
and  condition  of  the  organ  ;  it  must  not  be  forgotten,  however, 
that  the  size,  as  recognised  by  a  finger  in  the  rectum,  cannot 
measure  in  any  way  the  amount  of  obstruction  to  the  passage  of 
the  urine,  and,  in  fact,  it  often  happens  that  where  the  gland  does 
not  feel  especially  large  from  the  rectum,  the  obstruction  is  the 


Fig.  394. — Catheter  Coude  and  Bicoude. 

greatest.  The  careful  introduction  of  a  catheter  will  assist  in 
making  the  diagnosis,  inasmuch  as  the  barrier  at  the  neck  of  the 
bladder  is  easily  detected,  and  sometimes  with  difficulty  passed. 

Treatment. — All  that  is  required  at  first  is  regular  catheterism, 
in  order  to  prevent  the  bladder  from  becoming  over-distended, 
and  this  the  patient  may  sometimes  be  taught  to  do  for  himself. 
To  pass  a  catheter  in  a  case  of  enlarged  prostate  is  not  always 
easy,  owing  to  the  fact  that  the  middle  lobe  (Fig.  393,  B)  projects 
across  the  urethra,  and  bars  the  onward  progress  of  an  instrument 
of  the  ordinary  shape.  The  surgeon  should  therefore  use  either 
a  catheter  coude  or  bicoude  (Fig.  394),  which  consists  of  a  soft, 
straight  instrument  of  the  usual  French  type,  the  end  of  which 
is  bent  or  doubly  bent  at  an  angle,  so  as  to  enable  it  to  ride 
over  the  obstruction ;  or  he  may  employ  an  English  gum-elastic 
catheter,  the  stilette  of  which  is  drawn  out  a  little  so  as  to  increase 
its  curve ;  or  he  may  utilize  the  silver  prostatic  catheter,  which 
is  longer  and  more  curved  than  usual,  depressing  it  well  between 
the  thighs  after  clearing  the  pubic  arch.  Whichever  method  is 
adopted,  no  force  is  required,  since  with  a  little  skill  the  point 
of  the  instrument  will  pass  round  the  obstruction  and  enter  the 
bladder.  Every  precaution  must  be  taken  to  ensure  the  efficient 
sterilization  of  all  instruments  employed,  and  it  should  be  remem- 


1 1 14  A   MANUAL  OF  SURGERY 


bered  that  as  a  general  rule  large  rather  than  small  instruments 
will  pass  most  easily. 

During  the  first  fortnight  of  catheter  life  the  patient  must  be 
carefully  guarded  from  cold  and  exposure,  to  avoid  the  occurrence 
of  constitutional  disturbance.  Not  unfrequently  a  certain  amount 
of  fever  (to  which  the  name  of  Catheter  Fever  was  given  by  the 
late  Sir  Andrew  Clark)  is  produced,  which  either  passes  off  in  the 
course  of  a  few  days,  or  may  increase,  together  with  symptoms 
of  chronic  cystitis,  running  on  to  a  fatal  issue  at  the  end  of  three 
or  four  weeks.  The  origin  of  this  condition  is  still  somewhat 
doubtful ;  it  may  certainly  arise  from  the  absorption  of  micro- 
organisms or  their  products  from  the  urethra,  or  from  the  use  of 
impure  instruments,  but  possibly  reflex  nervous  disturbance  plays 
some  part  in  its  production.  The  only  treatment  required  in  the 
simpler  cases  is  to  keep  the  patient  warm  in  bed,  to  limit  his  diet, 
to  administer  quinine  and  opium,  and  to  keep  the  bowels  well  open. 

During  the  continuance  of  catheter  life,  the  patient  must  be 
warned  to  live  quietly,  and  abstain  from  all  excesses,  especially 
as  regards  eating  and  drinking  ;  sexual  excitement  should  be 
avoided,  and  horse-exercise  forbidden  ;  precautions  must  also  be 
taken  to  ensure  protection  from  cold  and  damp.  The  adminis- 
tration of  alkalies  is  desirable  if  the  urine  is  highly  acid,  so  as  to 
diminish  the  irritability  of  the  bladder. 

Under  such  a  regime,  it  is  possible  that  the  patient  may  live 
in  comparative  comfort  perhaps  for  years,  the  progress  of  the 
affection  being  entirely  checked  in  some  instances.  In  others, 
the  patient  suffers  from  intermittent  attacks  of  congestion  of  the 
prostate,  with  increased  pain  and  irritability  of  the  bladder,  and 
augmented  difficulty  in  micturition.  The  introduction  of  a  catheter 
is  then  very  likely  to  cause  bleeding,  but  a  few  days'  rest  in  bed 
usually  brings  about  considerable  improvement.  The  progress  of 
the  case  depends,  to  a  large  extent,  upon  the  bladder  remaining 
free  from  septic  contamination,  and  the  surgeon  must  realize  and 
impress  upon  his  patient  that  such  is  generally  due  to  infection 
from  without,  and  hence  the  most  scrupulous  care  must  be  taken 
to  sterilize  all  instruments  before  and  after  use.  In  cases  where 
the  relief  given  by  regular  catheterism  is  but  temporary,  and  the 
irritability  of  the  bladder  increases  seriously,  further  measures 
are  absolutely  imperative. 

Two  chief  plans  of  operative  treatment  have  been  adopted  in 
this  affection,  both  directed  to  reducing  the  size  of  the  organ,  and 
thus  removing  the  obstruction  to  the  passage  of  urine  ;  in  the 
one,  the  gland  itself  is  attacked,  and  portions  of  it  removed  or 
divided  (prostatotomy  or  prostatectomy)  ;  in  the  other,  the  diminu- 
tion in  size  is  attained  by  indirect  measures. 

Prostatotomy,  or  incision  of  the  prostate,  is  usually  undertaken 
from  the  perineum.  The  ordinary  incision  for  median  cystotomy 
is  made  after  the  passage  of  a  staff  with  a  median  groove.     The 


BLADDER  AND  PROSTATE  1115 


membranous  urethra  and  prostate  are  divided  in  the  middle  line 
to  a  sufficient  extent  to  allow  of  the  introduction  of  the  finger 
into  the  bladder,  and  an  elastic  tube  is  then  inserted  for  drainage. 
Any  projecting  nodules  or  masses  of  prostatic  substance  that 
can  be  detected  are  removed.  The  drainage  is  maintained  for 
a  week  or  ten  days,  and  considerable  improvement  is  said  to 
follow  in  some  cases.  The  chief  objection  to  this  plan  is  that  the 
perineum  in  these  patients  is  often  so  deep  that  it  is  impossible 
to  insert  the  finger  into  the  bladder  ;  considerable  haemorrhage 
may  also  take  place,  whilst  it  is  difficult  to  remove  tumour  masses 
that  might  be  easily  enucleated  by  other  means.  The  chief 
indication  for  its  use  is  when  cystitis  is  present  to  such  a  degree 
as  to  necessitate  continuous  drainage. 

It  has  also  been  proposed  to  divide  the  obstruction  at  the  neck 
of  the  bladder  by  a  concealed  knife,  to  destroy  it  by  a  galvano- 
cautery  (Bottini's  method),  or  snare  it  when  pedunculated;  such 
proceedings  are  uncertain,  and  not  free  from  risk. 

Prostatectomy,  or  removal  of  the  prostatic  enlargement,  has 
been  introduced  as  a  means  of  treatment  during  the  last  few  years. 
It  is  usually  conducted  through  a  suprapubic  incision  into  the 
bladder,  the  patient  being  previously  placed  in  the  Trendelenburg 
position.  The  enlargement  at  the  neck  of  the  bladder  can  be  felt, 
and,  by  the  use  of  suitable  illuminating  apparatus,  seen.  Pro- 
jecting growths  may  be  incised  and  shelled  out  without  much 
difficulty  or  haemorrhage ;  whilst  if  the  whole  organ  is  enlarged, 
the  mucous  membrane  over  it  may  be  divided  by  a  circular  in- 
cision, and  the  gland  substance  enucleated  from  its  fascial  capsule 
by  the  use  of  a  suitable  scoop,  or  with  the  fingers.  The  passage 
of  a  catheter  along  the  urethra  enables  the  surgeon  to  ascertain 
that  the  whole  of  the  projecting  growth  has  been  removed,  whilst 
a  finger  in  the  rectum  pushes  the  gland  forwards  and  makes  it 
more  prominent.  Most  satisfactory  results  have  followed  this 
operation,  although  sometimes  severe  haemorrhage  has  occurred. 
It  is  most  suitable  in  cases  where  a  pedunculated  or  encapsuled 
tumour  exists  in  the  middle  lobe,  but  the  whole  gland  can  be 
removed  without  much  difficulty,  and  without  seriously  damaging 
the  urethra. 

When  there  are  no  projecting  intra-vesical  growths,  it  is  pos- 
sible that  a  perineal  prostatectomy  (partial  or  complete)  is  a 
better  operation. 

The  chief  measures  which  have  been  employed  for  reducing  the 
size  of  the  prostate  by  indirect  means  are  as  follows  : 

(a)  Double  Castration. — This  plan  was  first  suggested  by  White 
of  Philadelphia,  in  1894,  and  has  now  been  followed  to  a  sufficient 
extent  to  enable  us  to  come  to  some  decision  as  to  its  utility. 
It  has  long  been  known  that  uterine  fibroids  diminish  in  size 
after  removal  of  the  ovaries,  and  the  similarity  between  such 
growths  and  an  enlarged  prostate  would  lead  one  to  anticipate  that 


im6  A   MANUAL  OF  SURGERY 

if  the  testes  are  excised  a  similar  shrinking  of  the  prostate  might 
follow ;  such,  in  certain  instances,  has  been  found  to  be  the  case. 
The  conditions  most  favourable  to  double  castration  are  those  in 
which  the  whole  gland  is  enlarged,  soft  and  vascular,  bleeding 
readily  on  the  introduction  of  a  catheter  ;  on  the  other  hand,  hard 
prostates,  or  those  in  which  fibroid  tumours  are  present,  are  not 
likely  to  be  much  improved  by  this  proceeding.  It  is  also 
interesting  to  note  that  the  tone  of  the  muscular  wall  of  the 
bladder  can  be  largely  regained,  even  after  considerable  distension 
and  atony  have  occurred. 

(b)  In  order  to  overcome  the  natural  objection  of  patients  to 
the  removal  of  their  testes,  vasectomy,  or  the  excision  of  a  portion 
of  the  vas  deferens  on  each  side,  has  been  practised.  In  suitable 
cases  the  results  have  been  good,  but  are  attained  more  slowly 
than  after  castration. 

(c)  Ligature  of  the  internal  iliac  arteries  has  also  been  employed 
in  order  to  starve  the  gland,  and  certainly  in  a  few  instances  with 
success. 

The  actual  treatment  to  be  adopted  in  any  particular  case  must 
be  determined  by  its  special  features.  Catheterism  will  suffice 
for  a  time,  but  when  this  fails  operation  should  be  undertaken. 
For  localized  outgrowths  projecting  into  the  bladder,  and  recog- 
nised by  the  cystoscope,  suprapubic  prostatectomy  is  to  be  recom- 
mended, but  for  general  enlargement  of  the  organ,  especially  if 
it  is  soft  and  succulent,  vasectomy  should  first  be  performed,  and 
may  be  followed  up  by  double  castration,  or  even  by  perineal 
prostatectomy,  if  necessary. 

Finally,  if  the  patient  refuses  these  operations,  or  if  his  general 
condition  prevents  them  from  being  undertaken  with  safety,  and 
catheterism  is  insufficient  to  give  relief  to  his  symptoms,  a  per- 
manent fistula  either  above  the  pubes  or  through  the  perineum  must 
be  established,  necessitating  the  use  of  a  portable  urinal.  This 
is  effected  by  introducing  a  trocar  and  cannula  into  the  bladder, 
and  leaving  it  there  until  a  sufficient  track  has  been  formed. 

Cancer  of  the  Prostate  occurs  in  elderly  men,  but  is  not  com- 
mon ;  it  is  usually  of  a  scirrhous  type,  though  sometimes  it  is  of  a 
soft  nature  ;  in  either  form  it  early  progresses  beyond  the  limits  of 
the  capsule.  The  symptoms  produced  are  those  of  obstruction  to 
the  flow  of  urine,  together  with  pain,  which  may  be  very  severe, 
and  at  a  later  date  haemorrhage.  The  progress  of  the  disease  is 
much  more  rapid  than  in  senile  hypertrophy.  On  rectal  examina- 
tion the  hard  mass  is  readily  detected,  whilst  secondary  deposits 
may  be  found  in  the  lumbar  and  abdominal  glands  on  palpating 
the  abdomen.  Occasionally  phenomena  referable  to  pressure  on 
the  abdominal  vessels  and  nerves  arise,  and  the  symptoms  of 
general  cachexia  soon  manifest  themselves.  Palliative  treatment 
alone  can  be  adopted. 


CHAPTER  XXXVIII. 
AFFECTIONS  OF  THE  URETHRA  AND  PENIS. 

Affections  of  the  Urethra. 

Congenital  Malformations. — Total  Absence,  or  Occlusion,  of  the 
urethra  has  been  met  with,  the  urine  under  such  circumstances 
being  sometimes  retained,  and  leading  to  dilatation  of  the  bladder, 
ureters,  and  kidneys,  a  condition  rapidly  fatal,  even  if  the  child 
be  born  alive.  In  a  few  cases  the  urachus  remains  patent,  and 
a  congenital  urinary  fistula  is  established  at  the  umbilicus,  whilst 
in  others  the  cloacal  condition  persists,  the  urine  passing  into 
the  rectum. 

Epispadias  is  a  deformity  in  which  the  urethra  is  partially  or 
wholly  exposed  along  the  upper  surface  of  the  penis.  According 
to  Mr.  Henry  Morris,  it  is  not,  properly  speaking,  a  division  or 
deficiency  in  the  upper  wall  of  the  urethra,  but  in  its  floor,  which 
has  been  transposed  to  the  dorsum  by  torsion  of  the  penis.  '  It 
is  thus,  in  fact,  a  hypospadias  reversed,  i.e.,  upside  down.'  In 
rare  instances,  the  external  meatus  is  situated  just  above  the 
glans,  which  is  cleft  and  deeply  grooved  superiorly.  More 
commonly  the  urethra  opens  at  the  root  of  the  penis,  just  in 
front  of  the  symphysis,  and  in  such  patients  the  organ  is  always 
rudimentary  and  stunted.  Complete  epispadias  is  only  present 
when  associated  with  extroversion  of  the  bladder  (p.  1072).  The 
incomplete  form  has  been  treated  with  success  by  the  use  of 
reversed  flaps  dissected  up  from  the  side  of  the  penis.  For  details 
of  the  operations  on  this  and  the  following  conditions,  see  larger 
text-books  on  operative  surgery. 

Hypospadias,  or  defective  development  of  the  lower  wall  of  the 
urethra,  is  a  much  more  common  malformation  than  the  fore- 
going. Three  varieties  are  described.  In  (a)  hypospadia  gland  is 
the  opening  of  the  urethra  corresponds  to  the  position  usually 
occupied  by  the  fraenum,  and  is  thus  directed  downwards  instead 
of  forwards.  The  prepuce  in  these  cases  is  always  voluminous, 
and  hangs  like  a  hood  over  the  glans,  which  is  bent  down  over 
the  orifice,  (b)  Hypospadia  penis  is  characterized  by  the  urethra 
opening  somewhere  along  the  under  surface  of  the  body  of  the 
penis,  which  is  often  small  and  stunted.  Considerable  discom- 
fort may  arise   in   the   act   of  micturition  owing   to  the  urethral 


mS  A  MANUAL  OF  SURGERY 

orifice  looking  downwards  ;  it  is  also  sometimes  so  small  as  to 
require  incision  and  dilatation.  (c)  Complete  hypospadias,  or 
hypospadia  pevincalis,  is  a  somewhat  complicated  condition,  in 
which  the  lower  wall  of  the  urethra  is  defective  as  far  back  as 
the  perineum,  the  scrotum  being  cleft,  and  thus  resembling  the 
vulva.  The  penis  is  always  small,  imperfectly  developed,  and 
bound  down  by  adhesions  between  the  scrotal  segments,  looking 
not  unlike  a  hypertrophied  clitoris.  Under  such  circumstances 
it  is  not  surprising  that  the  sex  of  the  child  has  been  mistaken, 
and  not  a  few  cases  are  on  record  where  it  has  been  educated  as 
a  female  until  the  age  of  eighteen  or  twenty.  Non-descent  of  the 
testes  is  often  associated  with  this  malformation. 

In  the  incomplete  varieties,  where  the  deformity  is  slight  and 
the  urethral  opening  well  in  front  of  the  scrotum,  no  interference 
is  necessary  ;  but  where  it  encroaches  on  the  scrotum,  causing 
inconvenience  and  discomfort,  and  threatening  to  prevent  effective 
sexual  intercourse  in  the  future,  the  restoration  of  the  urethra 
may  be  attempted  by  the  use  of  reversed  flaps  obtained  from 
either  side,  or  from  the  redundant  prepuce.  In  the  complete  form 
the  penis  must  first  be  liberated  from  its  adhesions  and  set  free ; 
the  integument  lining  the  scrotal  cleft  is  then  dissected  up  and 
turned  inwards  to  form  the  posterior  part  of  the  urethra,  whilst  the 
lateral  halves  of  the  scrotum  are  brought  together  with  sutures ; 
the  anterior  portion  of  the  urethra  may  then  be  dealt  with  as  for 
the  incomplete  variety. 

Traumatic  Laceration  of  the  Urethra  usually  results  from 
violence  applied  directly  to  the  perineum,  as  by  falling  astride  a 
stile,  fence,  or  beam  ;  it  has  also  been  caused  by  severe  jolting  in 
the  saddle,  or  by  a  kick  in  the  perineum.  In  fractures  of  the 
pelvis  it  may  be  produced  by  a  spicule  of  bone  puncturing  the 
canal,  and  the  membranous  portion  is  that  generally  affected. 
The  whole  circumference  of  the  urethra  may  be  involved,  the 
two  segments  being  entirely  disconnected,  or  only  a  portion  may 
be  ruptured,  and  that  most  frequently  the  floor. 

The  Symptoms  consist  of  pain  in  the  perineum  and  shock, 
followed  by  great  distension  of  the  scrotum  from  haemorrhage, 
whilst  blood  trickles  from  the  urethral  orifice.  If  the  patient  is 
able  to  restrain  himself  from  passing  water,  and  is  successfully 
treated,  no  extravasation  of  urine  results,  since  the  lesion  is  below 
the  sphincter  vesicas ;  if,  however,  he  attempts  to  micturate,  the 
urine  finds  its  way  into  the  perineal  and  scrotal  tissues.  Whether 
the  rupture  is  complete  or  not,  an  organic  stricture  of  considerable 
density  is  almost  certain  to  follow,  and  great  difficulty  is  sub- 
sequently experienced  in  keeping  it  dilated. 

Treatment. — In  the  slighter  cases,  where  it  is  probable  that  the 
mucous  membrane  has  alone  been  torn  and  there  is  no  perineal 
swelling,  the  patient  should  be  kept  quiet  in  bed,  and  no  attempts 
made   at  instrumentation.       If   urinary   infection    of   the   wound 


AFFECTIONS  OF  THE   URETHRA  AND  PENIS  1119 

occurs  and  an  abscess  forms,  it  can  be  dealt  with  by  incision  at  a 
later  date. 

Where,  however,  it  is  thought  that  the  urethra  is  partially  or 
wholly  divided,  no  temporizing  measures  such  as  tying  in  a 
catheter,  even  if  that  be  possible,  should  be  adopted.  An  incision 
ought  to  be  made  at  once  into  the  perineum  so  as  to  expose  the 
divided  ends  of  the  urethra,  which  it  is  the  surgeon's  aim  to  unite. 
The  blood-clot  is  removed,  bleeding  points  are  secured,  and  if  the 
ends  of  the  urethra  can  be  identified,  a  soft  catheter  is  introduced 
into  the  bladder,  and  they  are  sutured  together  around  it  with 
fine  catgut.  When  the  ends  are  much  torn,  it  is  wise  to  cut 
away  the  bruised  extremities  so  as  to  have  clean,  smooth  surfaces 
to  deal  with.  Under  all  circumstances  the  catheter  must  be  kept 
in  for  five  or  six  days,  if  possible,  and  subsequently  an  instrument 
must  be  passed  every  day  for  some  time. 

If  a  catheter  cannot  be  introduced,  or  if  extravasation  has  oc- 
curred, free  incisions  must  be  made  into  the  scrotum  and  perineum 
to  give  exit  to  the  blood  and  urine,  and  to  expose  the  seat  of  injury. 
A  catheter  is  passed  as  far  as  possible,  and  its  point  felt  for,  cut 
down  on,  and  guided  into  the  bladder  ;  a  prolonged  attempt  under 
anaesthesia  may  be  necessary  to  accomplish  this,  and  even  then 
it  is  useless  to  attempt  to  stitch  up  the  urethra,  as  the  sutures  are 
certain  to  cut  out.  Occasionally,  and  especially  if  treatment  has 
been  delayed,  the  swelling  of  the  parts  is  so  great  as  to  render 
the  passage  of  a  catheter  impossible.  The  patient  must  then  be 
put  to  bed  for  a  few  days  until  the  blood-clot  has  disappeared,  the 
urine  in  the  meantime  escaping  through  the  perineal  wound ;  but 
as  soon  as  possible  another  attempt  must  be  made.  When  once 
the  catheter  is  passed,  it  must  be  retained  for  several  days,  so  as 
to  establish  the  continuity  of  the  tube. 

Foreign  Bodies  are  sometimes  found  in  the  urethra,  usually 
consisting  of  a  portion  of  a  catheter,  pipe-stem,  or  in  children  a 
piece  of  slate-pencil.  Their  presence  gives  rise  to  partial  or  com- 
plete obstruction  to  the  flow  of  urine,  followed  by  ulceration  of 
the  mucous  membrane,  the  formation  of  a  peri-urethral  abscess, 
or  even  extravasation.  They  are  readily  detected  on  the  passage 
of  a  sound  or  catheter,  and  may  be  removed  by  suitable  forceps 
if  situated  near  the  orifice.  Should  this  fail,  the  urethra  may  be 
incised  and  the  body  extracted  ;  a  troublesome  urinary  fistula  is 
apt  to  follow  this  proceeding,  even  when  the  wound  in  the  urethra 
has  been  carefully  sutured. 

A  pin  is  sometimes  introduced  voluntarily  into  the  urethra,  and 
is  not  easily  removed,  since  it  has  usually  been  pushed  in  head- 
foremost. The  following  manoeuvre  is  necessary  in  order  to  remove 
it :  The  point  is  made  to  penetrate  the  floor  of  the  urethra  and  skin 
by  a  sharp  push  on  the  head  from  behind.  The  body  is  pulled 
out  until  the  head  catches  against  the  mucous  membrane,  and 
then  the  direction  of  the  pin  can  be  changed,  so  that  the  head 
presents  at  or  towards  the  meatus. 


A   MANUAL  OF  SURGERY 


Impacted  Calculus  is  a  not  unfrequent  cause  of  retention  in 
children.  It  can  usually  be  felt  through  the  walls  of  the  canal. 
The  symptoms  and  treatment  are  much  the  same  as  for  foreign 
bodies.  When  near  the  neck  of  the  bladder,  it  should  be  pushed 
back  into  that  viscus,  if  possible,  and  treated  by  lithotrity. 

Simple  Urethritis  may  arise  from  a  variety  of  causes  apart  from 
gonorrhoea,  e.g.,  the  presence  in  the  female  of  an  irritating  vaginal 
discharge,  such  as  leucorrhcea,  and  possibly  due  to  the  Bac.  coli. 
It  also  occurs  after  the  passage  of  an  instrument  or  of  a  calculus, 
and  is  occasionally  excited  in  gouty  individuals  by  highly  acid 
urine,  charged  presumably  with  spiculated  crystals  of  uric  acid. 
The  symptoms  are  much  the  same  as  those  of  gonorrhoea,  but  the 
discharge  is  thinner  in  character,  and  on  microscopical  examina- 
tion no  gonococci  are  detected.  The  treatment  consists  in  the 
administration  of  alkalies  and  saline  purgatives,  all  forms  of 
alcohol  being  interdicted.  In  more  severe  cases  oleo-balsams 
may  be  prescribed,  and  even  mild  injections. 

Polypoid  Tumours,  similar  in  character  to  the  caruncle  met 
with  in  the  urethra  of  women,  have  been  observed  at  the  orifice 
of  the  male  urethra.  They  are  red,  vascular,  and  sometimes 
exceedingly  painful,  and  are  best  dealt  with  by  excision,  followed 
by  the  application  of  the  galvano-cautery,  so  as  to  stop  the 
bleeding,  which  is  always  copious.  If  of  large  size,  the  base 
may  be  ligatured,  and  the  growth  cut  away. 

Stricture  of  the  Urethra. — By  stricture  of  the  urethra  is  meant 
a  condition  in  which  the  onward  passage  of  urine  is  hindered, 
owing  to  some  change  in  the  walls  of  the  urethra,  which  prevents 
them  from  dilating.  When  at  rest,  the  urethra  is  merely  a 
potential  canal,  the  walls  of  which  are  in  complete  apposition, 
and  it  is  only  converted  into  a  tube  when  urine  is  passing  along 
it.  When,  owing  to  some  change  in  the  structure  of  its  walls, 
this  functional  dilatation  is  impracticable,  the  patient  is  said  to 
suffer  from  stricture.  Three  forms  of  stricture  are  described,  viz., 
the  spasmodic,  congestive,  and  organic. 

Spasmodic  and  Congestive  Strictures  frequently  coexist,  although 
either  congestion  or  spasm  may  be  the  predominant  feature  in  any 
particular  case.  Thus,  in  acute  gonorrhoea  the  mucous  membrane 
often  becomes  engorged  and  thickened  to  such  an  extent  as  to 
interfere  with  the  act  of  micturition.  Spasm  is  the  chief  element 
under  the  following  conditions  :  (i)  When  a  patient,  suffering 
from  slight  organic  stricture,  is  exposed  to  wet  or  cold,  especially 
after  heavy  drinking ;  (2)  after  operations  on  the  rectum  or  sper- 
matic cord ;  (3)  as  a  result  of  catheterism  ;  and  (4)  from  perineal 
irritation  of  the  urethra,  as  by  a  blow  or  kick  in  this  region,  or 
from  prolonged  riding  on  a  bicycle  with  a  badly-fitting  saddle  or 
on  horseback.  Temporary  retention  is  the  usual  result  of  any  of 
these  conditions,  and,  as  a  rule,  no  treatment  is  required  beyond 
placing  the  patient  in  a  hot  bath,  and  unloading  the  lower  bowel 


AFFECTIONS  OF  THE  URETHRA  AND  PENIS 


by  the  use  of  a  large  warm  enema.  If  such  fails,  catheterism 
will  be  necessary,  and  must  be  conducted  with  the  greatest 
gentleness,  owing  to  the  congested  and  lacerable  condition  of  the 
mucous  membrane.  Full-sized  soft  instruments  should  first  be 
used,  and  will  usually  succeed ;  if  not,  a  silver  instrument  must 
be  substituted. 

Organic  Stricture  is  the  term  applied  to  an  undilatable  condition 
of  the  uretha,  resulting  from  the  development  of  cicatricial  tissue 
within  its  walls. 

The  Causes  of  organic  stricture  are  :  (a)  the  long  continuance 
of  a  urethral  discharge,  following  gonorrhoea,  or  the  frequent  re- 
currence of  this  affection.  Chronic  inflammations  are  always 
characterized  by  a  tendency  to  sclerosis  of  the  tissues  involved, 
and  the  urethra  is  no  exception  to  this  rule,  its  walls  under  these 
circumstances  becoming  thickened,  indurated,  and  contracted. 
(b)  The  cicatrization  of  a  urethral  chancre,  or  of  an  ulcer  caused 
by  the  impaction  of  a  stone,  or  the  contraction  produced  by  the 
healing  of  a  urethral  abscess,  may  also  lead  to  stenosis,  (c)  The 
most  intractable  forms  of  stricture  are  those  due  to  cicatrization 
after  rupture  or  laceration  of  the  urethral  wall. 

The  usual  Situation  is  within  the  bulb,  i.e.,  just  in  front  of  the 
triangular  ligament ;  but  the  orifice  and  body  are  not  unfrequently 
affected.  It  occurs  in  the  membranous  portion  only  as  a  result 
of  traumatism,  and  never  in  the  prostatic.  To  find  more  than 
two  strictures  in  any  particular  case  is  unusual,  although  three  or 
four  have  been  met  with. 

Various  terms  are  applied  to  a  stricture  according  to  the 
physical  conditions  present ;  thus,  it  is  termed  annular,  if  it 
involves  the  whole  lumen  of  the  urethra ;  bridled,  if  it  affects 
only  a  portion  of  the  circumference  of  the  tube.  A  ribbon-shaped 
stricture  is  one  in  which  a  considerable  extent  of  the  wall  is  con- 
tracted (i.e.,  as  if  a  ribbon  had  been  tied  around  the  urethra).  It 
is  termed  tortuous,  if  the  resulting  passage  is  not  straight ;  indurated, 
if  the  walls  are  very  hard  and  thickened ;  and  resilient,  when  the 
stricture,  though  readily  dilated,  rapidly  re-contracts.  The  terms 
impassable  and  impermeable  are  applied  to  strictures  through  which, 
on  the  one  hand,  a  surgeon  is  unable  to  pass  an  instrument,  or 
along  which,  on  the  other  hand,  urine  cannot  find  its  way ;  it  is 
doubtful  whether  the  latter  condition  ever  occurs,  whilst  the 
number  of  impassable  strictures  met  with  by  the  surgeon 
diminishes  with  his  experience  and  ability  in  passing  instru- 
ments. 

The  Symptoms  of  urethral  stricture  vary  according  to  the  case. 
The  patient  generally  complains  of  difficulty  in  the  act  of  micturi- 
tion, the  stream  becoming  small,  and  perhaps  forked  or  twisted. 
It  takes  a  longer  time  than  usual  to  empty  the  bladder,  and  even 
when  apparently  successful  a  few  drops  of  urine  may  trickle  away, 
wetting  the  patient's  clothes.  Irritability  of  the  viscus  follows, 
leading    to   frequent    attempts   to  pass  water  at    short    intervals 

7' 


A   MANUAL  OF  SURGERY 


during  the  day  and  night.  The  urine  under  these  circumstances 
often  becomes  alkaline,  and  loaded  with  muco-pus  and  phosphates. 
As  the  obstruction  increases,  more  and  more  residual  urine  is  left 
in  the  bladder,  which  may  in  time  form  a  tense,  rounded,  dull 
swelling  in  the  hypogastrium.  The  quantity  of  urine  trickling 
away  also  increases,  so  that  the  patient's  garments  are  always 
wet,  giving  him  an  unpleasant  urinous  odour.  A  certain  amount 
of  gleety  discharge  is  present,  whilst  if  the  individual  takes  an 
excess  of  alcohol,  or  is  exposed  to  wet  and  cold,  complete  reten- 
tion may  ensue.  Sometimes  the  onset  of  symptoms  is  so  insidious 
that  such  an  attack  of  retention  is  the  first  marked  feature  in  the 
case. 

The  Pathological  Conditions  arising  from  a  stricture  are  best 
considered  under  the  following  live  headings:  (i)  The  urethra 
anterior  to  the  stricture  is  usually  in  a  perfectly  normal  state, 
although  possibly  the  orifices  of  false  passages  may  be  seen.  A 
few  granulations  are  sometimes  present,  projecting  at  the  com- 
mencement of  the  stricture.  (2)  The  stricture  itself  is  characterized 
by  the  development  of  fibro-cicatricial  tissue  immediately  under 
the  mucous  membrane,  and  intimately  adherent  to  it.  It  extends 
for  a  variable  distance,  and  is  often  associated  with  a  good  deal 
of  peri-urethral  infiltration,  (j)  The  urethra  behind  the  stricture  is 
dilated,  and  the  mucous  membrane  velvety  and  friable  ;  the 
orifices  of  the  lacunae  and  other  glands  are  somewhat  enlarged 
and  more  than  usually  evident,  and  perhaps  ulceration  may  be 
present  around  them.  In  the  later  stages  the  inflammation  may 
extend  to  the  peri-urethral  tissue  owing  to  lymphatic  absorption,  or 
perhaps  to  the  escape  of  a  few  drops  of  urine  ;  a  perineal  abscess 
then  results,  leading  subsequently  to  perineal  fistulae.  When  the 
obstruction  becomes  almost  absolute,  this  portion  of  the  urethra 
may  give  way,  leading  to  extravasation  of  urine  into  the  perineum 
and  scrotum.  (4)  The  bladder  invariably  manifests  considerable 
changes  in  structure.  At  first  the  vesical  wall  undergoes  a  com- 
pensatory hypertrophy  of  its  muscular  elements  and  is  thickened, 
in  order  to  overcome  the  obstruction  to  the  onward  passage  of 
urine  (Fig.  395).  The  lattice-work  arrangement  of  the  muscular 
bands  becomes  coarse,  thickened,  and  evident,  causing  the  vesical 
wall  to  assume  a  fasciculated  appearance.  As  the  pressure  in- 
creases, the  mucous  membrane  protrudes  between  the  muscular 
fasciculi,  giving  rise  to  sacculation  ;  it  is  also  thickened  and  con- 
gested as  a  result  of  chronic  cystitis ;  the  superficial  veins  become 
varicose,  and  haematuria  may  be  caused  by  their  rupture,  whilst 
ulceration  may  also  occur.  The  urine  becomes  alkaline  and 
decomposes,  containing  muco-pus  and  phosphates.  It  is  likely  to 
stagnate  in  any  sacculi  which  exist,  and  may  then  determine  the 
formation  of  phosphatic  concretions ;  or  the  walls  of  the  sacculi 
ulcerate,  and  after  a  time  perforation  and  extravasation  of  urine 
into  the  cellular  tissue  lead  to  a  fatal  issue.  Occasionally  the 
bladder,  instead  of  being  thickened,  is  dilated  and  atonic  with  very 


AFFECTIONS  OF  THE  URETHRA   AND  PENIS 


1 1 23 


thin  walls.  (5)  Consequent  on  the  changes  in  the  bladder,  the 
conditions  already  described  as  hydronephrosis,  pyonephrosis,  or 
pyelonephritis  may  develop  partly  as  the  result  of  the  backward 
pressure,  and  partly  from  the  extension  of  septic  matter  along  the 
ureter  to  the  pelvis  of  the  kidney  and  calyces. 

Physical  Examination. — The  actual  diagnosis  of  a  stricture  can 


(College  of  Surgeons' 


Fig   395-~ Stricture  of  the  Urethra. 
Museum.) 

At  Au?nf  jB  s.tricture3  are  seen.  under  which  glass  rods  have  been  passed  The 
bladder  is  somewhat  dilated,  and  its  walls  are  thick  and  hypertrophic 
and  with  commencing  sacculation. 

only  be  confirmed  by  a  careful  physical  examination  of  the  urethra, 
which  is  usually  made  by  the  introduction  of  a  full-sized  catheter 
or  a  solid  bougie,  e.g.,  No.  9  or  10  (English),  so  as  to  ascertain 
where  the  obstruction  is  situated.  If  this  cannot  be  passed, 
smaller  instruments,  and  even  filiform  bougies,  are  inserted 
until  one  is  found  which  will  enter  the  bladder. 


1124  A   MANUAL  OF  SURGERY 


A  great  variety  of  catheters  is  in  use ;  in  old  days  only  metal 
instruments  were  obtainable,  and  even  now  the  silver  catheter 
is  the  favourite  with  many  surgeons  of  eminence.  In  selecting 
such  an  instrument,  care  must  be  taken  that  it  is  suitably 
curved,  and  that  the  '  eye '  is  sufficiently  large  and  bevelled 
inwards,  so  that  no  projecting  rim  lacerates  the  urethral  mucous 
membrane.  The  great  advantages  of  the  metal  instrument  are 
that  it  is  easily  kept  aseptic,  and  that  the  point  can  be  located 
and  thus  guided  more  readily  along  the  urethra.  Of  late  years 
many  different  forms  of  flexible  catheters  have  been  introduced, 
and  are  now  extensively  employed,  inasmuch  as  they  give  rise  to 
less  irritation  than  those  made  of  metal.  The  objections  to  them 
are  that  the  materials  of  which  they  consist  are  readily  attacked 
and  injured  by  antiseptics,  whilst  they  are  less  easily  directed 
through  a  stricture  on  account  of  their  flexibility,  it  being  impos- 
sible to  know  with  certainty  the  situation  of  the  point.  Probably 
the  best  means  of  sterilizing  a  soft  instrument  is  to  expose  it  to 
the  action  of  steam,  which  should  be  made  to  act  not  only  on  the 
exterior,  but  also  inside  the  tube  ;  many  appliances  to  obtain  this 
object  have  been  devised.  Amongst  the  best  flexible  instru- 
ments are  the  English  or  gum-elastic  catheter,  the  French  olive- 
headed  or  catheter-a-boule,  and  others  made  of  silk-web  coated 
with  shellac,  etc.  Some  varieties  are  now  polished  and  prepared 
inside  as  well  as  out,  and  they  should,  if  possible,  always  be 
selected. 

Bougies  or  solid  instruments  are  preferred  by  some  surgeons 
for  the  examination  and  treatment  of  strictures.  Those  known 
as  Lister's  bougies  are  the  best,  consisting  of  solid  metal  rods, 
curved  like  catheters,  the  bulbous  ends  of  which  are  three 
sizes  smaller  than  the  shanks,  thus  enabling  each  instrument 
passed  to  prepare  the  way  for  the  next.  Flexible  bougies  are 
also  made,  whilst  for  finding  a  way  through  a  tight  and  tortuous 
stricture  a  filiform  or  a  long  graduated  whip-lash  bougie,  made 
of  whalebone  or  catgut,  may  be  employed ;  in  the  latter  variety, 
the  fine  end  is  passed  through  the  stricture,  and  coils  up  in  the 
bladder,  whilst  the  thicker  portion  is  thus  brought  to  bear  on  the 
stricture. 

In  order  to  introduce  a  silver  catheter  or  bougie,  the  patient  is  laid 
on  his  back,  the  surgeon  standing  on  his  left  side.  The  umbilicus 
should  always  be  exposed,  as  also  the  upper  parts  of  the  thighs. 
The  catheter,  which  has  been  previously  sterilized,  warmed,  and 
covered  with  some  antiseptic  oil  or  grease,  is  taken  in  the  right 
hand,  and  inserted  into  the  urethra,  with  the  handle  directed 
over  the  left  thigh  and  slightly  downwards.  The  point  of  the 
instrument  is  guided  as  far  as  the  perineum,  and  then  the  handle 
is  carried  round  to  the  middle  line  of  the  body  towards  the 
umbilicus ;  it  is  then  raised  to  the  vertical,  the  penis  being  held 
in    the   left   hand,  and    gently   depressed  between  the   patient's 


AFFECTIONS  OF  THE   URETHRA   AND  PENIS  1125 

thighs,  the  so-called  tour-de-mailre.  The  catheter  finds:  its  way 
along  the  urethra  into  the  bladder  rather  by  its  own  weight  than 
by  any  forcible  action  of  the  surgeon.  The  chief  points  at  which 
difficulty  may  be  experienced  are  :  (a)  The  orifice",  which  may  be 
small  and  contracted  ;  (b)  the  lacuna  magna,  which  is  avoided  by 
keeping  the  point  of  the  instrument  against  the  floor  ;  and  (c)  the 
opening  in  the  triangular  ligament,  which  is  best  entered  by 
keeping  the  point  against  the  upper  wall  of  the  canal. 

Some  authorities  recommend  that  the  patient  should  stand  up, 
with  the  back  resting  against  a  wall  or  firm  support,  the  surgeon 
sitting  in  front,  and  manipulating,  it  is  said,  with  greater  accuracy. 
The  objections  to  this  position  are  :  (a)  The  liability  of  the  patient 
to  faint,  and  (b)  the  existence  of  greater  muscular  tension  than 
obtains  in  the  horizontal  posture. 

When  a  flexible  instrument  without  a  stilette  is  used,  it  is 
passed  by  pressing  the  point  on  with  a  little  rotatory  movement 
until  the  bladder  is  reached,  withdrawing  a  little,  and  pushing 
on  again,  if  any  obstruction  is  met.  In  some  instances,  however, 
the  use  of  a  stilette  is  absolutely  necessary. 

The  chief  Dangers  of  catheterism  are  as  follow  :  1.  A  consider- 
able degree  of  shock  is  sometimes  experienced,  especially  in  sensi- 
tive individuals,  and  if  an  instrument  has  not  been  passed  before. 
It  may  be  obviated  to  a  large  extent  by  first  introducing  about 
half  a  drachm  of  the  5  per  cent,  solution  of  cocaine  into  the 
urethra. 

2.  Hemorrhage  may  be  induced  by  laceration  or  abrasion  of  the 
mucous  membrane,  even  though  no  false  passage  has  been  made ; 
it  is  best  avoided  by  gentleness  and  the  use  of  well-finished 
instruments.  In  spite  of  these  precautions,  when  the  mucous 
membrane  is  soft  and  congested,  and  in  many  cases  of  stricture, 
some  bleeding  cannot  be  avoided.  It  is  rarely  sufficient  to  call 
for  special  treatment,  but  if  very  abundant  may  be  arrested  by 
injections  of  hazeline. 

3.  False  passages  are  frequently  produced  in  the  treatment  of 
strictures.  The  point  of  the  instrument  is  most  likely  to  leave 
the  canal  at  some  spot  in  the  floor,  travelling  for  a  variable 
distance,  according  to  the  force  employed,  under  the  mucous 
membrane,  occasionally  re-entering  the  dilated  urethra  behind 
the  stricture,  which  it  avoids  altogether,  or  perforating  the 
posterior  wall  of  the  bladder  by  tunnelling  under  the  prostate,  an 
accident  which  can  only  occur  in  unskilful  hands.  The  occur- 
rence of  a  false  passage  is  indicated  by  the  sudden  onward  move- 
ment of  the  instrument,  combined  with  pain  and  haemorrhage  ; 
the  point  is  usually  deflected  from  the  middle  line,  as  is  plainly 
seen  by  the  obliquity  of  the  rings  at  the  end  of  the  shaft ;  no  urine 
comes  unless  the  urinary  passages  are  opened  behind  the  stricture. 
On  rectal  examination,  the  instrument  can  be  felt  out  of  the 
middle  line,  and  nearer  the  rectum  than  is  normal,  and  in  some 


1 126  .A  MANUAL  OF  SURGERY 


exceptional  cases  has  even  been  found  in  it.  False  passages  are 
not  necessarily  matters  of  great  importance,  but  when  extensive 
may  lead  to  peri-urethral  suppuration  and  extravasation  of  urine, 
possibly  followed  by  fatal  results. 

4.  Inflammatory  phenomena  may  be  lighted  up  in  the  prostate 
and  acute  epididymitis  induced  by  extension  along  the  vas 
deferens  ;  these  are  almost  always  due  to  sepsis. 

5.  Urinary  Fever,  or,  as  it  is  sometimes  termed,  urethral  or 
catheter  fever,  is  always  liable  to  develop  as  a  result  of  the  intro- 
duction of  instruments.  It  may  occur  as  a  solitary  rigor  even  in 
individuals  with  healthy  urinary  organs,  but  is  much  more  fre- 
quently observed  in  those  with  damaged  kidneys.  As  to  its 
causation,  there  has  been  much  discussion,  but  there  can  now  be 
little  doubt  that  it  is  essentially  septic  in  origin.  Possibly  the 
instrument  employed  may  be  dirty,  or  the  urethra  itself  contains 
septic  material,  especially  in  its  deeper  parts.  It  is  quite  sufficient 
for  a  slight  abrasion  to  occur  near  the  neck  of  the  bladder,  to  allow 
of  the  absorption  either  of  toxins  or  of  bacteria,  and  then  general 
phenomena  show  themselves  at  once.  If  merely  toxic  products 
are  absorbed,  probably  a  passing  febrile  condition,  such  as  one  or 
more  rigors,  will  develop,  with  no  more  serious  phenomena  ;  but 
if  bacteria  find  their  way  into  the  submucous  tissues,  they  are 
likely  to  develop  rapidly  in  the  lymphatics,  extending  to  the 
bladder  and  thence  up  the  ureters  owing  to  the  continuity  of 
lymphatic  supply,  giving  rise  finally  to  pyelonephritis  (p.  1056). 
Formerly  reflex  congestion  of  the  kidneys  was  thought  to  be  an 
important  factor  in  these  cases  ;  probably  the  congestion  which 
occurs  is  due  to  the  direct  irritation  of  bacteria,  and  is  not  of 
nervous  origin. 

The  clinical  manifestations  vary  considerably,  according  to  the 
character  of  the  case  and  the  type  of  infection,  (a)  The  simplest 
form  consists  in  the  development  of  a  single  rigor,  the  temperature 
perhaps  running  up  to  1050  F. ;  the  patient  shivers  and  feels  very 
ill,  and  the  head  aches,  but  when  the  temperature  falls  he  soon 
recovers,  and  within  a  few  hours  is  all  right  again,  (b)  Sometimes 
the  temperature  does  not  fall  to  the  normal  after  the  initial  rigor, 
but  remains  elevated  a  few  degrees  for  a  day  or  two,  and  there 
may  even  be  a  repetition  of  the  rigor.  The  patient,  however, 
recovers  perfectly,  and  no  permanent  harm  is  done,  (c)  In  the 
more  serious  cases  the  symptoms  of  pyelonephritis  supervene, 
and  are  very  likely  to  prove  fatal,  the  patient  perhaps  dying  in 
seven  or  eight  days,  (d)  General  pyaemia  may  appear  as  a  com- 
plication of  the  last  condition,  (e)  In  patients  who  are  com- 
mencing the  regular  passage  of  catheters  for  enlarged  prostate  a 
series  of  phenomena  develop,  which  have  been  already  alluded 
to  (p.  1 1 14),  and  though  often  mild,  are  of  a  similar  nature. 
(/)  Finally,  suppression  of  urine  may  accompany  any  of  the 
conditions  alluded  to  above. 


AFFECTIONS  OF  THE   URETHRA  AND  PENIS  1127 

Treatment. — Whenever  it  seems  probable  that  the  kidneys  are 
damaged,  the  greatest  care  must  be  taken  in  order  to  avoid 
septic  infection.  The  instruments  employed,  whether  bougies  or 
catheters,  must  be  thoroughly  sterilized,  and  it  would  also  be  well 
to  irrigate  the  urethra  with  a  mild  antiseptic  lotion.  It  is  perhaps 
better  to  use  soft,  elastic  instruments  rather  than  silver  ones,  as 
the  latter  give  rise  to  more  irritation  than  the  former,  and  are 
more  likely  to  abrade  the  mucous  membrane. 

For  the  single  rigor  following  catheterism,  the  patient  must  be 
kept  warm,  plenty  of  hot  diluent  drinks  given,  and  quinine 
(2  grains)  and  opium  (-J  to  1  grain)  administered  in  a  pill,  although 
the  latter  drug  must  be  sparingly  used  if  any  evidences  of  uraemia 
are  existent.  If  the  febrile  symptoms  continue,  the  skin  and 
bowels  are  freely  acted  on,  and  a  milk  diet  prescribed,  although  a 
certain  amount  of  stimulant  may  be  given  if  necessary  ;  all 
operative  measures  must  be  avoided,  unless  it  is  essential  to 
relieve  obstruction,  as  they  are  almost  invariably  fatal.  Should 
suppression  of  urine  ensue,  the  loins  should  be  cupped  in  the 
hope  of  relieving  renal  congestion,  a  free  action  of  the  bowels 
obtained  by  the  use  of  watery  purgatives,  and  the  patient  made 
to  sweat  freely,  either  by  the  use  of  hot-air  baths  or  by  the  in- 
jection of  pilocarpine.  Uraemic  symptoms  may  sometimes  be 
relieved  by  copious  and  repeated  intravenous  injections  of 
normal  saline  solution,  which  encourage  diuresis  and  a  watery 
diarrhoea  ;   several  successful  cases  have  been  recorded. 

The  Treatment  of  Passable  Strictures  is  conducted  either  by 
dilatation  or  by  a  cutting  operation  (internal  or  external  ure- 
throtomy). 

Treatment  by  Dilatation  is  effected  in  various  ways,  according 
to  the  nature  of  the  stricture  and  the  urgency  of  the  symptoms. 
Where  the  obstruction  is  not  serious,  and  an  instrument  can  be 
easily  passed,  gradual  dilatation  should  always  be  employed ;  this 
consists  in  the  use  of  instruments  once  or  twice  a  week,  steadily 
increasing  the  size  until  a  No.  12  is  reached.  If  the  intervals  are 
too  short,  the  urethra  may  become  irritated,  spasm  be  induced,  and 
the  lumen  of  the  canal  temporarily  diminished  in  size  ;  by  keeping 
the  patient  quiet  for  a  few  days  on  a  bland  diet,  and  the  bowels 
well  open,  the  spasm  disappears.  In  cases  where  time  is  an 
object,  rapid  dilatation  may  be  undertaken  by  the  passage  of  several 
sizes  of  bougie  at  one  sitting ;  for  this  purpose,  Lister's  instru- 
ments are  particularly  useful.  Where  only  a  very  small  catheter 
can  be  introduced,  and  that  with  difficulty,  continuous  dilatation 
may  be  adopted  by  keeping  the  patient  in  bed,  tying  in  the  small 
instrument  for  forty-eight  hours  or  more,  at  the  expiration  of 
which  period  a  catheter  several  sizes  larger  can  be  substituted. 
This  in  turn  may  be  tied  in  if  the  patient  can  bear  it ;  but  the 
presence  of  a  catheter  within  the  urethra  for  any  length  of  time 


1128 


A   MANUAL  OF  SURGERY 


is  not  always  tolerated,  and  may  give  rise  at  the  end  of  two  or 
three  days  to  considerahle  constitutional  disturbance  and  fever. 
Forcible  dilatation  is  a  plan  which  has  now  but  few  advocates. 
I*  consists  in  the  passage  of  an  instrument,  the  shaft  of  which 
is;  made  in  two  portions,  which  can  be  separated  from  one 
another  in  such  a  way  as  to  destroy  the  stricture  either  by  dis- 
tension or  rupture  of  its  substance.  It  is  but  little  used,  on 
account  of  the  great  tendency,  when  cicatrization  is  complete,  to 
the  formation  of  an  even  more  intractable  stricture  than  before. 

By  whichever  of  these  methods  dilatation  is  accomplished,  it  is 
essential  that  either  the  surgeon  or  the  patient  should  subsequently 
pass  an  instrument  through  the  stricture  at  first  every  week  or 
two,  and  then  at  longer  intervals,  to  overcome  the  tendency  to 
recontraction  which  is  ever  present. 

The  Treatment  of  Passable  Stricture  by  a  Cutting  Operation  is 
conducted  either  by  internal  or  external  urethrotomy. 

Internal  Urethrotomy  is  a  valuable  means  of  treatment  when 
rightly  employed,  but  in  careless  or  inexperienced  hands  may  be 
attended  with  considerable  danger.     It  has  been  performed  either 


Civiale's  Urethrotome.     (Down  Brothers.) 


by  passing  an  instrument  through  the  stricture,  and  dividing  it 
from  behind  forwards,  or  by  passing  an  instrument  down  to  the 
stricture,  and  dividing  it  from  before  backwards.  The  latter  plan 
of  treatment,  though  recommended  by  some  skilled  authorities, 
is  not  an  operation  which  commends  itself  to  our  judgment,  inas- 
much as  it  is  almost  impossible  to  gauge  the  amount  of  tissue 
divided.  The  former  plan  of  incising  a  stricture  from  behind  for- 
wards is  of  course  only  called  for  under  special  circumstances, 
since  if  the  urethrotome  can  be  passed  through  a  stricture,  ordi- 
nary dilatation  is  in  the  majority  of  cases  practicable.  It  is  use- 
ful, however,  (a)  in  the  treatment  of  very  old  and  dense  carti- 
laginous strictures,  as  also  (b)  for  resilient  strictures,  and  (c)  when 
the  urethra  is  excessively  irritable.  It  should  only  be  employed 
when  the  obstruction  is  situated  in  the  anterior  two-thirds  of  the 
urethra.  Many  forms  of  urethrotome  have  been  devised,  but 
perhaps  the  most  useful  is  that  known  as  Civiale's  (Fig.  396), 
which  can  only  be  used  for  a  stricture  which  will  admit  the  passage 
of  a  No.  5  catheter.  The  end  is  bulbous,  and  contains  a  hidden 
knife,  worked  by  means  of  a  button  in  the  handle.  The  instrument 
is  passed  through  the  stricture,  the  cutting  blade  projected,  and  by 
withdrawing  it  the  cicatricial  tissue  is  notched  to  such  an  extent 


AFFECTIONS  OF   THE  URETHRA  AND  PENIS 


1 1 29 


as  to  allow  a  full-sized  catheter  to  be  inserted  at  once,  and,  if 
possible,  tied  in,  Where  the  deeper  part  of  the  urethra  is  being 
dealt  with,  the  incision  should  be  made  along  the  roof  so  as  to 
avoid  the  bulb.  Care  must  be  taken  not  to  cut 
beyond  the  limits  of  the  cicatricial  tissue,  other- 
„  wise  haemorrhage,  peri-urethral  suppuration,  or 
I  even  extravasation  of  urine,  may  ensue.  It  is 
]  also  advisable  to  sterilize  the  urethra  as  far  as 
J  possible  by  washing  it  out  with  weak  antiseptic 
\    solutions  before  operating. 

External  Urethrotomy,  or  Syme's  Operation,  is 
;  required  under  circumstances  similar  to  those 
I  needing  internal  urethrotomy,  if  the  stricture  is 
situated  in  the  posterior  third  of  the  urethra,  but 
!  is  chiefly  employed  where  perineal  fistulas  are 
!  present.  It  is  performed  by  passing  a  special 
:  shouldered  staff  (Syme's,  Fig.  397),  the  distal  end 
'<  of  which  is  small  enough  to  pass  through  the 
:  stricture,  and  grooved  in  the  middle  line,  whilst 
the  shaft  of  the  instrument  is  of  larger  size,  and 
:  ends  abruptly,  so  that  the  shoulder  rests  against 
the  face  of  the  stricture ;  the  groove  extends  on 
;  to  the  larger  portion  for  about  \  inch.  The 
patient  is  then  placed  in  the  lithotomy  position, 
and  the  surgeon,  seated  opposite  the  perineum, 
which  is  shaved  and  well  purified,  incises  it  in 
the  middle  line,  carrying  his  dissection  carefully 
downwards  so  as  to  reach  the  groove  in  the  staff 
behind  the  stricture.  The  knife  is  then  carried 
forwards  to  the  anterior  extremity  of  the  groove, 
and  inasmuch  as  it  extends  on  to  the  shaft  of 
the  instrument,  the  stricture  is  completely  divided. 
Any  fistulae  which  exist  are  laid  open  into  the 
median  wound,  and  thoroughly  scraped  and  puri- 
fied. A  full-sized  soft  catheter  is  then  passed 
into  the  bladder,  through  either  the  penis  or  the 
perineum,  according  to  circumstances,  and  re- 
•  tained  in  position  for  some  days,  the  urine  being 
1  syphoned  off  in  the  usual  way,  whilst  the  perineal 
wound,  after  all  haemorrhage  has  been  stopped, 
is  packed  with  strips  of  antiseptic  gauze,  and 
allowed  to  heal  by  granulation.  The  catheter  is 
removed  early  or  late  according  to  the  amount 
of  general  disturbance  caused  thereby,  and  subsequently  a  full- 
sized  instrument  can  be  passed  into  the  bladder  daily.  Some 
surgeons  have  recommended  the  use  of  the  so-called  self-retaining 
catheters,  in  the  hope  of  preventing  urine  from  finding  its  way 
through  the  external  wound;  several  varieties  have  been  suggested, 


A  MANUAL  OF  SURGERY 


but  they  are  of  little  practical  value,  since  the  escape  of  urine  along 
the  side  of  the  instrument  can  never  be  totally  prevented. 

Excision  of  a  Stricture  has  been  undertaken  with  success  in 
several  cases  where  dilatation  and  urethrotomy  had  failed  to  give 
permanent  relief.  As  much  as  one  inch  of  the  urethra  has  been 
removed,  and  the  ends  sutured  together  with  successful  primary 
union. 

The  Treatment  of  Impassable  Stricture  varies  according  to 
whether  or  not  the  condition  is  complicated  with  retention  of 
urine. 

If  no  retention  is  present,  it  is  possible  that  the  inability  to  pass  an 
instrument  is  due  to  some  temporary  spasm  or  congestion  induced 
by  errors  of  diet  or  drink, 
or  perhaps  by  exposure  to 
cold.  Hence  the  patient 
should  rest  in  bed  for  a 
few  days,  his  bowels  be 
well  opened,  the  diet 
regulated,  and  a  mixture 
containing  some  alkaline 
purgative  and  tincture  of 
henbane  administered. 
Further  attempts  at  in- 
strumentation should  then 
be  made,  if  necessary, 
under  an  anaesthetic,  and 
if  the  stricture  still  remains 
impassable,  Wheelhouse's 
operation  (Fig.  398)  is  in- 
dicated. This  consists  in 
the  urethra  in 
the  constriction, 


Fig.  393. — Wheelhouse's  Operation  for 
Impassable  Stricture.  (Bryant's  '  Sur- 
gery.') 


incising 

front  of 

tracing  the  passage  backwards,  and  dividing  it.  A  Wheelhouse's 
straight  staff  with  a  median  groove  and  a  blunt  hook  at  the  end 
is  inserted  down  to  the  stricture,  and  the  urethra  opened  just  in 
front  of  it  by  cutting  down  on  the  groove.  The  staff  is  then 
twisted  round,  the  upper  end  of  the  incision  drawn  up  by  the 
projection  of  the  hook,  and  the  sides  of  the  urethra  held  apart 
with  artery  forceps.  The  orifice  of  the  stricture  is  thus  exposed, 
and  granulations  may  often  be  seen  projecting  from  it.  A  fine 
probe-pointed  director  can  generally  be  insinuated  along  the 
urethra  through  the  stricture,  which  is  then  divided.  A  full-sized 
instrument  is  passed  into  the  bladder  and  retained  for  a  few  days, 
whilst  the  wound  is  allowed  to  heal  by  granulation. 

If  retention  of  urine  is  present  in  a  case  of  impassable  stricture, 
no  time  must  be  lost.  If  seen  at  an  early  stage,  and  the 
symptoms  are  not  urgent,  the  patient  is  given  a  hot  bath, 
and  the  bowels  are  opened  by  a  warm  enema,  whilst  a  moderate 


AFFECTIONS  OF  THE    URETHRA    AND  PENIS 


dose  of  opium  or  preferably  a  morphia  suppository  is  adminis- 
tered. If  the  urine  is  not  passed  naturally  in  the  bath,  and 
the  bladder  is  becoming  distended,  being  felt  in  the  lower  part  of 
the  abdomen,  suprapubic  aspiration,  or  puncture  with  a  trocar 
and  cannula,  should  be  undertaken,  and  temporary  relief  thus 
obtained.  Probably,  when  tension  has  been  removed  from  the 
posterior  part  of  the  urethra,  a  catheter  will  be  introduced  without 
much  difficulty.  Failing  this,  aspiration  may  be  several  times 
resorted  to,  but  it  is  generally  wiser  to  open  the  urethra  in  front 
of  or  behind  the  stricture,  and  drain  the  bladder,  since  the  risks  of 
septic  troubles,  extravasation  of  urine,  dangerous  pressure  upon 
the  kidneys,  and  urinary  infiltration  along  the  lines  of  puncture, 
are  thereby  lessened. 

Cock's  Operation,   or   Perineal   Section,   is   sometimes  adopted 
when  no  guide  can  be  passed  into  the  bladder  (Fig.  399).     The 


Fig.  399 


Cock's  Operation  of  Perineal  Section. 
(Eryant's  '  Surgery.') 


patient  is  placed  in  the  lithotomy  position,  and  the  situation  of  the 
membranous  urethra  ascertained  by  inserting  the  index-finger 
into  the  rectum.  A  median  perineal  incision  is  then  made,  and 
after  dividing  the  cutaneous  structures,  the  surgeon  plunges  the 
scalpel  boldly  in  towards  the  apex  of  the  prostate,  guided  by  his 
finger  in  the  rectum.  He  must  keep  strictly  in  the  middle  line,  so 
as  to  avoid  the  important  vascular  and  other  structures  which  are 
so  abundantly  present  in  the  perineum.  As  soon  as  the  urethra 
is  opened,  a  gush  of  urine  often  escapes ;  the  upper  urethral  wall 
should  not  be  damaged  with  the  knife,  for  fear  of  opening  up  the 
deep  pelvic  cellular  tissue. 

This  operation  may  be  tolerably  simple  if  the  urethra  behind 
the  stricture  is  dilated,  as  is  not  uncommonly  the  case ;  but 
sometimes  it  is  extremely  difficult,  especially  if  the  urethra  has 
been  displaced  laterally.  If  the  stricture  is  not  situated  too  far 
from  the  incision,  it  is  always  wise  to  complete  the  operation  by 


"32 


A   MANUAL  OF  SURGERY 


dividing  it,  and  a  full-sized  catheter  can  then  be  passed  into  the 
bladder,  and  the  perineal  wound  allowed  to  granulate.  If  the 
stricture  cannot  be  dealt  with  during  the  operation,  and  is  of  a 
dense  cartilaginous  nature,  a  tube  is  inserted  into  the  bladder 
through  the  perineum  ;  probably  at  the  end  of  a  few  days  the 
tissues  will  yield  sufficiently  to  allow  of  the  passage  of  a  catheter, 
or  Wheelhouse's  operation  can  be  subsequently  adopted. 

The  chief  complications  of  stricture  other  than  those  already 
mentioned  are  perineal  abscess,  perineal  fistula,  and  extravasation 
of  urine. 

A  Perineal  Abscess  consists  in  a  focus  of  peri-urethral  suppura- 
tion, which  is  due  either  to  a  limited  extravasation  of  urine,  or  to 
the  absorption  of  septic  material  through  an  ulcerated  surface. 
It  is  indicated  by  the  formation  of  a  hard,  brawny  swelling  in  the 
perineum,  which  is  tender  to  the  touch.     As  it  approaches  the 


•-, 


Fig.  400. — Perineal  Fistula      (Bryant's  'Surgery.') 


surface,  fluctuation  can  be  detected,  and  the  skin  over  it  becomes 
congested  and  cedematous.  Constitutional  disturbance  and  fever 
of  an  asthenic  type  are  also  present.  Left  to  itself,  it  bursts  and 
usually  gives  rise  to  a  perineal  sinus  or  fistula,  discharging  either 
pus,  or  urine  mixed  with  pus.  One  or  many  of  these  fistulas  may 
occur  (Fig.  400),  and  the  openings  are  not  limited  to  the  perineum, 
but  may  also  be  found  in  the  thighs,  buttocks,  or  even  the  groins. 
In  chronic  cases,  the  scrotal  or  perineal  tissues  become  infiltrated 
and  of  an  almost  cartilaginous  consistency. 

Diagnosis.— Every  abscess  in  the  scrotum  or  perineum  is  not 
necessarily  associated  with  stricture,  for  simple  irritation  of  the 
skin  may  lead  to  a  superficial  abscess  ;  suppuration  in  the  lacunae, 
or  Cowper's  glands,  may  follow  gonorrhoea  ;  a  prostatic  or  ischio- 
rectal abscess  may  point  in  the  perineum  ;  whilst  the  injury 
inflicted  by  the  passage  of  instruments,  or  the  existence  of  false 
passages,  may  lead  to  a  similar  result. 

The  Treatment  of  a  Perineal  Abscess  consists  in  the  application 


AFFECTIONS  OF  THE  URETHRA  AND  PENIS  1133 


of  fomentations  during  the  early  stages  ;  as  soon  as  pus  is  present, 
it  should  be  let  out  through  a  free  incision,  and  it  is  often  advisable 
to  take  the  opportunity  of  dealing  radically  with  the  stricture  by 
section  at  the  same  time.  Perineal  fistulae  can  rarely  be  cured 
without  operation,  since,  although  the  stricture  may  be  completely 
dilated,  the  discharge  of  urine  and  pus  continues.  Under  these 
circumstances  Syme's  or  Wheelhouse's  operation  is  the  proper 
treatment. 

Extravasation  of  Urine  is  a  condition  due  to  a  solution  of  con- 
tinuity of  the  urethral  walls,  allowing  the  urine  to  find  its  way 
into  the  perineal  and  scrotal  tissues.  It  usually  results  from  over- 
distension of  the  urethra  behind  a  neglected  stricture ;  during 
some  violent  effort  at  micturition,  the  patient  experiences  severe 
pain  and  a  sensation  as  if  something  had  given  way  in  the 
perineum,  followed  by  a  feeling  of  relief.  This,  however,  is  of 
short  duration,  as  it  is  soon  succeeded  by  the  local  and  constitu- 
tional effects  of  extravasation.  The  same  phenomena  are  pro- 
duced in  cases  of  traumatic  laceration  of  the  urethra  if  the  patient 
attempts  to  empty  his  bladder.  Occasionally  the  onset  of 
symptoms  is  more  gradual,  being  preceded  by  a  peri-urethral 
abscess,  which  bursts  into  the  urethra ;  at  each  act  of  micturition 
the  cavity  becomes  more  and  more  distended  with  urine ;  finally 
the  wall  yields,  resulting  in  diffuse  extravasation. 

The  membranous  urethra  is  almost  always  the  site  of  the  rupture, 
the  urine  finding  its  way  subsequently  through  the  anterior  layer 
of  the  triangular  ligament,  and  being  guided  towards  the  an- 
terior abdominal  wall  by  the  arrangement  of  the  fasciae.  The 
root  of  the  penis,  covered  by  its  appropriate  muscles,  lies  in  an 
interfascial  cul-de-sac,  formed  by  the  anterior  layer  of  the 
triangular  ligament  above,  and  the  deep  layer  of  the  perineal 
fascia  (or  fascia  of  Colles)  below ;  these  two  layers  are  con- 
tinuous, passing  round  the  transversus  perinei  muscles,  and  are 
both  attached  laterally  to  the  ischio-pubic  rami.  Into  this  space 
the  urine  finds  its  way,  after  the  anterior  layer  of  the  triangular 
ligament  has  yielded,  and  owing  to  the  fact  that  its  passage  back- 
wards and  laterally  is  checked  by  the  attachment  of  the  fasciae,  it 
is  necessarily  forced  forwards,  infiltrating  in  order  the  perineum, 
scrotum,  and  body  of  the  penis.  If  more  extensive,  it  travels 
along  the  spermatic  cords  to  the  anterior  abdominal  parietes,  its 
passage  downwards  into  the  thighs  being  prevented  by  the  attach- 
ment of  the  deep  layer  of  the  superficial  fascia  01  the  abdomen  to 
the  fascia  lata  just  below  Poupart's  ligament.  In  the  most  severe 
cases  the  urine  may  even  find  its  way  as  far  as  the  axillae. 

The  Effects  of  extravasation  of  urine  are  always  serious. 
Possibly,  if  the  urine  were  pure  and  aseptic,  part  of  it  might  be 
absorbed ;  but  even  then  prolonged  infiltration  of  the  tissues  is 
likely  to  result  in  suppuration  and  sloughing.  In  cases  of  stricture, 
however,  the  urine  is  almost  certain  to  be  foul  and  alkaline,  and 


ii34  A   MANUAL  OF  SURGERY 

hence  wherever  it  travels  it  gives  rise  to  a  gangrenous  cellulitis. 
The  parts  at  first  become  infiltrated  and  brawny,  but  soon  emphy- 
sematous crackling  and  putrefaction  are  observed,  owing  to  necrosis 
of  the  cellular  tissue.  The  congested  and  cedematous  skin  turns  to 
a  dusky  purple  or  black  colour,  and  finally  gives  way  or  separates, 
allowing  exit  to  a  mixture  of  pus,  urine,  and  decomposing  slough 
of  a  most  offensive  and  penetrating  odour.  The  superficial  loss  of 
substance  may  be  so  extensive  as  to  lay  bare  both  testicles,  and 
even  the  body  of  the  penis,  or  part  of  the  anterior  abdominal  wall. 
The  inflammatory  process  is  necessarily  associated  with  severe 
constitutional  disturbance,  at  first  characterized  by  high  fever  and 
a  quick,  bounding  pulse  ;  but  later  on  the  temperature  may  become 
subnormal,  and  the  patient  profoundly  collapsed  from  toxaemia. 

The  Treatment  consists  in  early  and  free  incisions,  so  as  to  give 
exit  to  the  urine  and  pus,  and  to  prevent,  if  possible,  the  sloughing 
of  the  skin  and  subcutaneous  tissues.  Every  part  that  the  urine 
has  infiltrated  must  be  dealt  with  in  this  way ;  thus,  the  perineum 
should  be  incised  in  the  middle  line  ;  the  scrotum  is  similarly 
divided,  if  need  be,  down  to  the  urethra,  the  testicles  being  laid 
on  either  side ;  the  penis  should  be  incised,  if  necessary,  on  either 
side  of  the  urethra,  and  along  the  dorsal  surface.  It  is  often 
possible  to  expel  a  large  portion  of  the  urine,  especially  in  the 
scrotum,  by  firmly  squeezing  the  infiltrated  tissues.  A  full-sized 
catheter  must  be  passed  into  the  bladder,  and  to  effect  this  the 
urethra  has  often  to  be  laid  open  and  the  stricture  divided ; 
perineal  drainage  is  always  preferable  for  these  cases.  The  parts 
should  be  subsequently  dusted  over  with  iodoform,  and  dressed 
with  warm  antiseptic  applications,  e.g.,  a  charcoal  or  carbolic 
linseed  poultice,  or  boracic  fomentations.  Frequent  hip-baths 
should  be  employed,  and,  if  practicable,  a  continuous  sitz-bath 
would  be  the  very  best  means  of  treating  the  case.  As  soon  as 
the  wounds  become  clean,  they  should  be  dressed  in  the  ordinary 
way  to  allow  them  to  granulate.  The  general  health  of  the 
patient  must  of  course  be  attended  to,  plenty  of  easily  assimilated 
nourishment,  stimulants,  and  quinine  being  administered. 

Urinary  Fistnlse  are  mcst  commonly  found  in  the  perineum, 
scrotum,  or  body  of  the  penis.  They  usually  result  from  peri- 
urethral suppuration  in  connection  with  a  stricture,  but  are  occa- 
sionally due  to  other  causes,  e.g.,  a  lacunar  a.bscess  after  gonor- 
rhoea, or  a  prostatic  abscess.  They  vary  much  in  size  and 
number;  when  the  result  of  a  stricture,  many  may  be  present 
(Fig.  400),  and  great  infiltration  of  the  surrounding  tissues  is 
usually  produced.  The  Treatment  of  perineal  fistulas  has  been 
already  in  measure  described,  .external  urethrotomy  being  neces- 
sary if  a  stricture  exists.  Occasionally  the  perineal  wound  does 
not  close  after  such  an  operation,  even  when  the  stricture  has  been 
divided ;  the  edges  of  the  fistula  should  then  be  pared,  and  the 
wound   brought   together   by   deep   quilled  sutures.     A  catheter 


AFFECTIONS  OF  THE  URETHRA   AND  PENIS  1135 

should  be  kept  in  the  bladder  for  a  few  days,  and  the  urine  regu- 
larly drawn  off  after  its  removal. 

When  of  small  size,  and  situated  either  in  the  perineum  or  the 
penis,  cure  may  be  determined  by  cauterizing  the  passage  either 
with  a  probe  coated  with  nitrate  of  silver  or  by  a  gal  vano- cautery, 
but  in  other  cases  some  form  of  urethroplasty  is  necessary. 

Affections  of  the  Penis. 

Phimosis,  when  complete,  is  a  condition  in  which  the  prepuce 
is  so  long,  and  the  orifice  so  narrow,  that  it  cannot  be  retracted 
behind  the  corona.  It  is  usually  Congenital  in  origin,  and  may 
exist  to  such  a  degree  as  to  render  micturition  impossible.  More 
frequently  the  opening  is  a  very  small  one  (pinhole  prepuce), 
permitting  micturition,  but  leading  to  irritability  of  the  bladder 
from  the  obstruction.  In  such  cases  the  prepuce  is  usually 
adherent  to  the  glans,  and  considerable  irritation  is  caused  by 
the  retention  of  the  smegma  secreted  by  Tyson's  glands  ;  this 
may  collect  and  become  so  inspissated  as  to  give  rise  to  definite 
concretions.  The  child  pulls  at  the  foreskin,  owing  to  the  itching 
produced,  and  thus  the  symptoms  of  vesical  calculus  may  be 
simulated.  Attacks  of  balanitis  are  also  frequent,  and  should  the 
prepuce  be  withdrawn,  paraphimosis  is  almost  certain  to  follow. 
If  allowed  to  remain  untreated  long  enough,  distension  of  the 
bladder,  and  even  hydronephrosis,  may  supervene.  Not  only  is 
this  condition  in  itself  a  cause  of  irritation  and  even  danger  to  the 
individuals  affected,  but  it  is  often  provocative  of  masturbation, 
whilst  it  tends  to  aggravate  the  symptoms  of  venereal  disease, 
and  there  is  but  little  doubt  that  it  acts  as  a  predisposing  cause  to 
epithelioma  of  the  penis.  Phimosis  also  occurs  as  an  Acquired 
condition,  resulting  from  the  cicatrization  of  venereal  sores. 

The  Treatment  of  phimosis  consists  in  circumcision.  Other 
methods  have  been  suggested — e.g.,  dilatation  of  the  prepuce,  and 
merely  slitting  it  up — but  they  are  not  satisfactory. 

Circumcision  should  always  be  performed  on  children  with  a 
long  prepuce  within  the  first  year  of  life,  since  at  that  time  the 
parts  are  but  slightly  developed,  the  operation  is  a  trifling  one, 
and  but  little  inconvenience  is  subsequently  experienced ;  the 
longer  it  is  postponed,  the  more  troublesome  does  it  become. 
The  best  method  of  operating  is  as  follows :  The  dorsal  aspect 
of  the  prepuce  is  put  on  the  stretch  by  grasping  it  on  either  side 
of  the  median  line  with  a  pair  of  catch  forceps  ;  a  director  is  then 
introduced  between  it  and  the  glans,  and  held  exactly  in  the 
middle  line,  and  the  prepuce  slit  up  with  a  curved  pointed 
bistoury  or  scissors.  The  lateral  halves  are  now  separated  from 
the  glans,  adhesions,  if  necessary,  being  broken  down  ;  this  must 
be  very  thoroughly  attended  to,  so  as  to  enable  all  retained 
smegma  to  be  removed,  and  the  corona  glandis  defined.      The 


1 136 


A    MA  N  UA  L  OF  SURGE R  Y 


redundant  preputial  tissue,  both  skin  and  mucous  membrane, 
is  cut  away  on  each  side  by  scissors,  special  attention  being 
directed  to  the  removal  of  sufficient  tissue  on  the  under  side  to 
prevent  the  unsightly  projection  so  frequently  seen  just  below  the 
frsenum.  In  adults  several  vessels  will  bleed  and  require  to  be 
ligatured,  especially  that  in  the  fraenum,  but  in  a  child  the  haemor- 
rhage is  trifling.  Having  carefully  trimmed  up  the  edges,  and 
snipped  off  all  ragged  corners  so  as  to  render  the  margins  of  the 
wound  regular,  catgut  sutures  are  inserted  to  prevent  any  raw 
surface  being  left  exposed  ;  in  children  only  a  few  are  required, 
but  possibly  a  considerable  number  in  adults  ;  a  continuous  suture 
should  never  be  employed.  The  wound  is  dressed  with  strips  of 
gauze  or  lint  dipped  in  carbolic  oil,  and  around  this,  again,  a  wisp 
of  antiseptic  wool ;  no  bandage  or  tape  is  required.  In  adults 
considerable    after-trouble    may    be    experienced   from    nocturnal 

erections,  which  may  be  so  marked 
and  prolonged  as  to  tear  through  the 
stitches  ;  to  control  this  the  patient's 
bowels  should  be  freely  opened,  and 
he  should  be  kept  on  a  low  and  un- 
stimulating  diet,  and  bromide  of 
potassium  or  other  sedatives  ad- 
ministered. The  stitches  are  usually 
removed  at  the  end  of  five  days,  and 
the  parts  are  then  dusted  over  with 
a  mixture  of  powdered  boric  acid, 
zinc  oxide,  and  starch,  so  as  to  re- 
duce their  sensitiveness. 

When  a  phimosed  prepuce  is  com- 
pletely retracted,  the  patient  often 
finds  it  impossible  to  -replace  it,  thus 
giving  rise  to  a  condition  known  as 
Paraphimosis.  It  is  due  to  the  narrow  orifice  of  the  prepuce 
getting  behind  the  corona,  and  is  characterized  by  great  cedema 
and  congestion,  not  only  of  the  exposed  mucous  membrane,  but 
also  of  the  glans  itself.  If  left  untreated,  ulceration  takes  place 
along  the  line  of  constriction,  and  the  parts  become  fixed  in  their 
deformed  position,  the  vessels  sooner  or  later  accommodating 
themselves  to  the  new  conditions,  and  the  cedema  slowly  dis- 
appearing.    In  some  cases  sloughing  of  the  glands  may  occur. 

Treatment  consists  in  forcible  replacement  of  the  prepuce. 
This  is  accomplished  by  grasping  the  penis  between  the  first  and 
second  finger  of  each  hand,  and  compressing  the  glans  penis  with 
the  thumbs  so  as  to  empty  the  vessels  and  diminish  the  amount  of 
cedema  present,  and  thus  reduce  its  size  (Fig.  401).  At  the  same 
time  the  fingers  draw  the  prepuce  forwards,  and  thus  finally 
reposition  is  effected.  When  the  cedema  of  the  prepuce  is  very 
marked,  it  should  be  punctured  in  several  places  to  permit  the 


Fig.  401. — Reduction  of 
Paraphimosis. 


AFFECTIONS  OF  THE  URETHRA   AND  PENIS  1 137 

escape  of  serum  and  diminish  the  tension  previous  to  reduction 
as  just  described.  In  more  advanced  cases  reposition  becomes 
impossible,  and  then  the  narrow  constricting  band  caused  by  the 
orifice  of  the  prepuce  must  be  divided  on  the  dorsal  aspect.  This 
will  free  the  parts,  which  can  be  subsequently  drawn  forwards, 
and  after  the  cedema  has  been  reduced  by  applying  lotio  plumbi 
for  a  few  days,  circumcision  may  be  advantageously  undertaken. 

Balanitis,  or  inflammation  of  the  glans,  may  be  simple  in  nature, 
arising  from  want  of  cleanliness  in  persons  with  a  long  foreskin, 
but  more  frequently  is  associated  with  gonorrhoea  or  soft  chancres. 
The  under  surface  of  the  prepuce  is  often  involved,  and  then  the 
term  Balano  -  posthitis  is  sometimes  applied  to  it.  A  muco- 
purulent or  purulent  discharge  escapes  from  under  the  prepuce, 
which  is  often  swollen  and  cedematous.  Occasionally,  when  a 
considerable  degree  of  phimosis  exists,  the  under  surface  of  the 
prepuce  may  become  ulcerated,  and  even  perforated  ;  whilst  in 
very  neglected  cases,  and  especially  if  phagedena  is  present,  the 
prepuce  will  slough,  and  allow  the  glans  to  protrude,  usually 
through  its  upper  surface. 

Treatment. — In  simple  cases,  all  that  is  required  is  to  thoroughly 
cleanse  the  parts  by  washing  beneath  the  foreskin,  and  then  apply 
lead  lotion  on  lint  between  the  glans  and  the  prepuce  ;  but  when 
there  is  much  discharge,  and  the  foreskin  is  long  and  swollen,  or  if 
perforation  is  threatening,  the  prepuce  must  be  slit  up,  and,  after 
the  parts  have  been  restored  to  a  healthy  state,  the  redundant 
tissues  should  be  cut  away  by  a  modified  circumcision. 

A  Soft  Chancre  is  a  local  infective  disorder,  which  is  rarely  seen 
elsewhere  than  on  the  genital  organs,  and  is  almost  invariably  the 
result  of  impure  connection.  The  nature  of  the  virus  is  still  a 
little  uncertain,  though  it  is  certainly  microbic  and  probably  due  to 
Ducrez's  strepto-bacillus.  If  artificially  inoculated,  it  runs  a  typical 
course.  The  spot  becomes  a  distinctly  red  papule  in  twenty-four 
hours,  whilst  in  two  or  three  days  a  vesicle,  surrounded  by  a  zone 
of  angry  hyperemia,  is  seen.  The  serum  within  the  vesicle  soon 
becomes  turbid,  and  by  the  fourth  or  fifth  day  a  fully-developed 
pustule  is  present ;  as  soon  as  the  cuticle  is  lost,  an  ulcer  forms 
with  cleanly  cut  edges,  and  a  sharp,  distinct  outline.  The 
chancre  gradually  increases  in  size  up  to  a  certain  limit,  and 
then  if  kept  clean  heals  in  about  three  weeks.  Such  sores  may 
be  met  with  on  any  part  of  the  penis,  but  more  especially  on  the 
prepuce  and  glans,  or  on  the  corona  glandis,  and  are  very  painful 
and  tender.  The  secretion  is  highly  infective,  and  if  inoculated 
elsewhere  on  the  patient  produces  a  typical  sore,  showing  that 
the  condition  is  purely  local,  and  that  no  constitutional  immunity 
results  from  its  presence.  The  discharge  from  a  true  syphilitic 
chancre,  if  inoculated  on  the  same  patient,  may  produce  a  localized 
pustule,  but  no  typical  sore.  Frequently  several  sores  are  present 
at  the  same  time,  whilst  the  discharge  from  one  chancre  is  very 

72 


1 138  A  MANUAL  OF  SURGERY 


likely  to  produce  a  similar  affection  ('  satellite '  chancre)  on  any 
cutaneous  or  mucous  surface  brought  into  contact  with  it ;  e.g., 
it  may  spread  from  prepuce  to  glans,  or  vice  versa,  or  from  one  lip 
of  the  vulva  to  the  other.  It  is  a  curious  but  well-authenticated 
fact  that  soft  chancres  are  rarely  seen  on  any  part  of  the  body 
other  than  the  genital  organs. 

Various  Modifications  of  the  typical  chancre  are  seen,  usually 
resulting  from  neglect  or  carelessness  on  the  part  of  the  patient. 
Thus,  if  a  long  foreskin  is  present,  the  discharge  may  be  retained 
behind  it,  and  an  extensive  ulcerative  balanitis  occur,  which  may 
even  result  in  the  glans  sloughing  through  the  upper  part  of  the 
prepuce,  which  drops  beneath  it.  If  the  fraenum  is  involved, 
smart  haemorrhage  takes  place  from  ulceration  into  a  branch  of 
the  artery  found  in  that  structure.  When  there  is  much  inflam- 
mation, the  base  of  the  sore  becomes  indurated  and  infiltrated, 
somewhat  resembling  the  Hunterian  chancre.  Not  unfrequently 
syphilitic  infection  occurs  at  the  same  time  as  a  soft  chancre  is 
contracted,  or  subsequently;  the  sore  is  then  likely  to  run  a  longer 
course,  does  not  heal,  even  if  kept  clean,  and  after  a  time  the 
patient  presents  the  characteristic  signs  of  syphilis. 

In  all  cases  the  neighbouring  Lymphatic  Glands  become  en- 
larged and  tender,  and  the  process  is  very  liable  to  terminate  in 
suppuration,  constituting  a  bubo.  Two  forms  of  this  affection 
are  described :  (a)  The  simple  or  sympathetic  bubo  results  from 
the  absorption  of  ordinary  pyogenic  organisms  from  the  abraded 
surface.  The  pus  in  this  case,  if  inoculated  elsewhere,  may 
produce  a  pustule,  but  not  a  true  chancre.  The  process  is  usually 
limited  to  the  interior  of  the  lymphatic  glands,  (b)  The  virulent 
bubo  is  one  due  to  the  absorption  into  the  lymph  stream,  not 
only  of  pyogenic  organisms,  but  also  of  the  specific  virus,  so  that 
when  suppuration  ensues,  the  pus,  if  inoculated,  always  produces 
a  typical  soft  sore.  In  these  cases  the  suppuration  occurs  not 
only  within,  but  even  more  abundantly  around  the  lymphatic 
glands  [periadenitis),  so  that  the  skin  becomes  considerably  under- 
mined, and  the  wound  produced  by  opening  the  abscess  may  take 
on  the  form  of  a  huge  soft  chancre  in  the  groin,  in  the  centre  of 
which  may  be  seen  the  lymphatic  gland  only  slightly  enlarged. 

The  Treatment  of  soft  chancre  consists  in  keeping  it  clean, 
dusting  its  surface  with  iodoform,  and  covering  it  with  lint  dipped 
in  lotio  nigra  or  boric  acid  lotion,  healing  usually  occurring  in 
from  ten  to  twenty  days ;  where  much  balanitis  exists  it  may 
be  necessary  to  slit  up  the  prepuce,  but  circumcision  should  not 
be  undertaken  until  the  sores  have  healed.  The  surface  of  the 
chancre  may  be  treated  with  caustics,  such  as  pure  carbolic  or 
nitric  acid,  and  may  perhaps  heal  quicker  for  such  applications; 
but  they  need  not  be  employed  as  a  routine  treatment,  since  soft 
chancres,  if  kept  clean,  are  usually  devoid  of  serious  consequences. 
If  the  smell  of  iodoform  is  objected  to,  iodol  or  aristol  may  be 
substituted. 


AFFECTIONS  OF  THE  URETHRA  AND  PENIS  1139 

Buboes  are  treated  in  the  early  stages  by  keeping  the  patient  at 
rest  and  applying  fomentations,  when  resolution  sometimes  occurs. 
If  suppuration  ensues,  the  abscess  should  be  incised  vertically,  so 
as  to  allow  free  exit  to  the  pus,  even  when  the  patient  is  sitting, 
the  cavity  being  subsequently  dressed  by  stuffing  it  with  gauze 
impregnated  with  iodoform.  Some  surgeons  recommend  that 
enlarged  glands  of  this  nature  should  be  freely  removed  by 
dissection,  but  such  is  not  required  as  a  general  rule. 

Herpes  not  uncommonly  affects  the  prepuce  and  glans.  It  may 
result  from  simple  local  irritation,  more  especially  in  gouty 
individuals ;  but  is  most  frequently  se^n  in  patients  who  have 
suffered  from  syphilis,  and  is  then  likely  to  be  somewhat  intract- 
able. It  manifests  itself  as  a  crop  of  small  vesicles  on  a  hyperaemic 
base,  which  become  abraded,  leaving  a  number  of  small  ulcers, 
li  is  preceded  by  pain  of  a  neuralgic  type,  and  accompanied  by 
much  itching  and  irritation.  The  only  treatment  required  is  to 
keep  the  parts  clean,  and  dust  them  over  with  powdered  oxide  of 
zinc  and  starch.  In  the  majority  of  cases  the  disease  lasts  from  a 
week  to  ten  days.  During  the  healing  of  the  herpetic  ulcers,  a 
patient  is  very  liable  to  be  inoculated  with  the  virus  of  either  the 
soft  chancre  or  syphilis  if  he  exposes  himself  to  the  risk  of  infection. 

Warts  often  arise  on  the  penis  in  the  shape  of  red,  vascular 
excrescences,  usually  pedunculated,  and  sometimes  of  considerable 
size.  They  are  met  with  most  frequently  as  a  sequela  of  gonor- 
rhoea, and  must  be  carefully  distinguished  from  mucous  tubercles. 
They  should  be  treated  by  snipping  them  away  with  scissors,  and 
cauterizing  the  base  with  a  galvano-cautery. 

Horns  are  also  occasionally  seen  arising  from  the  body  of  the 
penis.  They  are  of  the  usual  sebaceous  type,  as  described  at 
p.  36  t,  and  should  be  excised. 

Epithelioma  of  the  penis  rarely  arises  except  in  patients  who  are 
the  subject  of  congenital  phimosis  or  possess  long  foreskins,  and 
hence  it  is  stated  that  the  disease  is  unknown  amongst  the  Jews. 
It  usually  commences  in  the  sulcus  behind  the  corona  glandis, 
and  rapidly  spreads  to  the  surrounding  parts,  manifesting  itself 
either  as  an  irregular,  papillated,  wart-like  outgrowth,  or  as  a 
diffuse  infiltration,  ulcerating  early,  and  leading  to  considerable 
destruction  of  tissue.  At  first  the  tumour  is  mainly  beneath  the 
prepuce,  which  becomes  distended,  producing  a  sanious  discharge, 
which  contains  epithelial  cells  as  well  as  pus  corpuscles ;  but  as 
the  case  progresses,  the  prepuce  itself  is  attacked,  and  even 
perforated.  Later  on  the  body  of  the  penis  is  invaded  and,  owing 
to  its  great  vascularity,  the  disease  makes  rapid  progress.  The 
inguinal  glands  are  early  affected,  but  when  the  body  of  the  penis 
is  involved,  the  lumbar  glands  are  also  implicated. 

The  Diagnosis  of  epithelioma  from  warts  is  easily  made  by 
contrasting  the  infiltration  of  the  base  produced  by  the  former  with 
the  soft  and  normal  condition  of  the  glans  in  the  latter  condition. 


ii40  A  MANUAL  OF  SURGERY 

The  Treatment  of  epithelioma  consists  in  amputation  of  the 
penis  whenever  the  disease  is  sufficiently  limited  to  lead  to  the 
hope  that  it  can  be  eradicated.  When  confined  to  the  distal  end 
of  the  organ,  the  operation  may  be  performed  through  the  body  ; 
but  when  this  is  impracticable,  owing  to  the  extent  of  the  growth, 
the  whole  penis  must  be  removed. 

Amputation  through  the  body  of  the  penis  is  an  operation  of  but 
little  difficulty.  A  short  flap  is  reflected  from  the  dorsum,  and 
the  corpora  cavernosa  cut  through,  the  urethra  and  remaining 
portions  of  the  organ  being  removed  at  a  lower  level.  Bleeding 
is  then  arrested  by  securing  the  divided  vessels  ;  five  ligatures 
are  usually  required,  viz.,  one  for  the  artery  to  the  corpus  caver- 
nosum  on  either  side,  one  for  each  dorsal  artery,  and  one  for  the 
artery  to  the  septum.  The  urethra  is  then  isolated,  and  passed 
through  an  opening  made  in  the  upper  integumental  flap.  It  is 
split  along  its  upper  wall,  and  secured  by  sutures  to  the  margins 
of  the  opening,  so  as  to  prevent  subsequent  retraction  ;  the  flaps 
are  then  united  by  stitches. 

A  mputation  of  the  whole  penis  is  a  much  more  serious  proceeding. 
The  patient  is  placed  in  the  lithotomy  position,  and  the  perineum, 
after  being  shaved  and  purified,  incised  freely  in  the  middle  line. 
The  corpus  spongiosum  is  traced  backwards,  and  divided  at  such 
a  level  as  to  allow  the  mucous  membrane  lining  the  proximal 
portion  of  the  urethra  to  be  stitched  to  the  skin  at  the  posterior 
angle  of  the  incision.  The  corpora  cavernosa  are  freed  from  their 
connections,  and  separated  at  their  origins  from  the  ischio-pubic 
rami  by  suitable  raspatories.  An  elliptical  incision  is  then  made 
round  the  root  of  the  penis,  the  dorsal  vessels  are  divided  and 
secured,  and  the  suspensory  ligament  cut  through.  The  penis 
can  then  be  drawn  forwards,  and  by  a  few  final  touches  of  the 
knife  completely  removed.  All  bleeding  points  are  ligatured,  and 
the  anterior  wound  closed  by  a  continuous  suture  in  the  middle 
line,  a  drainage-tube  being  placed  in  the  perineal  portion  for  a 
few  days.  The  results  of  this  operation  have,  on  the  whole,  been 
very  satisfactory,  although  the  patient  has  to  assume  the  sitting 
posture  in  order  to  micturate. 

APPENDIX. 

With  regard  to  the  surgical  affections  of  the  female  genital 
organs,  it  is  not  our  intention  to  do  more  than  briefly  refer  to  a 
few  of  those  affecting  the  region  of  the  vulva  and  labia. 

Vulvitis,  or  inflammation  of  the  lining  membrane  of  the  vesti- 
bule, is  due  to  gonorrhoea  or  to  irritating  discharges  coming  from 
above.  It  is  characterized  by  injection  of  the  mucous  mem- 
brane, by  itching  or  smarting  pain,  especially  on  walking,  and  a 
secretion  of  mucus  or  muco-pus,  causing  the  labia  to  stick  together. 
The  mucous  follicles  may  become  affected,  and  a  localized  abscess 


AFFECTIONS  OF  THE  URETHRA   AND  PENIS  1141 


result,  situated  either  immediately  beneath  the  mucous  membrane 
or  in  the  substance  of  the  labium.  The  treatment  consists  in  the 
use  of  warm  and  mild  antiseptic  lotions  to  purify  the  part,  sitting 
in  hot  water  being  most  beneficial.  At  the  same  time  the  patient 
is  kept  quiet,  and  the  bowels  opened  by  a  saline  purge.  When  a 
follicular  abscess  forms,  k  should  be  incised  through  the  mucous 
membrane  and  its  cavity  stuffed  with  a  small  portion  of  dressing. 
A  labial  abscess  should  be  freely  opened  at  any  spot  where  it  is 
tending  to  point,  and  the  cavity  packed  with  gauze  to  ensure 
healing  from  the  bottom. 

Cysts  of  the  Labia  are  occasionally  seen,  being  due  to  the  blocking 
of  the  duct  of  a  mucous  follicle,  or  of  the  more  specialized  vulvo- 
vaginal glands  (glands  of  Bartholin) ;  they  may  attain  considerable 
dimensions  and  must  be  freely  dissected  out. 

Hematoma  of  the  vulva  is  due  to  traumatism,  e.g.,  a  kick  or 
fall,  or  to  rupture  of  a  varicose  vein,  especially  during  parturition. 
The  labium  is  much  swollen  and  firm  to  the  touch,  owing  to 
the  coagulation  of  the  blood  ;  suppuration  often  follows,  especi- 
ally if  the  injury  is  associated  with  a  superficial  abrasion. 
Treatment. — If  the  swelling  persists,  or  if  suppuration  ensues,  an 
incision  should  be  made  and  the  blood  removed ;  the  cavity  is 
then  stuffed,  but  of  course  the  most  thorough  antiseptic  precautions 
must  be  adopted. 

Another  occasional  result  of  traumatism  is  laceration  of  the 
recto-vaginal  septum,  which  may  be  caused  by  kicks,  or  by 
falling  on  a  stick  or  paling.  The  wound  is  usually  contused, 
and  the  margins  irregular,  so  that  immediate  suture  is  unlikely 
to  succeed.  The  parts  are,  therefore,  kept  clean  by  frequent 
douches  and  allowed  to  granulate,  and  the  loss  of  substance  is  in 
that  way  often  repaired.  Should  a  fistula  persist,  a  plastic  opera- 
tion will  be  subsequently  necessary. 


CHAPTER   XXXIX. 

AFFECTIONS  OF  THE  TESTIS,  CORD,  SCROTUM,  AND 
SEMINAL  VESICLES. 

Congenital  Affections  of  the  Testis. 

It  is  scarcely  necessary  to  state  that  the  testicles  are  not  developed  in  the 
scrotum,  but  from  the  posterior  wall  of  the  abdominal  cavity,  so  that  they  lie 
at  first  behind  the  peritoneum  close  to  the  kidneys.  The  body  of  the  gland 
arises  from  the  so-called  genital  ridge,  which  is  covered  by  columnar  epithelial 
cells,  and  lies  to  the  mesial  side  of  the  Wolffian  body.  The  vasa  efferentia 
are  developed  from  the  tubules  of  the  latter  structure,  coming  into  relation  at 
a  later  date  with  the  seminal  tubules,  whilst  the  vas  deferens  is  formed  by  the 
Wolffian  duct. 

Occasionally  the  body  of  the  testis  is  entirely  absent,  whilst  a  few  cases  are 
on  record  of  absence  or  deficiency  of  the  vas.  Very  rarely  two  testicles  have 
been  developed  on  one  side,  and  have  both  found  their  way  into  the  scrotum 
{polyorchism). 

The  passage  of  the  testis  from  the  abdominal  cavity  to  the  scrotum  takes 
place  at  about  the  end  of  the  eighth  month  of  intra-uterine  life.  '  The  guber- 
naculum  testis  is  the  active  agent  in  bringing  about  the  descent  of  the  testis. 
This  is  a  band  of  involuntary  muscular  fibres  which  traverses  the  inguinal 
canal,  and  establishes  important  connections  both  within  and  without  the 
abdominal  cavity.  Below  three  main  attachments  of  the  gubernaculum  may 
be  recognised,  viz.:  (a)  to  the  abdominal  wall;  (b)  to  the  pubis;  (c)  to  the 
bottom  of  the  scrotum.  Above,  the  gubernacular  fibres  are  chiefly  connected 
with  the  testicle  ;  but  many  of  them  are  also  attached  to  the  peritoneum  on 
the  posterior  wall  of  the  abdomen.  By  the  traction  which  the  gubernaculum 
exerts  on  the  testicle  the  descent  of  that  organ  is  brought  about.  By  the  portion 
attached  to  the  abdominal  wall  the  testicle  is  pulled  down  to  the  internal 
abdominal  ring,  the  pubic  portion  drags  it  through  the  inguinal  canal,  whilst 
the  scrotal  part  finally  leads  it  into  the  scrotum. 

'  The  formation  of  the  processus  vaginalis  is  accounted  for  in  the  same  way. 
Some  of  those  gubernacular  fibres  which  are  inserted  into  the  peritoneum  drag 
down  the  peritoneal  diverticulum  which  lines  the  inguinal  canal  and  scrotum 
and  prepares  the  way  for  the  testicle.'  (Cunningham's  '  Manual  of  Anatomy,' 
vol.  i.,  pp.  426,  427.) 

Two  chief  forms  of  malposition  of  the  testis  are  described,  arising  either 
from  its  incomplete  or  abnormal  descent. 

1.  Incomplete  Descent  or  Retention  of  the  Testis. — The  testis  may 
remain  in  the  abdominal  cavity  attached  to  the  abdominal  wall  by  a  mesor- 
chium  {retentio  abdominalis) ;  more  frequently,  it  is  found  just  within  the 
internal  abdominal  ring  {retentio  iliaca) ;  but  most  commonly  it  occupies  the 
inguinal  canal,  or  lies  just  outside  of  it  {retentio  inguinalis) .  The  organ  in  the 
latter  position  is  freely  mobile,  being  readily  pressed  up  towards  the  abdo- 


AFFECTIONS  OF  THE  TESTIS,  CORD,  ETC.  1143 

minal  cavity.  The  Causes  of  this  condition  must  be  looked  for  mainly  in 
some  abnormal  attachment  of  the  gubernaculum,  or  possibly  in  the  existence 
of  intra-uterine  peritonitis.  Less  commonly  a  contracted  condition  of  the 
external  abdominal  ring,  or  an  unduly  large  epididymis,  may  determine  its 
occurrence. 

The  condition  is  easily  recognised  by  the  absence  of  the  testicle  in  the 
scrotum,  whilst  in  the  inguinal  variety  the  organ  can  usually  be  detected  as 
a  small  moveable  swelling  about  the  size  of  a  horse-bean,  giving  the  charac- 
teristic testicular  sensation  on  pressure.  The  scrotum  on  the  affected  side  is 
imperfectly  developed. 

In  any  of  these  varieties  a  late  descent  of  the  testis  may  occur,  usually 
accompanied  by  a  congenital  hernia,  possibly  of  an  interstitial  type. 

2.  Malposition  of  the  Testis.— Two  distinct  forms  are  described  :  (a)  Ectopia 
Perinealis. — In  this  variety  the  testis  finds  its  way  into  the  perineum,  slipping 
along  the  groove  between  the  thigh  and  the  scrotum.  It  may  exist  as  a  con- 
genital condition,  being  then  due  to  the  contraction  of  an  accessory  band  of 
gubernacular  fibres  :  or  it  may  happen  in  consequence  of  a  late  descent  of  the 
testicle,  owing  to  atrophy  of  the  scrotum.  It  always  causes  considerable  in- 
convenience to  the  patient,  especially  on  sitting  or  riding,  (b)  Ectopia  Cruvalis, 
— The  testicle  here  lies  on  the  inner  side  of  Scarpa's  triangle,  in  the  region  of 
the  saphenous  opening.  It  is  said  to  escape  along  the  crural  canal,  but 
more  probably  it  passes  down  the  inguinal  canal  as  usual,  and  then  finds  its 
way  over  Poupart's  ligament  to  this  situation,  guided  by  a  second  accessory 
band  of  gubernacular  tissue.  When,  as  not  uncommonly  happens,  a  con- 
genital hernia  also  exists,  it  may  travel  outwards  to  the  anterior  superior 
spine,  being  directed  there  by  the  arrangement  of  the  fasciae,  as  in  a  femoral 
hernia  (extraparietal  interstitial  hernia,  p.  979). 

In  all  cases  of  retained  or  misplaced  testis  the  organ  is  atrophic,  and 
probably  functionally  useless.  At  first  it  is  normal  in  texture,  but  as  a  resulc 
of  frequently  repeated  injury  and  inflammation  it  is  likely  to  undergo  de- 
generative changes.  If  only  one  organ  is  affected,  but  little  harm  follows ; 
but  if  both  are  involved,  the  individual  is  probably  sterile. 

Complications  of  a  Retained  or  Misplaced  Testicle. — Any  of  the  conditions 
to  be  described  hereafter  in  this  chapter  may  involve  a  retained  or  misplaced 
testicle,  just  as  if  it  were  in  the  scrotum,  and  give  rise  to  considerable  trouble, 
especially  when  the  organ  is  lying  in  close  proximity  to  the  peritoneum.  A 
testis  misplaced  or  retained  in  the  inguinal  canal  is  much  exposed  to  injury, 
and  a  subacute  traumatic  orchitis  often  occurs  ;  it  is  stated  that  such  organs 
are  very  prone  to  become  the  seat  of  malignant  disease  at  a  later  period  of  life, 
but  the  accuracy  of  this  statement  is  a  little  doubtful. 

Treatment. — Taking  into  consideration  the  discomfort  occasioned  by  this 
condition,  as  well  as  the  risk  arising  from  the  tendency  to  malignant  disease, 
there  can  be  little  doubt  that  the  best  method  of  treatment  is  the  removal  of 
the  testicle.  Many  operations  have  been  devised  with  the  idea  of  placing  the 
organ  in  its  normal  position  in  the  scrotum,  but  the  majority  of  such  methods 
have  proved  useless,  owing  to  the  traction  required  and  the  defective  length  of 
the  spermatic  vessels  and  cord. 

Another  condition  met  with  congenitally  is  Inversion  of  the  testis,  the 
epididymis  lying  in  front,  and  the  body  of  the  organ  behind.  It  is  of  no 
clinical  significance,  except  that  in  careless  hands  it  may  be  injured  whilst 
tapping  a  hydrocele. 

Torsion  of  the  Spermatic  Cord,  resulting  in  acute  strangulation  of  the  test's, 
has  attracted  some  attention  of  late  years.  The  cause  still  remains  unknown, 
but  several  of  the  cases  recorded  have  been  associated  with  late  descent  of  the 
testicle,  and  others  have  been  attributed  to  twists  and  strains.  The  symptoms 
are  tolerably  characteristic  :  the  patient  complains  of  an  acute  sickening  pain 
in  the  testis  which  persists  until  gangrene  has  supervened,  and  may  then  dis- 
appear ;  it  is  accompanied  by  a  certain  amount  of  pyrexia,  and  the  appearance 
of  a  tumour,  either  in  the  inguinal  region  or  in  the  scrotum.     The  testicle, 


1144  A   MANUAL  OF  SURGERY 

slightly  enlarged,  is  felt  below,  and  above  it  a  larger  mass,  consisting  of  the 
twisted  cord  and  the  congested  and  swollen  epididymis.  In  some  cases  the 
latter  swelling  has  been  crepitant,  owing  to  the  development  of  gases  due  to  its 
putrefaction.  The  condition  is  very  likely  to  be  mistaken  for  a  strangulated 
hernia,  which  it  closely  resembles  ;  but  the  presence  of  fever,  and  the  absence 
of  abdominal  distension  and  of  faecal  vomiting,  are  important  distinctive  signs  ; 
moreover,  constipation,  though  often  present,  is  never  absolute.  If  the  testis 
is  situated  in  the  scrotum,  the  cord  and  inguinal  canal  are  found  to  be  clear  ; 
whilst  if  in  the  canal,  the  affected  side  of  the  scrotum  is  empty.  The  only 
Treatment  possible  is  exploration  and  removal  of  the  inflamed  or  gangrenous 
testis  and  cord,  unless  the  case  is  seen  very  early,  when  it  may  be  feasible  to 
untwist  it. 

Injuries  of  the  Testis  and  Cord. 

Contusion  of  the  Testis  is  a  very  common  form  of  injury.  It 
arises  from  blows,  kicks,  squeezes,  and  the  like,  and  is  always 
associated  with  immediate  pain  of  a  most  sickening  and  intense 
character,  which  is  not  only  experienced  in  the  testicle,  but  also 
radiates  along  the  cord  towards  the  loins  and  back,  and  down 
the  front  of  the  thigh.  Severe  shock  accompanies  the  pain,  and 
may  be  so  profound  as  to  lead  to  a  fatal  issue.  A  well-marked 
traumatic  orchitis  often  follows,  and  this  may  in  turn  induce 
atrophy  of  the  organ,  although  the  same  condition  sometimes 
occurs  without  much  evidence  of  inflammation,  as  a  result  of 
thrombosis  and  occlusion  of  the  spermatic  vessels.  A  hematocele 
is  also  induced  by  a  subcutaneous  lesion  of  this  nature.  Treatment 
consists  in  keeping  the  patient  in  the  recumbent  posture  with 
the  scrotum  well  raised,  and  in  applying  fomentations  or  an 
icebag. 

Penetrating  Wounds  or  Punctures  are  uncommon  except  as  a 
result  of  surgical  treatment  (e.g.,  tapping  a  hydrocele).  A  certain 
amount  of  haemorrhage  usually  follows,  whilst  the  immediate 
lesion  is  associated  with  severe  testicular  pain.  If  the  wound 
becomes  septic,  the  tubules  are  likely  to  protrude,  and  a  hernia 
testis  may  result.  All  that  is  ordinarily  required  is  to  purify  the 
parts  and  allow  them  to  heal ;  sutures  should  not  be  inserted 
into  the  tunica  albuginea.  If  the  gland  is  totally  disorganized, 
as  by  a  gunshot  wound,  castration  must  be  undertaken. 

Hsematocele,  or  a  localized  collection  of  blood  in  the  tunica 
vaginalis  or  cord,  is  a  common  result  of  injuries. 

i.  Hematocele  of  the  Tunica  Vaginalis  arises  from  traumatism, 
such  as  a  sudden  blow  or  severe  strain,  and  occasionally  follows 
the  tapping  of  a  hydrocele  if  a  superficial  vessel  has  been  ruptured 
or  punctured,  or  if  the  body  of  the  testis  has  been  wounded  ;  it 
may,  however,  be  due  to  general  oozing  from  dilated  capillaries 
in  the  serous  membrane  owing  to  the  sudden  relief  of  tension. 
It  also  occurs  more  or  less  spontaneously  in  connection  with 
malignant  disease.  The  History  generally  given  is  that  the 
patient  was  seized  with  a  sudden  sickening  pain  in  the  testicle, 
which  became  quickly  enlarged  without  any  evidence  of  inflam- 
mation.    If  blood  is  extravasated   at    the   same    time   into   the 


AFFECTIONS  OF  THE  TESTIS,  CORD,  ETC.  11-15 

scrotum,  the  integument  becomes  discoloured  in  the  course  of  a 
few  days  owing  to  a  diffusion  of  the  blood  pigment.  At  first  the 
swelling  is  smooth  and  fluctuating,  exactly  resembling  a  hydro- 
cele, except  in  the  absence  of  translucency ;  but  owing  to  a 
deposit  of  fibrin  on  the  walls  from  the  coagulation  of  the  blood,  it 
becomes  hard  and  firm  in  a  short  time,  closely  simulating  a  solid 
tumour.  In  slight  cases  the  blood  is  entirely  absorbed,  but  when 
the  effusion  is  considerable  the  coagulum  is  likely  to  persist.  On 
laying  open  such  a  swelling,  the  testicle  is  usually  found  in  a 
healthy  state,  whilst  the  enlarged  tunica  is  occupied  by  some 
blood-stained  brownish-yellow  fluid,  and  surrounded  by  a  mass 
of  fibrinous  coagulum,  part  of  which  is  deposited  in  laminae 
upon  the  walls,  and  part  remains  as  shreddy  masses  projecting 
into  its  lumen.  In  very  chronic  cases  the  walls  of  the  tunica 
become  thick  and  indurated,  and  may  even  undergo  calcareous 
changes.  Suppuration  is  sometimes  met  with  as  a  result  of 
auto-infection.  The  Diagnosis  of  a  haematocele  in  the  earlier 
stages  is  easily  made ;  but  when  it  has  solidified  it  can  only 
be  suspected  by  the  history,,  and  by  the  exclusion  of  other 
sources  of  enlargement,  whilst  an  exploratory  incision  or  puncture 
is  often  necessary  to  settle  the  diagnosis.  Treatment. — -When 
the  patient  is  seen  soon  after  the  injury,  he  must  be  kept  at  rest, 
the  parts  elevated,  and  evaporating  lotions  applied ;  whilst  if  the 
effusion  is  large,  removal  of  a  portion  by  aseptic  tapping  will 
expedite  the  process  of  absorption.  In  more  chronic  cases  it  may 
be  necessary  to  lay  the  cavity  open  and  remove  its  contents,  whilst 
in  the  later  stages,  if  the  tunica  has  become  thick  and  indurated 
and  the  testis  atrophied,  castration  may  be  advisable. 

2.  Hematocele  of  the  Cord  is  but  rarely  seen.  It  is  due  to  the 
rupture  of  one  of  its  vessels,  as  a  result  of  injury  or  strain.  A 
swelling  of  considerable  size  rapidly  forms,  extending  along  the 
cord  from  the  inguinal  region  to  the  scrotum,  but  the  testis 
remains  free  and  unimplicated.  Such  a  condition  may  be  mis- 
taken for  an  omental  hernia,  but  on  careful  examination  the 
tumour  is  felt  to  be  more  uniform  in  consistency,  more  rounded 
in  outline,  and  even  semi-fluctuating.  It  is  irreducible  and  with- 
out impulse,  whilst  the  history  of  the  case  will  assist  the  surgeon 
in  making  a  correct  diagnosis.  Treatment  in  the  early  stages 
consists  in  the  application  of  evaporating  lotions,  and  later  on,  if 
the  blood-clot  is  not  absorbed,  the  cavity  may  be  laid  open  and 
the  coagulum  removed. 

Rupture  of  the  Vas  Deferens  has  resulted  from  excessive  strain  ; 
it  is,  however,  very  rare,  not  more  than  half  a  dozen  cases 
being  on  record.  It  may  affect  the  intra-abdominal  portion  of 
the  vas,  and  then  gives  rise  to  haemorrhage  from  the  urethra, 
together  with  some  amount  of  fever  and  hypogastric  pain,  leading 
possibly  to  atrophy  of  the  organ.  Rupture  of  the  scrotal  portion 
is  followed  by  enlargement  of  the  testis,  and  perhaps  scrotal 
haemorrhage.     This  was  associated  in  a  case  under  our  observa- 


1 146 


A  MANUAL  OF  SURGERY 


tion  with  haemorrhage  from  the  urethra  on  attempting  coitus 
shortly  after  the  accident,  and  subsequently  with  severe  pain 
and  swelling  of  the  testis  produced  by  the  same  act,  but  atrophy 
did  not  follow.  If  it  occasions  any  inconvenience,  it  is  best  treated 
by  castration. 

Inflammatory  Affections  of  the  Testis. 

Inflammation  of  the  Testicle  may  be  chiefly  confined  at  its 
onset  either  to  the  body  of  the  organ  or  to  the  epididymis  ;  in 
the  former  case  the  term  Orchitis  is  applied  to  it,  in  the  latter 
Epididymitis  ;  either  condition  may  be  acute  or  chronic. 


ABC 

Fig.    402. — Diagrammatic    Sections    of    (A)    Orchitis,    (B)    Epididymitis 

and  (C)  Hydrocele  of  Tunica  Vaginalis.     (Tillmanns.) 

Ho,  Testis ;  N,  epididymis  ;  Hy,  hydrocele. 

Acute  Orchitis  most  frequently  results  from  injury,  but  it  is 
also  met  with  as  a  primary  affection  in  gouty  and  rheumatic 
individuals,  sometimes  arising  spontaneously  ;  or  it  may  follow 
mumps,  typhoid,  or  other  eruptive  fevers,  as  a  result  of 
metastasis,  whilst  it  is  always  to  some  extent  associated  with 
epididymitis.  In  mumps  it  may  precede  the  parotid  lesion,  or 
may  even  occur  without  it. 

The  testicle  becomes  considerably  enlarged,  exceedingly  pain- 
ful, and  tender  to  the  touch.  The  shape  of  the  organ  is  more  or 
less  globular  (Fig.  402,  A),  whilst  the  pain  is  of  a  peculiarly 
sickening  character,  extending  upwards  along  the  course  of  the 
cord  towards  the  back  and  loins.  The  scrotal  integuments 
become  red  and  infiltrated,  and  owing  to  the  acuteness  of  the 
process,  more  or  less  adherent  to  the  coverings  of  the  gland. 
A  plastic  or  serous  effusion  into  the  tunica  vaginalis  is  some- 
times present,  giving  rise  to  what  is  known  as  an  '  acute  hydro- 
cele.' Some  constitutional  disturbance  accompanies  the  process, 
the  temperature  being  elevated  two  or  three  degrees,  whilst 
vomiting  and  constipation  are  marked  symptoms.  It  is  unusual 
for  suppuration  to  ensue,  but  an  abscess  occasionally  forms,  and 
then,  after  the  pus  has  been  let  out,  a  hernia  testis  may  follow. 
Atrophy  is  a  more  common  sequela,  especially  in  adults,  being 


AFFECTIONS  OF  THE  TESTIS,  CORD,  ETC.  1 147 

caused  by  constriction  of  the  vessels  and  tubules,  owing  to 
organization  of  the  inflammatory  exudation. 

Acute  Epididymitis  is  almost  always  due  to  the  extension  of  an 
inflammatory  process  from  the  urethra,  the  usual  cause  being 
gonorrhoea ;  it  occasionally  follows  the  passage  of  instruments  or 
the  lodgment  of  a  calculus ;  or  it  may  be  secondary  to  a  suppura- 
tive prostatitis,  unconnected  with  gonorrhoea.  It  is  ushered  in 
by  pain  in  the  inguinal  region  and  perhaps  in  the  hypogastrium 
along  the  course  of  the  vas  deferens,  which  soon  extends  to  the 
scrotum.  The  testicle  becomes  enlarged,  but  its  shape  is  that  of 
an  elongated  oval,  somewhat  flattened  laterally.  The  epididymis 
is  readily  felt  as  a  crescentic  swelling,  partially  overlapping 
the  gland  in  all  directions,  and  in  its  concavity  the  rounded  out- 
line of  the  anterior  wall  of  the  testis  can  usually  be  distinguished 
(Fig.  402,  B),  or  the  tunica  vaginalis  distended  with  fluid.  The 
scrotum  is  red,  cedematous,  and  adherent  to  the  testis,  whilst  the 
cord  is  infiltrated,  enlarged,  and  tender.  The  same  constitutional 
symptoms  are  met  with  as  in  orchitis.  Suppuration  is  perhaps 
more  common  than  after  the  latter  affection,  since  the  condition  is 
usually  due  to  a  suppurating  inflammation  of  the  deeper  parts  of  the 
urethra  ;  but  it  is  a  rare  complication.  Atrophy  of  the  testis  is  a 
not  unfrequent  result  in  cases  which  are  not  efficiently  treated, 
the  plastic  material  exuded  into  the  epididymis  being  organized 
into  fibro-cicatricial  tissue,  and  constricting  the  spermatic  vessels; 
an  acute  attack  of  double  epididymitis  may  in  this  way  render  the 
individual  sterile. 

The  Treatment  of  both  these  conditions  in  the  acute  stage 
consists  in  keeping  the  patient  in  bed,  with  the  scrotum  supported 
on  a  small  pillow.  The  part  is  assiduously  fomented,  except 
when  the  case  is  seen  very  early,  an  icebag  or  Leiter's  coil 
being  then  employed.  Leeching  should  not  be  utilized,  as  the 
triangular  leech-bites  are  very  liable  to  become  irritated  and 
septic,  and  never  heal  well  in  the  scrotum ;  if  local  abstraction 
of  blood  appears  desirable,  one  or  more  of  the  scrotal  veins 
may  be  punctured  ;  the  haemorrhage  is  easily  arrested  by  elevating 
the  part.  Pain,  if  severe,  may  be  mitigated  by  a  hot  sitz-bath, 
or  by  morphia  suppositories.  As  regards  general  treatment, 
the  patient,  after  a  preliminary  dose  of  calomel,  is  kept  on 
a  fluid,  unstimulating  diet,  whilst  alkaline  purgatives  are  ad- 
ministered, with  the  addition  of  tincture  of  henbane  or  opium  as 
a  sedative ;  if  the  pulse  is  hard  and  the  temperature  high,  vinum 
antimonialis  in  10  minim  doses  is  also  beneficial.  When  the 
acute  stage  is  passed,  the  organ  usually  remains  enlarged,  and 
for  a  time  somewhat  tender ;  it  is  then  best  treated  by  strapping 
with  lead  plaster,  or  with  the  emplastrum  ammoniaci  cum 
hydrargyro.  This  must  be  continued  until  all  signs  of  thickening 
and  induration  have  disappeared. 

Subacute  or  chronic  forms  of  inflammation  are  also  met  with 
affecting  the  testis  or  epididymis,  either  as  a  consequence  of  the 


1 148 


A   MANUAL  OF  SURGERY 


above,  or  resulting  primarily  from  blows  or  strains.  The  charac- 
teristic enlargement  is  readily  detected,  associated  with  a  certain 
amount  of  tenderness.  A  useful  diagnostic  point  between  the 
chronic  epididymitis  following  gonorrhoea  and  that  due  to  syphilis 
is  that  the  former  usually  involves  the  globus  minor,  and  the 
latter  is  almost  limited  to  the  globus  major.  The  condition  is 
best  treated  by  strapping,  and  perhaps  the  administration  of 
small  doses  of  mercury  and  iodide  of  potassium  may  assist  in  the 
absorption  of  the  inflammatory  products.  Chronic  orchitis  is  very 
similar  to  the  enlargement  produced  by  syphilis,  from  which,  indeed, 
it  can  only  be  distinguished  by  the  absence  of  a  syphilitic  history. 

Tuberculous  Disease  of  the  Testis  (Syn. :  Tuberculous  Sarcocele, 
Chronic  Tuberculous  Orchitis). — This  affection  is  most  commonly 
seen  in  young  adults  with  a  distinct 
tuberculous  history,  but  it  also  occurs  in 
otherwise  healthy  individuals.  It  may 
commence  as  a  primary  affection  of  the 
epididymis,  or  it  may  be  secondary  to 
tuberculous  disease  elsewhere. 

Pathological  Anatomy. — The  process 
originates  in  the  connective  tissue  of  the 
epididymis,  and  runs  its  usual  course, 
at  first  consisting  merely  of  miliary 
elements  deposited  around  the  vessels, 
which  by  their  coalescence  and  casea- 
tion lead  to  the  formation  of  cheesy 
masses,  and  these  at  a  later  stage  may 
emulsify  and  give  rise  to  abscesses.  It 
may  be  limited  to  any  one  part  of  the 
epididymis  (most  often  the  globus 
major),  or  may  widely  infiltrate  its 
substance,  causing  a  general  enlarge- 
ment (Fig.  403).  In  the  latter  case  it  early  tends  to  spread,  either 
into  the  body  of  the  testis  or  along  the  vas  deferens.  The  corpus 
Highmorianum  becomes  first  involved  by  a  similar  deposit,  and 
finally  the  intertubular  connective  tissue  of  the  gland  ;  this  is 
always  associated  with  overgrowth  of  the  epithelium  in  the  tubuli 
seminiferi,  the  cells  after  a  time  undergoing  fatty  degeneration, 
and  perhaps  to  such  an  extent  that,  on  microscopic  section,  the 
normal  appearance  of  the  organ  has  entirely  disappeared.  An 
abscess  may  form  within  it,  and  find  its  way  to  the  surface  by 
burrowing  through  the  tunica  albuginea,  the  visceral  and  parietal 
layers  of  the  tunica  vaginalis  having  previously  become  adherent. 
After  the  pus  has  escaped,  a  hernia  testis  is  likely  to  develop. 
If  the  process  extends  upwards  along  the  cord,  the  vas  is  mainly 
implicated,  becoming  perceptibly  thickened,  the  other  structures 
of  the  cord  being  but  little  affected.  The  disease  spreads  along 
the  vas  on  the  outside  of  the  bladder  to  the  vesicular  seminales  and 


Fig.  403.  —  Tuberculous 
Disease  of  Testis, 
mainly  affecting  the 
Epididymis.  (Treves' 
'  Surgery.') 


AFFECTIONS  OF  THE  TESTIS,  CORD,  ETC  1149 

prostate,  and  may  even  involve  the  base  of  the  bladder,  the  ureters, 
and  kidneys.  Lastly,  general  dissemination  of  tuberculous  disease 
may  occur,  and  it  is  a  curious  fact  that  meningeal  mischief  is 
frequently  associated  with  genital  tuberculosis. 

Clinical  Signs. — The  disease  is  generally  unilateral,  although  the 
other  testicle  often  becomes  involved  at  a  somewhat  later  date. 
Its  onset  may  be  abrupt  or  gradual ;  in  the  former  case  the  attack 
simulates  an  acute  orchitis,  but  at  the  end  of  a  week,  although 
the  pain  subsides,  the  swelling  persists,  being  followed  by  the 
development  of  abscesses  containing  cheesy  pus.  In  the  more 
chronic  cases,  one  or  more  firm  and  indurated  nodules,  which  are 
free  from  tenderness,  are  felt  in  the  epididymis,  but  more  often 
the  whole  of  this  structure  is  found  to  be  enlarged  and  thickened, 
forming  a  painless  crescentic  swelling,  surrounding  the  posterior 
half  of  the  body  of  the  testis,  from  which  it  is  usually  separated 
by  a  deep  groove  or  sulcus.  The  epididymis  is  nodular  and 
craggy  to  the  feel,  and  may  be  of  unequal  consistency,  areas  of 
softening  being  interposed  between  portions  which  are  distinctly 
hard.  The  vas  is  early  thickened,  and  the  body  of  the  testis  may 
be  involved  and  enlarged,  the  line  of  demarcation  between  it  and 
the  epididymis  becoming  indistinct.  Testicular  sensation  remains 
as  long  as  any  normal  glandular  tissue  exists,  but  effusion  into 
the  tunica  vaginalis  is  not  usual.  When  suppuration  occurs, 
the  pain  increases,  especially  if  the  abscess  is  in  the  substance  of 
the  organ.  As  it  finds  its  way  to  the  surface,  the  skin  becomes 
adherent  to  the  testis,  and  is  red  and  congested.  Gradually 
fluctuation  manifests  itself,  and  escape  of  the  pus  may  be  followed 
by  a  hernia  testis.  An  abscess  forming  in  connection  with  the 
epididymis  is  less  painful,  and  may  attain  considerable  dimensions 
before  it  bursts  ;  it  never  gives  rise  to  a  hernia  testis.  Extension 
of  the  disease  to  the  seminal  vesicles  causes  no  characteristic 
symptoms,  and  is  only  detected  on  rectal  examination  ;  when, 
however,  the  base  of  the  bladder,  and  prostate  are  affected,  con- 
siderable dysuria  and  irritability  of  the  bladder  are  induced. 

The  differential  diagnosis  is  discussed  at  p.  1162. 

Treatment.— Amongst  the  rich,  if  seen  in  the  very  earliest  stage, 
when  only  a  small  nodule  exists  in  the  epididymis,  it  is  possible 
that  prolonged  residence  at  the  seaside,  or  a  sea-trip,  combined 
with  suitable  constitutional  treatment  and  local  strapping,  may 
lead  to  its  disappearance.  If  apparently  limited  to  one  portion  of 
the  epididymis,  the  disease  may  be  dealt  with  by  the  conservative 
measure  of  incision,  curetting,  and  applying  pure  carbolic  acid ; 
but  such  is  seldom  feasible,  since  the  disease  is  rarely  sufficiently 
localized. 

If  the  whole  epididymis  is  enlarged  and  solid,  and  the  body  of 
the  testis  more  or  less  normal,  epididymectomy  may  be  undertaken. 
In  this  procedure  the  tuberculous  mass  is  freed  from  the  body  of 
the  organ,  the  spermatic  vessels  lying  on  the  inner  side  are  care- 
fully guarded,  and  the  vas  is  dissected  out  and  cleared  as  high  as 


1 150 


A   MANUAL  OF  SURGERY 


possible.  The  presence  of  an  abscess  or  sinus  is  no  contra-indica- 
tion,  since  it  merely  involves  a  somewhat  freer  removal  of  scrotal 
integument.  Should  foci  exist  in  the  body  of  the  testis,  they  are 
likely  to  atrophy  subsequently,  or  they  can  be  scraped  out  at  a  later 
date.  In  this  way  the  function  of  the  gland  as  the  producer  of  a 
valuable  internal  secretion  can  be  retained,  although  its  use  as  a 
generative  organ  is  lost — a  retention  the  more  important  owing  to 
the  likelihood  of  the  other  testis  being  subsequently  invaded.  If 
the  vas  is  thickened  at  the  external  abdominal  ring,  it  need  not 
deter  the  surgeon  from  operating,  even  if  the  vesiculae  are  enlarged, 
since  tuberculous  disease  is  not  like  cancer  ;  if  the  great  bulk  of 
the  mischief  is  removed,  Nature  can  frequently  eliminate  any  small 
portion  that  remains.  In  such  cases  the  inguinal  canal  should  be 
freely  opened,  and  the  vas  traced  backwards  and  divided.  In  one 
case  thus  dealt  with,  the  bladder  was  distended  with  boracic  lotion, 
the  patient  placed  in  the  Trendelenburg  position  (p.  1105),  and  the 
vas  followed  back  along  the.  side  of  the  bladder  nearly  as  far  as  the 
seminal  vesicles.  For  tuberculous  disease  of  the  seminal  vesicles, 
see  p.  1 164. 

Castration  (p.  1163)  is  reserved  for  cases  where  the  testis  is  dis- 
organized, and  its  value  as  a  secreting  gland  totally  destroyed.  Of 
course  the  cord  is  then  removed  also  after  its  division  as  high  up 
as  possible. 

Syphilitic  Disease  of  the  Testicle. — The  testicle  may  become 
affected  by  syphilis,  either  in  the  late  secondary  or  in  the  ter- 
tiary stage  ;  most  commonly  it  results 
from   the   acquired  variety,  but   occa- 
sionally is  met  with  in  the  inherited. 

Secondary  Syphilitic  Epididymitis  is 
not  very  frequently  seen.  It  occurs  in 
the  form  of  a  chronic  enlargement  of  the 
epididymis,  associated  perhaps  with  a 
hydrocele,  about  six  to  twelve  months 
after  infection.  The  case  is  very  similar 
to  a  simple  chronic  epididymitis,  but 
the  nodular  thickening  mainly  involves 
the  globus  major,  and  is  usually  sym- 
metrical. It  readily  disappears  on  the 
administration  of  mercury. 

Tertiary  Syphilitic  Orchitis  is  ob- 
served at  a  much  later  period  of  the 
disease,  even  twenty  or  thirty  years  after 
infection.  It  is  not  unfrequently  bi- 
lateral. Pathologically,  it  resembles  the 
majority  of  tertiary  manifestations  in 
consisting  of  a  diffuse  infiltration  accompanied  by  overgrowth  of 
the  connective  tissue.  If  the  process  affects  equally  the  whole 
organ,  the  ordinary  syphilitic  sarcocele  or  sclerosis  of  the  testis 


Fig  404. — Tertiary  Syphi- 
litic Disease  of  Testis 
with  Gumma  of  the  Body. 
(Treves'  'Surgery.') 


AFFECTIONS  OF  THE  TESTIS,  CORD,  ETC.  1151 


results ;  if  it  is  more  localized  in  its  distribution,  the  gummatous 
variety  is  said  to  be  present  (Fig.  404).  The  former  affection  is 
much  more  common  than  the  latter. 

In  the  tertiary  syphilitic  sarcocele,  the  body  of  the  testis  is 
primarily  involved,  and  becomes  evenly  enlarged  and  stony  hard. 
It  is  globular  in  outline,  frequently  accompanied  by  a  hydrocele, 
and  the  normal  testicular  sensation  early  disappears.  The  same 
process  occasionally  extends  to  the  epididymis  and  cord.  Sup- 
puration is  exceedingly  rare.  On  section  the  characteristic 
appearance  of  a  testicle  has  entirely  vanished ;  the  tunica 
albuginea  is  much  thickened,  and  extending  from  it  through  the 
substance  of  the  organ  are  bands  of  connective  tissue,  represent- 
ing the  normal  septa  ;  in  bad  cases  the  gland  substance  is  almost 
completely  destroyed. 

In  the  gummatous  variety  a  similar  condition  involves  the  greater 
part  of  the  organ,  but  in  addition  one  or  more  gummatous  foci 
are  present.  On  section  they  appear  as  yellowish-white  masses, 
fairly  well  defined,  and  since  the  central  portions  are  non- vascular, 
they  undergo  the  usual  degenerative  changes,  becoming  soft  and 
diffluent.  If  the  gumma  comes  to  the  surface  the  skin  may 
give  way,  and  a  deep  syphilitic  ulcer  with  a  sloughy  base  like 
wet  wash-leather  results.  Hernia  testis  very  rarely  follows  such 
an  occurrence.  The  clinical  features  of  the  gummatous  variety 
are  at  first  similar  to  those  of  the  former,  but  after  a  time  one 
portion  of  the  organ  becomes  prominent  and  painful,  and  as  this 
increases  in  size  the  central  parts  become  soft  and  fluctuating, 
and  finally  yield,  giving  exit  to  the  characteristic  gummy  contents. 
Under  suitable  treatment  the  swelling  in  each  of  these  varieties 
may  disappear  entirely,  leaving  the  testicle  either  of  normal  size 
or  atrophied  ;  but,  as  in  tuberculous  disease,  its  functional  utility, 
if  not  entirely  destroyed,  is  probably  considerably  impaired. 

For  the  differential  diagnosis  see  p.  1162. 

Treatment  consists  in  the  administration  of  iodide  of  potassium 
and  mercury,  whilst  the  hydrocele  may  be  tapped,  and  the  organ 
strapped  or  supported  by  a  suspender.  If  a  gummatous  ulcer  is 
produced,  it  may  be  possible  to  excise  the  greater  portion  of  the 
characteristic  slough  at  its  base ;  but  in  all  cases  it  should  be 
dressed  with  lint  or  gauze  steeped  in  lotio  nigra,  or  some  other 
mercurial  preparation. 

Hernia  Testis  is  the  term  applied  to  a  protrusion  of  the  sub- 
stance of  the  gland,  more  or  less  infiltrated  with  granulation 
tissue,  through  an  opening  in  the  tunica  albuginea  and  skin  of 
the  scrotum.  It  arises  from  various  causes,  such  as  a  septic 
penetrating  wound  of  the  testis,  acute  suppurative  orchitis,  or 
from  a  chronic  abscess,  whether  simple  or  tuberculous  in  nature. 
It  is  rarely  produced  by  the  breaking  down  of  a  gumma,  owing 
to  the  extensive  infiltration  of  the  organ  with  fibro-cicatricial 
tissue,  and  necessarily  it  never  follows  suppuration   in  the  epi- 


1 152 


A   MANUAL  OF  SURGERY 


didymis.  It  is  always  preceded  by  a  condition  of  increased  pressure 
within  the  tunica  albuginea,  and  consequently  as  soon  as  an  aper- 
ture is  formed  in  this  membrane,  its  natural  elasticity,  allowing  of 
its  contraction,  forces  a  portion  of  its  contents  out  of  the  opening  ; 
this  may  even  proceed  to  such  an  extent  as  to  cause  the  whole  of 
the  substance  of  the  gland  to  protrude,  the  tunica  albuginea  being 
practically  turned  inside  out.  A  mass  resembling  granulation 
tissue  is  then  seen  to  project  through  an  opening  in  the  scrotum  ; 
it  is  often  somewhat  pedunculated  or  mushroom-like  in  shape, 
possibly  overhanging  the  margins  of  the  skin,  but  in  less  advanced 
cases  the  integument  may  be  distinctly  undermined.  A  consider- 
able discharge  of  pus  usually  accompanies  it.  The  condition  must 
be  distinguished  from  the  fungating  growth  which  occasionally 
results  from  malignant  disease  of  the  organ,  when  the  protrusion 
consists  of  tumour  substance,  with  no  trace  of  testicular  tissue. 

The  Treatment  of  hernia  testis  usually  consists  in  extirpation 
of  the  organ,  especially  when  it  is  affected  by  tuberculous  disease. 
In  simple  cases  it  may  be  possible  to  obtain  healing  of  the  wound 
by  keeping  the  part  aseptic,  and  applying  pressure  by  means  of  a 
pad  of  gauze.  In  other  cases  it  may  be  possible  to  separate  the 
mass,  and  after  paring  the  edges  of  the  wTound,  to  bring  them 
together  by  sutures,  and  thus  cover  in  the  gland  substance, 
which,  however,  remains  projecting  from  the  opening  in  the 
tunica  albuginea.     Such  proceedings  are  seldom  very  satisfactory. 

Tumours  of  the  Testis  are  generally  malignant  in  character,  only 
one  non-malignant  form  being  at  all  common,  viz.,  fibro-cystic 
disease,  or  adenoma  testis. 

Fibro-Cystic  Disease  (Syn. :  Adenoma  Testis,  Cystic  Sarcocele). — 
This  condition  is  characterized  by  the  formation  of  a  tumour  of 
variable  size,  scattered  through  the  substance  of  which  are 
numerous  cystic  cavities,  lined  with  cuboidal  or  stratified  epithe- 
lium (Fig.  405).  These  cysts  are  usually  rounded,  but  occasionally 
tubular  in  shape,  and  may  communicate  with  one  another ;  they 
contain  serous  fluid  and  sometimes  intracystic  growths.  They 
are  surrounded  by  connective  tissue,  the  amount  and  character 
of  which  vary  greatly  in  different  cases.  It  consists  mainly  of 
simple  fibrous  tissue,  but  it  is  very  common  to  see  cartilaginous 
nodules  and  myxomatous  foci  scattered  through  its  substance. 
It  is  thus  very  similar  in  its  structure  to  the  simple  parotid 
tumour  (p.  787),  and  like  it  is  very  prone  after  a  time  to  undergo 
a  malignant  transformation.  According  to  Bland  Sutton  and 
Eve,  these  tumours  arise  from  the  remains  of  the  Wolffian  body 
or  mesonephros,  which  is  almost  always  normally  represented  in 
the  neighbourhood  of  the  globus  major  of  the  epididymis  by  the 
structure  known  as  the  organ  of  Giraldes  (paradidymis).  The 
testicle  can  be  found  in  most  cases  spread  out  in  a  thin  layer  over 
the  tumour  substance. 

Clinical  Signs. — This  condition  is  met  with  in  young  adults. 


AFFECTIONS  OF  THE  TESTIS,  CORD,  ETC. 


ii52 


and  may  possibly  be  attributed  to  an  injury.  The  organ  steadily 
becomes  enlarged,  but  this  gives  rise  to  no  inconvenience  except 
by  its  size  and  weight.  It  is  round  in  outline  a/id  elastic  in  con- 
sistency, the  cord  remaining  unaffected  unless  malignant  disease 
supervenes.  When  of  great  size,  the  skin  of  the  scrotum  may 
ulcerate.  The  case  runs  a  chronic  course,  and  even  should  the 
growth  become  malignant,  the  change  of  type  only  appears  late 
in  the  disease. 

Treatment  consists  in  removal  after  an  exploratory  incision  has 
demonstrated  the  nature  of  the  growth. 

Other  non-malignant   tumours   have   been   described,   such   as 


Fig.  405. 


-Fibrocystic  Disease  of  the  Testis. 
Surgeons'  Museum  ) 


(College  op 


chondroma,  osteoma,  fibroma,  myxoma,  etc.,  but  they  are  ex- 
ceedingly uncommon,  if  they  occur  at  all  apart  from  sarcoma  or 
fibro-cystic  disease. 

Sarcoma  of  the  Testis  commences  in  the  body  of  the  organ, 
either  within  the  first  decade  of  life  or  between  the  ages  of  thirty 
and  forty,  and  is  sometimes  a  sequela  of  late  or  imperfect  descent. 
It  is  usually  a  soft,  round-celled  growth,  taking  on  the  form  of 
a  lympho-sarcoma ;  in  other  cases  it  is  harder,  and  of  the  nature 
of  a  nbro-sarcoma.  Frequently  cartilaginous  nodules  are  incor- 
porated in  its  substance,  and  patches  of  myxomatous  tissue  or 
cystic  degeneration  from  haemorrhage  are  also  seen.  As  already 
stated,  it  is  sometimes  secondary  to  fibro-cystic  disease.  It 
originates  in  the  connective-tissue  elements  of  the  organ,  the 
glandular  substance  being  early  destroyed.  It  appears  as  a 
rounded  swelling,  and  at  first  its  outline  is  irregularly  smooth  ; 

73 


1 154  A   MANUAL  OF  SURGERY 


as  the  disease  progresses,  however,  it  may  become  nodulated 
from  the  development  of  cysts.  The  tumour  may  attain  very 
large  dimensions,  but  the  cord  and  scrotal  tissues  only  become 
affected  in  the  later  stages,  and  then  ulceration  and  the  forma- 
tion of  a  fungus  testis  occasionally  follow.  Secondary  growths 
are  always  found  in  the  lumbar  glands  and  internal  organs, 
whilst,  when  it  has  spread  beyond  the  tunica  albuginea,  involv- 
ing the  scrotal  structures,  the  inguinal  glands  may  be  similarly 
affected.  There  are  but  few  subjective  symptoms  at  first,  a 
feeling  of  weight  and  dragging  being  alone  experienced,  whilst 
testicular  sensation  is  soon  lost ;  but  at  a  later  date,  when  the 
cord  is  involved,  pain  and  cachexia  become  very  marked.  The 
Course  of  these  cases  is  slow  up  to  a  certain  point,  but  the  tumour 
may  then  rapidly  increase  in  size,  spreading  along  the  cord  to  the 
interior  of  the  abdomen  even  in  the  course  of  a  few  weeks,  thereby 
rendering  removal  utterly  impossible,  although  it  would  have 
been  easily  practicable  at  an  earlier  period.  Treatment  consists 
in  the  extirpation  of  the  growth  with  the  testis  as  early  as  possible, 
the  cord  being  divided  high  up. 

Carcinoma  of  the  Testis  is  usually  of  the  encephaloid  type,  and 
arises  in  the  body  of  the  organ  as  a  soft  rapidly-growing  tumour, 
which  soon  extends  to  the  tissues  of  the  cord,  and  contracts 
adhesions  to  the  scrotum  ;  ulceration  and  the  formation  of  a 
fungating  mass  follow,  whilst  secondary  deposits  are  found  in  the 
lumbar  and  inguinal  glands,  and  sometimes  in  the  viscera.  It  is 
impossible  to  distinguish  a  carcinoma  from  a  sarcoma  of  the  testis 
by  clinical  signs,  since  it  occurs  at  the  same  period  of  adult  life, 
although  never  in  children.  Very  rapid  growth,  and  early  enlarge- 
ment of  the  cord  and  lymphatic  glands,  point,  however,  to  cancer 
rather  than  sarcoma.     The  only  treatment  is  castration. 


Hydrocele. 

Any  collection  of  fluid,  other  than  pus  or  blood,  in  the  neigh- 
bourhood of  the  testis  or  cord,  is  termed  a  Hydrocele.  The  fluid 
usually  consists  of  serum,  but  in  some  forms  spermatozoa  are 
also  present,  and  in  rare  cases  it  may  consist  of  chyle  or  a  similar 
milky  fluid  (chylous  hydrocele).  Two  chief  varieties  are  described, 
according  to  whether  the  testis  or  the  cord  is  involved.  ■ 

I.  In  Hydrocele  of  the  Testis  the  fluid  is  contained  in  the  tunica 
vaginalis  (vaginal  hydrocele)  or  exists  as  a  circumscribed  swelling 
in  its  neighbourhood  (encysted  hydrocele). 

i.  A  Vaginal  Hydrocele  is  one  in  which  there  is  an  accumula- 
tion of  fluid  in  the  tunica  vaginalis,  and  the  following  varieties 
may  be  differentiated : 

(a)  Acute  Hydrocele  occurs  in  conjunction  with  acute  inflamma- 
tion of  the  testis  or  epididymis.  The  effusion  of  fluid  is  never 
abundant,  and  is  often  only  made  out  on  careful  examination  ; 
at  first  it  consists  of  plasma,  as  in  all  acute  inflammations  of  a 


AFFECTIONS  OF  THE   TESTIS,  CORD,  ETC.  1155 


serous  membrane,  and  is  therefore  spontaneously  coagulable.  It 
may  merge  into  the  chronic  type,  or  may  disappear  entirely, 
perhaps  leaving  a  few  adhesions. 

(b)  A  Congenital  Hydrocele  occurs  in  cases  in  which  the  funicular 
process  is  still  patent.  The  general  signs  of  a  vaginal  hydrocele, 
as  described  below,  are  present,  but  the  fluid  can  be  returned  by 
pressure  into  the  abdominal  cavity.  It  is  rarely  seen  in  others 
than  infants,  and  may  be  treated  by  the  application  of  evaporating 
lotion  to  the  scrotum,  whilst  a  light  truss  or  woollen  support  is 
placed  over  the  inguinal  canal,  as  for  congenital  hernia.  It  is 
often  associated  with  phimosis,  which  should  of  course  be  dealt 
with  by  circumcision.  If  it  persists,  it  may  be  treated  by  operation 
as  for  congenital  hernia,  to  which,  indeed,  it  frequently  leads. 

(c)  An  Infantile  Hydrocele  is  one  due  to  non- obliteration  of  the 
funicular  process  of  peritoneum,  except  at  its  upper  extremity. 
It  presents  the  signs  of  an  ordinary  acquired  hydrocele,  the  fluid, 
however,  extending  along  the  cord,  even  into  the  inguinal  canal. 
Its  treatment  is  the  same  as  for  an  acquired  hydrocele. 

(d)  A  Bilocular  Hydrocele  is  one  in  which  there  is  an  additional 
loculus  without  the  abdominal  cavity,  communicating  by  a  neck  of 
variable  size  with  the  distended  tunica  vaginalis.  It  is  due  to  a 
persistence  of  the  intra-abdominal  portion  of  the  funicular  process 
between  the  peritoneum  and  internal  abdominal  ring;  this  becomes 
distended  with  fluid,  and  the  collection  burrows  downwards  in  front 
and  by  the  side  of  the  bladder  towards  the  pelvis.  We  have 
operated  on  a  similar  condition  in  a  woman,  originating  in  the 
upper  portion  of  the  canal  of  Nuck. 

(e)  Acquired  Vaginal  Hydrocele  is  the  most  common  variety. 
Causes. — It  may  arise  idiopathically  in  middle-aged  persons,  and 
has  then  been  looked  on  as  resulting  from  some  functional 
disorder  rather  than  from  any  organic  change  in  the  membrane,  the 
normal  balance  between  secretion  and  absorption  being  disturbed. 
In  the  majority  of  cases,  however,  the  testicle  is  swollen  and 
perhaps  in  a  state  of  chronic  inflammation,  and  the  tunica  vaginalis 
thickened.  A  hydrocele  almost  always  accompanies  a  tertiary 
syphilitic  enlargement  of  the  organ,  but  is  uncommon  in  tubercu- 
lous or  malignant  disease.  Hydrocele  is  very  frequently  seen  in 
those  who  dwell  in  hot  climates,  probably  as  a  result  of  the  lax 
and  pendulous  conditions  of  the  scrotum  and  testicles.  In  India 
natives  always  support  the  scrotum. 

Signs. — Vaginal  hydrocele  appears  as  a  rounded  pyriform 
swelling  in  the  scrotum,  which  extends  for  a  variable  distance 
along  the  cord.  Its  tension  differs  with  the  amount  of  fluid 
present,  and  with  the  thickness  of  its  walls ;  it  is  generally 
elastic,  and  with  obvious  fluctuation.  The  cord  is  felt  distinctly 
above  the  rounded  upper  part  of  the  tumour,  and  the  testis  is 
generally  situated  posteriorly  (Fig.  402,  C),  although  it  projects 
forwards  into  the  cavity,  and  is  thus  not  readily  detected.     Its 


1 1 56 


A   MANUAL  OF  SURGERY 


ME 


position  may  be  ascertained  by  pressure  over  it,  when  the  charac- 
teristic testicular  sensation  is  evolved.  On  holding  a  light  close 
to  the  scrotum,  the  tumour  is  seen  to  be  translucent,  and  the 
position  of  the  testicle  can  be  demonstrated.  In  old-standing 
cases  the  walls  become  exceedingly  thick,  and  even  cartilaginous 
or  osseous  plates  have  been  observed  in  them  ;  the  translucency 
in  such  cases  will  be  lost.  Occasionally,  when  inflammation  has 
existed,  adhesions  may  form  between  the  testis  and  the  anterior 
wall,  and  irregularity  in  the  shape  of  the  tumour  is  thereby 
induced,  or  the  cavity  may  be  divided  into  compartments  by 
fibrous  bands  or  septa. 

It  is  scarcely  necessary  to  mention  that  there  is  no  impulse  on 
coughing,  and  that  the  tumour  is  dull  on  percussion.  When  the 
distension  is  very  great,  its 
weight  causes  a  dragging  pain  ; 
the  penis  becomes  buried  in 
the  swelling,  and  eczema  of  the 
scrotum  may  result  from  the 
urine  trickling  over  it.  The  fluid 
in  the  sac  is  yellowish  or  straw- 
coloured  ;  its  specific  gravity 
varies  from  1015  to  1025 ;  it 
contains  a  large  amount  of 
albumen,  especially  fibrinogen. 
In  old-standing  cases  cholesterin 
may  also  be  present. 

The  Treatment  of  vaginal 
hydrocele  is  palliative  or  radical. 
Palliative  treatment  consists  in 
tapping  the  cavity  and  remov- 
ing the  fluid,  the  patient  being 
subsequently  directed  to  wear  a 
suspender,  and,  where  inflam- 
mation of  the  testis  exists,  to 
apply  cooling  lotions.  In  infants 
it  can  often  be  cured  without 
tapping  by  simply  applying  an 
evaporating  lotion.  In  order  to 
tap  a  hydrocele,  the  tumour  must  be  firmly  grasped  in  the  palm 
of  the  left  hand,  and  the  skin  over  its  anterior  wall  purified  and 
made  tense.  A  spot  at  the  antero-inferior  margin  is  then  selected, 
as  free  from  vessels  as  possible,  and  a  fine  sterilized  trocar  and 
cannula  inserted  in  a  direction  almost  directly  upwards,  so  as 
to  pass  in  front  of  the  body  of  the  testis.  The  site  selected  for 
tapping  must  of  course  vary  with  the  position  of  the  testicle, 
which  should  be  previously  demonstrated.  The  fluid  having 
been  withdrawn,  the  cannula  is  removed,  and  the  puncture 
covered  with  some  wool  and  collodion.  The  condition  recurs 
after  a  longer  or  shorter  period,  and  the  operation  must  be  re- 


Fig.  406. — Method  of  tapping  a 
Hydrocele.     (Tillmanns.) 

Ho,  Testis;  NH,  epididymis; 
Hy,  hydrocele. 


AFFECTIONS  OF  THE  TESTIS,  CORD,  ETC.  1157 

peated.  If  a  dirty  instrument  is  employed,  inflammation,  and 
even  suppuration,  may  follow,  whilst  if  a  vessel  or  the  body  ol 
the  testis  is  punctured,  a  hematocele  may  result. 

Many  different  plans  have  been  suggested  for  the  Radical  treat- 
ment of  hydrocele.  It  is  unnecessary,  however,  to  do  more  than 
describe  the  two  most  frequently  adopted,  (i.)  Injection  of  the 
cavity  after  tapping  has  long  been  a  favourite  method.  Many 
different  reagents  have  been  employed,  such  as  port  wine,  tincture 
of  iodine,  solution  of  corrosive  sublimate  (1  in  500),  or  glycerine 
of  carbolic  acid.  Perhaps  the  best  is  the  tincture  of  iodine,  but 
that  contained  in  the  British  Pharmacopoeia  is  not  strong  enough, 
and  the  old  Edinburgh  tincture,  which  is  nearly  the  same  strength 
as  the  lin.  iodi,  B.P.,  should  be  employed.  The  amount  used 
varies  with  the  size  of  the  hydrocele,  but  for  one  of  moderate 
dimensions  it  will  suffice  to  inject,  after  tapping,  2  drachms  of  the 
tincture,  and  after  manipulating  it  well  within  the  cavity,  a  part, 
say  1  drachm,  is  allowed  to  escape.  Smart  inflammatory  reaction 
follows,  and  a  cure  will  probably  result,  either  from  obliteration 
of  the  vaginal  space  by  the  formation  of  adhesions,  or  by  impress- 
ing some  change  of  function  upon  the  serous  membrane.  In  a 
certain  percentage  of  cases  failure  may  be  expected,  and  this  is 
more  likely  to  happen  if  too  weak  an  irritant  has  been  employed, 
or  if  the  hydrocele  is  a  chronic  one  with  thick  and  indurated  walls, 
and  has  been  tapped  on  several  previous  occasions,  (ii.)  The 
open  method  of  operation  is  now  generally  adopted,  and  is  par- 
ticularly recommended  in  large  and  chronic  cases.  The  hydro- 
cele is  cut  down  on  through  an  incision  in  the  upper  part  of  the 
scrotum,  and  the  tunica  vaginalis  isolated  from  the  superjacent 
structures.  The  cavity  is  opened,  and  the  parietal  portion  of  the 
tunica  snipped  away  with  scissors  close  to  the  testicle.  A  number 
of  vessels  will  need  to  be  ligatured  ;  a  drainage-tube  is  inserted, 
and  the  wound  closed  in  the  ordinary  way.  The  results  of  this 
practice  are  most  satisfactory. 

2.  Encysted  Hydrocele  of  the  testis  occurs  in  two  main  forms, 
according  to  whether  it  arises  in  connection  with  the  epididymis 
or  the  body  of  the  testis. 

(a)  Encysted  Hydrocele  of  the  Epididymis  exists  usually  as  a 
rounded  globular  swelling,  tense  and  elastic  in  consistency,  and 
translucent.  It  is  situated  above  the  body  of  the  testis,  and 
close  to  the  head  of  the  epididymis  (Fig.  407).  As  a  rule,  it  does 
not  attain  a  size  greater  than  that  of  the  body  of  the  testis  itself, 
so  that  it  may  appear  as  if  a  double  testicle  was  present ;  the 
hydrocele  is,  of  course,  devoid  of  testicular  sensation.  Less 
frequently  it  may  attain  considerable  dimensions,  even  projecting 
below  and  around  the  testicle,  which,  though  enveloped  by  it, 
is  quite  distinct  from  it.  The  fluid  contained  within  these  cysts 
is  usually  milky  and  opalescent  in  appearance,  owing  to  an  ad- 
mixture of  semen  ;  under  the  microscope  spermatozoa,  either 
living   or  dead,  can  be  demonstrated  ;    on  account  of  this  it  is 


ii58 


A   MANUAL  OF  SURGERY 


sometimes  termed  a  spermatocele.  The  specific  gravity  is  lower  than 
that  of  ordinary  hydrocele  fluid,  and  there  is  but  little  albumen. 
The  origin  of  these  cysts  has  given  rise  to  much  discussion. 
They  are  of  a  very  different  nature  to  the  ordinal  y  vaginal 
hydrocele,  or  even  to  the  encysted  hydrocele  of  the  cord,  since 
the  walls  are  not  lined  with  en- 
dothelium, but  with  cuboidal  or 
columnar  epithelium.  They  are 
probably  due  either  to  a  dilatation 
of  one  or  more  of  the  vasa  effer- 
entia  testis,  or  more  frequently  to 
distension  of  some  of  the  fcetal 
relics  always  found  near  the  head 
of  the  epididymis,  especially  of 
those  known  as  Kobelt's  tubes ; 
these,  as  also  the  vasa  efferentia 
testis,  are  derived  from  the  tubules 
of  the  Wolffian  body,  differing, 
however,  from  them  in  not  be- 
coming attached  to  the  body  of 
the  testis  (Fig. 44).  They  are  thus 
homologous  with  the  parovarian 
cysts  found  in  the  female.  Smaller 
pedunculated  cysts  containing  clear  \ 
serum  are  sometimes  met  with  in  vj 
this  region,  arising  from  a  disten- 
sion of  the  hydatid  of  Morgagni, 
which  is  developed  from  the  re- 
mains of  the  Mullerian  duct. 

Treatment  is  conducted  along 
the  same  lines  as  for  vaginal 
hydrocele,  viz.,  by  tapping   as  a 

palliative  measure,  and  injection  or  excision,  in  order  to  establish 
a  radical  cure. 

(b)  Encysted  Hydrocele  of  the  Tunica  A  Ibuginea  is  a  condition  rarely 
seen,  consisting  of  a  small  collection  of  serous  fluid  beneath  the 
visceral  portion  of  the  tunica  vaginalis.  It  is  probably  due  to 
dilatation  of  lymphatic  spaces,  and  has  absolutely  no  clinical 
significance. 

II.  Hydrocele  of  the  Cord  occurs,  as  already  described,  in  con- 
nection with  the  congenital  and  infantile  varieties  of  vaginal 
hydrocele.  If  limited  to  the  cord,  it  exists  in  one  of  two  forms, 
the  encysted  or  the  diffuse. 

i.  Encysted  Hydrocele  of  the  Cord  arises  from  imperfect  oblitera- 
tion of  the  funicular  process  of  peritoneum,  the  patent  portion 
becoming  distended  with  fluid  and  giving  rise  to  a  cavity  lined 
with  endothelium.  It  is  usually  detected  as  a  rounded  elastic 
swelling,  occupying  the  inguinal  canal,  moving  freely  up  and 
down   within  it.      The  upper  border  is   sharply  limited,   and  in 


Fig.  407. — Encysted  Hydrocele 
of  Epididymis.  (College  of 
Surgeons'  Museum.) 


AFFECTIONS  OF  THE  TESTIS,  CORD,  ETC 


1159 


favourable  cases  translucency  can  be  demonstrated.  On  fixing 
the  testicle  the  cyst  is  no  longer  moveable.  The  fluid  contained 
within  it  is  identical  in  nature  with  that  in  a  vaginal  hydrocele. 
In  the  female  a  similar  condition  arises  from  imperfect  obliteration 
of  the  canal  of  Nuck,  giving  rise  to  what  is  known  as  a  hydrocele 
of  the  round  ligament.  Treatment  consists  in  removal  of  the  fluid 
by  tapping,  or,  if  a  more  radical  proceeding  is  necessary,  injection 
or  excision. 

2.  Diffuse  Hydrocele  of  the  Cord  is  but  rarely  seen.  It  results 
from  a  diffuse  oedema  of  its  cellular  tissue,  and  presents  on  exami- 
nation a  fusiform  or  sausage-shaped  tumour,  which  extends  along 
the  cord  for  a  variable  distance. 

The  term  Chylous  Hydrocele  is  applied  to  a  distension  of  the 
tunica  vaginalis  with  a  chylous  fluid,  recognised  by  being  milky 
in  appearance,  and  under  the  microscope  seen  to  consist  of  a 
fatty  emulsion.  Several  modes  of  origin  have  been  suggested, 
but  none  are  very  satisfactory.  In  a  case  recently  under  treat- 
ment, a  series  of  dilated  lymphatics  filled  with  a  similar  fluid 
extended  upwards  from  the  testicle  to  the  inguinal  canal. 


Varicocele. 

A  varicose  condition  of  the  pampiniform  plexus  is  very  com- 
monly met  with  in  young  men,  but  seldom  in  those  of  advanced 
age,  except  when  it  has  become  chronic, 
or  is  due  to  malignant  disease  of  the 
kidney  (p.  1067).  It  usually  occurs  in 
individuals  with  a  lax  and  pendulous 
scrotum,  and  is  often  associated  with 
masturbation,  which  induces  abnormal 
vascularity  of  the  testis.  It  may  also 
be  caused  by  the  pressure  of  a  truss 
applied  for  the  relief  of  a  hernia.  It  is 
almost  invariably  on  the  left  side,  and 
the  reasons  given  for  this  are  as  follows  : 
(a)  The  left  testis  usually  hangs  lower 
than  the  right,  and  hence  the  spermatic 
veins  are  longer  and  exposed  to  greater 
blood  pressure,  (b)  The  left  spermatic 
vein  opens  into  the  left  renal  vein  at 
right  angles,  and  no  valve  is  present 
at  the  orifice,  whilst  that  on  the  right 
side  opens  obliquely  into  the  vena  cava 
and  is  valved.  (c)  The  presence  of  the 
sigmoid  flexure  on  the  left  side  of  the 
body,  and  its  distension  by  accumulated 
faeces  as  a  result  of  constipation,  may  lead  to  pressure  on  the 
abdominal  portion  of  the  left  spermatic  vein. 


Fig.  408. — Varicocele 
(Treves'   '  Surgery.') 


n6o  A   MANUAL  OF  SURGERY 

A  varicocele  is  characterized  by  the  presence  of  a  soft  irregular 
swelling  in  the  scrotum,  which  is  somewhat  pyramidal  in  shape, 
the  main  mass  being  below  and  slightly  overlapping  the  testis, 
and  the  apex  above.  It  consists  of  dilated  and  tortuous  veins 
the  outlines  of  which  can  often  be  seen  through  the  skin  ;  they 
impart  a  sensation  to  the  finger  which  has  been  likened  to  a  col- 
lection of  worms  in  a  bag  ;  there  is  a  distinct  impulse  down  the 
veins  on  coughing.  On  assuming  the  recumbent  posture  the 
swelling  almost  disappears,  owing  to  the  vessels  being  emptied 
of  their  contained  blood  ;  if  pressure  is  subsequently  applied  over 
the  external  abdominal  ring,  and  the  patient  allowed  to  stand, 
the  tumour  reappears,  filling  from  below  upwards.  A  sensation 
of  weight  and  pain  usually  accompanies  a  varicocele,  whilst  severe 
neuralgia  of  the  testis  may  be  induced.  It  is  a  frequent  source  of 
seminal  emissions,  and  may  result  in  testicular  atrophy.  Phlebitis 
is  liable  to  follow  an  injury,  and  may  lead  to  a  spontaneous  cure ; 
if  one  of  the  dilated  veins  is  ruptured,  severe  haemorrhage  ensues, 
causing  a  diffuse  haematocele  of  the  cord.  In  favourable  cases 
the  condition  disappears  spontaneously. 

The  Diagnosis  of  varicocele  is  easily  made,  the  only  condition 
for  which  it  is  likely  to  be  mistaken  being  an  omental  hernia  ; 
the  difference  between  the  two  conditions  has  been  discussed  at 
p.  981. 

The  Treatment  of  slight  cases  of  varicocele  consists  of  support- 
ing the  testicle  and  scrotum  by  means  of  a  well-fitting  suspender, 
whilst  the  patient  is  also  instructed  to  bathe  the  parts  with  cold 
water  night  and  morning,  and  to  take  such  measures  as  shall 
ensure  a  daily  action  of  the  bowels. 

Radical  Treatment  by  excision  of  the  veins  is  advisable  in 
neuralgic  cases,  where  atrophy  of  the  testis  is  threatening,  or  in 
order  to  fit  the  patient  for  admission  into  any  of  the  public  services. 
The  operation  is  conducted  as  follows  :  The  pubic  region  having 
been  shaved  and  purified,  an  incision  1^  inches  long  is  made  in  the 
direction  of  the  cord,  with  its  centre  a  little  below  the  external 
abdominal  ring.  The  structures  of  the  cord  are  raised  on  the 
fingers,  and  the  coverings  divided,  so  as  to  expose  the  spermatic 
veins  at  their  upper  end.  Two  main  branches  are  usually  found  in 
this  situation,  but  occasionally  there  is  only  one.  These  are  cleaned 
and  carefully  isolated  from  the  other  structures  of  the  cord,  and  a 
ligature  is  applied  to  them  at  the  external  abdominal  ring.  The 
vessels  are  now  clamped  with  a  pair  of  Spencer  Wells'  forceps 
below  the  ligature,  and  divided  between  it  and  the  forceps.  The 
lower  end,  grasped  by  the  forceps,  is  stripped  downwards, 
so  as  to  free  the  pampiniform  plexus  from  the  other  elements 
of  the  cord,  and  the  dissection  can  be  carried  nearly  as  far  as 
the  epididymis  by  drawing  the  testicle  up  into  the  wound. 
The  lower  end  of  the  veins  is  ligatured  in  one  or  two  portions, 
and  divided.     By  this  means  the  whole  varicocele  is  removed. 


AFFECTIONS  OF  THE  TESTIS,  CORD,  ETC.  1161 

If  the  scrotum  is  pendulous,  and  the  testicle  hangs  low,  it  may 
be  advisable  to  raise  it  by  tying  the  upper  and  lower  ligatures 
together,  care  being  taken  net  to  pull  them  off  in  so  doing  ; 
perhaps  it  is  wiser  to  introduce  a  suture  through  the  divided 
ends  of  the  veins  above  and  below,  which  are  purposely  left  long. 
The  wound  is  then  closed  without  a  drainage-tube,  and  dressed 
as  usual.  The  patient  is  kept  in  the  recumbent  posture  for  ten 
days  or  a  fortnight,  until  a  firm  cicatrix  has  formed.  This  method 
of  treatment  is  infinitely  superior  to  that  often  practised  of  ex- 
posing the  veins  in  the  scrotum,  since  a  wound  in  the  groin 
always  heals  much  more  readily  than  one  in  the  scrotum  ;  whilst 
it  is  easier  to  dissect  the  veins  out  from  above,  where  only  one 
or  two  trunks  exist.  The  venous  return  after  the  operation  is 
maintained  by  the  vein  or  veins  running  with  the  artery  to  the  vas 
in  the  posterior  portion  of  the  cord. 

Neuralgia  of  the  Testis  is  characterized  by  the  organ  becoming 
exquisitely  tender  and  painful,  although  apparently  healthy.  It 
usually  occurs  in  young  adults  of  nervous  temperament,  or  in 
middle-aged  gouty  men.  It  is  not  uncommonly  associated  with 
a  varicocele.  The  pain  is  usually  paroxysmal  in  character,  and 
very  intractable. 

Treatment  must  be  directed  mainly  to  the  general  health,  con- 
sisting in  the  administration  of  nerve  tonics,  such  as  iron  and 
quinine,  whilst  locally  sedatives,  such  as  belladonna  and  aconite, 
may  be  applied.      It  is  also  advisable  for  a  suspender  to  be  worn, 

Atrophy  of  the  Testis  results  from  several  causes :  (i.)  It  may 
be  due  to  a  congenital  arrest  of  development,  as  met  with  in 
displacement  or  late  descent,  (ii.)  It  is  most  frequently  the  con- 
sequence of  inflammatory  affections,  either  of  the  body  or  epi- 
didymis, owing  to  the  cicatricial  contraction  caused  thereby  lead- 
ing to  compression  of  the  vessels.  It  occasionally  follows  the 
metastatic  orchitis  of  mumps,  especially  in  adults,  whilst  it  is 
also  due  to  syphilitic  disease.  (iii.)  It  arises  from  impaired 
nutrition,  as  after  the  division  of  the  spermatic  arteries  in  opera- 
tions for  varicocele  or  hernia,  or  from  compression  of  the  cord  by 
closing  the  inguinal  canal  too  firmly  in  the  operation  for  the 
radical  cure  of  hernia,  (iv.)  Chronic  congestion  of  the  organ,  as 
by  a  varicocele,  may  induce  atrophy  ;  whilst  (v.)  sexual  excesses 
are  also  stated  to  lead  to  it.  If  unilateral,  it  is  of  comparatively 
little  importance;  but  where  both  organs  are  affected,  sterility  is 
sure  to  result,  and  the  patient,  if  previously  young  and  healthy, 
is  likely  to  become  depressed  in  spirits  and  melancholic.  This 
may  be  due  in  part  to  mental  causes,  but  also  in  measure  to  the 
absence  of  seminal  secretion,  the  reabsorption  of  which  into  the 
system  is,  according  to  Brown-Sequard,  an  important  factor  in 
the  maintenance  of  a  vigorous  state  of  mind  and  body. 


n62  A  MANUAL  OF  SURGERY 


General  Diagnosis  of  Scrotal  Tumours. 

When  a  patient  presents  himself  for  examination  with  a  swelling 
in  the  scrotum,  the  surgeon  has  to  decide  whether  it  is  a  hernia, 
a  hydrocele,  a  haematocele,  a  varicocele,  or  a  solid  enlargement  of 
the  testis,  and,  if  the  latter,  of  what  nature.  The  first  point  to 
which  attention  is  directed  is  the  condition  of  the  cord  immediately 
below  the  external  ring.  If  this  is  of  normal  size  and  consistency, 
hernia  and  diffuse  hydrocele  of  the  cord  are  thereby  excluded, 
whilst  the  existence  of  a  rounded  tense  swelling,  moveable  within 
the  canal,  but  becoming  fixed  on  holding  the  testis,  indicates  that 
an  encysted  hydrocele  of  the  cord  is  probably  present.  When, 
however,  the  cord  is  more  or  less  masked,  further  examination 
speedily  determines  whether  a  hernia,  or  a  diffuse  hydrocele  or 
haematocele  of  the  cord  exists,  since  the  former  is  often  reducible, 
has  an  impulse  on  coughing,  and  is  rounded  or  nodular  in  outline, 
and  the  latter  are  sausage-shaped,  always  irreducible',  and  semi- 
fluctuating. 

When  the  swelling  is  purely  scrotal,  inspection  and  manipula- 
tion will  at  once  decide  if  it  is  a  varicocele,  by  its  characteristic 
feel,  by  its  disappearance  on  assuming  the  recumbent  posture, 
and  filling  again  from  below  on  standing  up.  If  the  swelling  is 
rounded  in  outline,  the  next  point  to  be  determined  is  whether  it 
is  solid  or  fluid.  If  fluid,  it  is  probably  a  hydrocele,  or  the  early 
stage  of  a  haematocele ;  the  translucency  of  the  former,  and  the 
sudden  appearance  and  non-translucency  of  the  latter,  should 
suffice  to  demonstrate  its  nature.  It  is  possible  that  the  hydrocele 
is  merely  a  secondary  complication,  and  hence  no  final  opinion 
should  be  given  until  it  has  been  tapped,  and  the  condition  of  the 
body  of  the  testis  investigated.  If,  however,  a  solid  mass  exists 
in  the  scrotum,  it  is  either  a  haematocele  in  its  later  stages,  or 
some  form  of  sarcocele,  whether  simple,  syphilitic,  tuberculous,  or 
neoplastic.  A  hematocele  is  possibly  recognised  by  its  history, 
and  by  there  being  a  fluid  centre  to  the  swelling,  surrounded  by 
solidified  tissue.  Chronic  orchitis  and  syphilitic  enlargement  of 
the  testis  are  so  much  alike  as  to  render  diagnosis  always  uncer- 
tain in  the  absence  of  a  distinct  syphilitic  history ;  but  if  the 
swelling  is  extremely  hard,  with  a  smooth  and  regular  outline, 
without  testicular  sensation,  limited  to  the  body  of  the  testis,  and 
accompanied  by  a  hydrocele,  it  is  probably  syphilitic.  Tuberculous 
disease,  on  the  other  hand,  occurs  more  frequently  in  younger 
individuals  than  does  the  syphilitic  variety,  whilst  the  epididymis 
is  usually  first  attacked,  becoming  nodulated,  the  cord  is  early 
implicated,  hydrocele  is  rare,  suppuration  is  frequent,  and  tes- 
ticular sensation  remains  till  the  body  of  the  testis  is  disorganized. 
Tumours  always  impart  a  distinct  sense  of  weight  to  the  hand, 
quite  different  to  that  noticed  in  tuberculous  or  syphilitic  disease ; 


AFFECTIONS  OF  THE  TESTIS,  CORD,  ETC.  1163 


if  a  simple  tumour  is  present,  it  is  rounded,  slow  in  growth,  and 
the  cord  is  unaffected.  Malignant  disease  is  characterized  by 
rapid  growth,  more  severe  pain,  and  early  implication  of  the 
structures  of  the  cord  and  of  the  lumbar  lymphatic  glands.  The 
enlargement  of  both  testes  is  in  favour  of  tubercle  or  syphilis 
rather  than  of  malignant  disease.  A  certain  small  number  of 
cases  will  remain  where,  in  spite  of  every  care,  the  nature  of  the 
mass  is  still  a  matter  of  doubt ;  in  such  the  diagnosis  cannot  be 
established  without  puncture  or  an  exploratory  incision. 

Whilst  weighing  carefully  the  local  conditions,  we  must  not 
omit  to  thoroughly  investigate  and  appreciate  the  general  history 
and  condition  of  the  patient,  his  age,  appearance,  previous  habits 
and  illnesses,  etc.  At  the  same  time,  an  examination  of  the 
internal  organs  should  be  made  to  ascertain,  as  far  as  possible, 
the  existence  or  not  of  concurrent  disease,  e.g.,  tuberculous  disease 
of  the  lungs  or  kidneys,  or  secondary  malignant  deposits. 

Castration  is  required  for  many  different  conditions,  which  have 
been  already  described,  e.g.,  for  malposition,  tuberculous  disease, 
old-standing  hematoceles,  and  simple  or  malignant  tumours ;  it 
has  also  been  undertaken  for  chronic  enlargement  of  the  prostate. 
The  operation  is  conducted  as  follows  :  The  pubes  and  perineum 
having  been  previously  shaved  and  purified,  the  surgeon,  standing 
on  the  same  side  of  the  patient  as  the  organ  to  be  removed, 
makes  an  incision  down  to  the  testis.  If  large  and  adherent  to 
the  scrotal  tissues,  the  incision  must  necessarily  involve  the 
scrotum,  but  wherever  practicable  it  is  wise  to  avoid  the  scrotal 
integuments,  making  the  incision  over  the  cord.  It  should  always 
extend  upwards  as  far  as  the  external  abdominal  ring,  so  as  to 
enable  the  structures  of  the  cord  to  be  divided  high  up,  a  most 
important  matter  in  tuberculous  and  malignant  disease ;  the 
inguinal  canal  can  then  also  be  closed,  if  necessary.  The  testis 
or  tumour  is  enucleated  from  its  surroundings,  and  the  cord 
isolated  and  divided  as  high  as  possible,  after  transfixing  and 
securely  ligaturing  it  with  silk.  Some  surgeons  prefer  to  separate 
the  tissues  of  the  cord,  and  to  take  them  up  individually,  but  this 
is  a  matter  of  little  importance.  The  stump  should  not  be 
allowed  to  slip  back  into  the  canal  until  all  bleeding  has  completely 
stopped,  and  it  has  been  suggested  that  the  cut  end  of  the  vas 
should  be  touched  with  pure  carbolic  acid  as  a  precautionary 
measure.  Considerable  attention  was  formerly  directed  to  the 
condition  of  the  pulse  at  the  moment  when  the  cord  was  divided, 
and  it  was  a  regular  instruction  to  the  anaesthetist,  that  if  ether 
was  being  administered  it  should  be  pushed,  whilst  the  amount  of 
chloroform  should  be  diminished.  Such  a  distinction,  however, 
is  unnecessary,  since  it  is  now  fully  recognised  that  one  of  the 
best  means  of  preventing  shock  is  the  maintenance  of  complete 
anaesthesia,  the  medul'ary  centres  being  thereby  guarded  from  the 


1164  A  MANUAL  OF  SURGERY 


action  of  afferent  stimuli ;  consequently,  it  is  only  necessary  that 
the  patient  should  be  fully  under  the  influence  of  the  anaesthetic. 
All  bleeding  points  in  the  scrotum  are  now  secured  by  ligature, 
and  these  may  be  numerous ;  the  wound  is  closed  by  sutures,  a 
drainage-tube  being  inserted  in  the  scrotum,  and  by  choice  coming 
to  the  surface  at  the  upper  end  of  the  wound,  that  is,  as  far  from 
the  perineum  as  possible. 

In  the  performance  of  double  castration,  it  is  recommended  to 
make  two  crescentic  flaps  from  side  to  side,  so  as  to  include 
between  them  a  portion  of  the  scrotal  integument,  in  order  to 
reduce  the  subsequent  redundancy  of  unnecessary  tissue. 

Affections  of  the  Vesiculae  Seminales. 

Acute  Vesiculitis  is  not  often  met  with,  but  sometimes  arises,  in  association 
with  prostatitis,  as  a  complication  of  gonorrhoea.  It  is  characterized  by 
deep-seated  pain  in  the  perineum,  together  with  irritability  of  the  neck  of 
the  bladder  and  increasing  frequency  of  micturition.  Defalcation  becomes 
painful,  and  on  examination  of  the  rectum  the  vesiculae  can  be  felt  enlarged 
and  tender.  If  suppuration  ensues,  an  abscess  forms,  which  usually  bursts 
into  the  rectum,  but  sometimes  into  the  bladder  or  peritoneal  cavity.  As  a 
rule,  the  condition  disappears  pari  passu  with  the  gonorrhoea;  but  when  sup- 
puration has  supervened,  it  is  advisable  to  open  the  abscess  by  a  deep  incision 
through  the  perineum,  guided  by  a  finger  in  the  rectum. 

Subacute  or  Chronic  Vesiculitis  is  not  uncommon,  the  latter  condition  being 
often  associated  with  prostatitis,  and  one  of  the  most  frequent  causes  of  gleet. 
Seminal  emissions  and  priapism  may  be  caused  by  it,  and  the  enlarged  organ 
can  be  felt  through  the  rectum.  A  good  deal  of  pain,  often  referred  to  the 
back,  is  experienced.     The  treatment  is  the  same  as  for  chronic  prostatitis. 

Tuberculous  Disease  attacks  the  vesiculae  seminales  as  a  result  of  extension 
from  the  testis  along  the  vas,  being  almost  always  associated  with  similar 
disease  of  the  prostate  and  base  of  the  bladder.  The  organs  can  be  felt 
enlarged,  and  if  suppuration  occurs,  the  abscess  may  burst  into  the  rectum  or 
bladder,  or  possibly  into  both,  a  recto-vesical  fistula  being  thereby  developed. 
It  is  possible  to  reach  the  vesiculae  through  a  semilunar  incision  in  the 
perineum,  displacing  the  rectum  backwards,  and  the  bladder  and  prostate 
forwards,  or  from  behind  by  removing  the  coccyx  and  part  of  the  sacrum, 
as  in  Kraske's  operation.  When  exposed,  complete  excision  is  sometimes 
possible,  or  an  opening  is  made  into  them,  and  the  cheesy  contents  scooped 
out. 

Affections  of  the  Scrotum. 

Injuries  of  the  Scrotum. — Contusions  and  blows  give  rise  to  ecchymosis, 
which  may  be  so  extensive  as  to  warrant  the  term  hematoma  scroti  which  has 
been  applied  to  it. 

Incised  wounds  may  affect  the  skin  and  subcutaneous  tissues,  or  may  lay 
open  the  tunica  vaginalis,  with  or  without  protrusion  of  the  testicle.  All  that 
is  needed  in  such  cases  is  to  render  the  wound  aseptic,  and  to  deal  with  it  on 
general  principles.  Considerable  destruction  of  scrotal  tissue  may  be  repaired 
by  transplantation  of  flaps  from  the  inguinal  region,  or  by  grafting  according 
to  Thiersch's  method. 

Cellulitis  of  the  Scrotum  most  commonly  results  from  extravasation  of  urine, 
for  which  see  p.  1133.  It  may  occasionally  arise  from  other  causes,  but  needs 
no  special  description. 

(Edema  of  the  Scrotum  is  usually  due  to  dropsy,  being  often  associated  with 


AFFECTIONS  OF  THE   TESTIS,  CORD,  ETC. 


1165 


general  anasarca  and  ascites.  It  may  attain  considerable  dimensions.  Acute 
inflammatory  oedema  of  the  scrotum  is  a  term  sometimes  applied  to  erysipelas 
affecting  this  region,  on  account  of  the  absence  of  the  vivid  red  colour  usually 
associated  with  that  affection.  Considerable  cedema  is  always  present,  and 
gangrene  of  the  skin  may  result.  As  soon  as  the  gangrene  becomes  limited,  it 
should  be  excised,  and  the  margins  of  the  wound  brought  together  by  sutures, 
or  allowed  to  heal  by  granulation. 

Scrotal  Fistulse  are  usually  due  to  the  bursting  of  abscesses  in  connection 
with  the  urethra  (see  Perineal  Abscess). 

Sinuses  of  the  Scrotum  are  often  found  in  connection  with  tuberculous  or 
syphilitic  disease  of  the  testicle. 

Eczema  of  the    Scrotum   is  a  troublesome  affection,  giving   rise   to   great 


Fig. 


409. 


-Epithelioma  Scroti  following  Paraffin  Eczema. 
(Tillmanns.) 


pruritus  and  irritation.  It  results  from  the  presence  of  pediculi,  but  the 
more  chronic  forms  occur  amongst  workers  in  tar  and  paraffin,  and  also  in 
chimney-sweeps,  being  due  to  the  constant  irritation  of  the  corrugated  scrotal 
integument  by  dirty  clothes.  It  is  characterized  by  the  presence  of  warty 
outgrowths,  and  not  unfrequently  runs  on  to  epithelioma,  originating  the  con- 
dition known  as  chimney-sweep' s  or  paraffin  cancer  (Fig.  409).  The  usual  charac- 
teristics of  such  a  new  growth  are  present,  and  in  some  of  the  deeper  cells 
particles  of  soot  have  been  demonstrated.  The  inguinal  glands  are  usually 
involved,  but  not  till  late,  and  the  progress  of  the  case  is  slow.  The  only 
treatment  which  can  be  adopted  is  complete  removal,  the  wound  caused 
thereby  being  closed  or  allowed  to  granulate. 
For  Elephantiasis  Scroti,  see  p.  31b. 


CHAPTER  XL. 

AMPUTATIONS 

By  the  term  Amputation  is  meant  the  removal  of  some  portion  of  the  body 
which  is  injured  or  diseased  to  such  a  degree  as  to  endanger  the  patient's  life, 
or  to  preclude  any  hopes  of  its  restoration  to  a  normal,  or  even  useful,  con- 
dition. In  this  chapter  we  shall  merely  deal  with  the  operation  as  applied  to 
the  extremities,  amputations  of  organs  such  as  the  breast  and  penis  having 
been  described  elsewhere.  Necessary  limitations  of  space  force  us  to  treat  the 
subject  somewhat  briefly. 

Methods  of  Amputation. — Since  the  introduction  of  anaesthesia,  the  methods 
employed  for  the  purpose  of  removing  limbs  have  been  almost  revolutionized  ; 
there  is  now  no  necessity  to  hurry  through  the  operation,  and  hence  many 
new  proceedings,  and  these  sometimes  of  a  most  complicated  nature,  have 


Fig.  410. — Circular  Amputation  for  the  Arm, 
showing  Flap  of  Skin  turned  back,  and 
Knife  applied  for  Division  of  the  Muscles. 


Fig.  411.  —  Section  of 
Parts  after  Circular 
Amputation. 

A,  Skin  and  subcutaneous 
fat;  B,  muscles;  C.bone. 


been  devised.     They  are  in  the  main  merely  modifications  of  three  cardinal 
operations,  the  circular,  the  racquet-shaped,  and  the  flap. 

The  Circular  Amputation  (Fig.  410),  although  formerly  much  employed,  is 
now  but  little  used  ;  in  it  the  skin  and  subcutaneous  tissues  are  divided  around 
the  whole  circumference  of  the  limb  by  a  circular  sweep  of  the  knife.  These 
are  then  retracted  or  dissected  back  like  a  cuff,  and  the  superficial  muscles 
divided  in  a  similar  manner.  The  soft  parts  are  again  further  retracted,  and 
the  deeper  muscles  divided,  allowing  the  bone  to  be  cleared  and  sawn  through 
at  a  still  higher  level.  The  end  of  the  bone  is  thus  placed  at  the  apex  of  a 
conical  hollow  (Fig.  411),  and  can  be  completely  covered  over;  the  vessels, 


AMPUTATIONS 


1167 


moreover,  are  divided  transversely.  The  stump  is  not  very  shapely,  and 
after  a  time,  owing  to  the  shrinking;  of  the  soft  parts,  the  cicatrix  is  likely 
to  become  attached  to  the  bone.  The  arm  is  almost  the  only  situation  in 
which  a  pure  circular  operation  is  ever  undertaken  at  the  present  day ;  but 
a  modified  form  is  still  occasionally  utilized  else- 
where. Thus,  one  or  two  vertical  incisions  may 
be  associated  with  the  circular  cut,  in  order  to 
facilitate  the  removal  of  the  bone  at  a  higher 
level,  as  in  disarticulation  of  the  hip-joint  by 
Furneaux  Jordan's  method  (p.  1182). 

The  Racquet-shaped  Method  (Fig.  416)  is  very 
similar  to  the  last-described  modification  of  the 
circular.  In  it  an  oval  incision  is  made  around 
the  limb  with  one  end  pointed,  and  if  necessary 
prolonged  upwards  to  form,  as  it  were,  the 
handle  of  the  racquet.  This  method  is  useful 
for  removing  fingers  and  toes,  and  is  also 
employed  at  the  hip  and  shoulder  joints. 

A  somewhat  similar  operation  is  known  as 
the  Elliptical  or  Oval  Method  (Fig.  417,  A).  In 
it  an  oval  incision  is  made  around  the  limb  ;  the 
lower  or  distal  portion  is  then  dissected  up  so  as 
to  enable  the  amputation  or  disarticulation  to  be 
completed  at  a  spot  a  little  below  the  proximal 
end.  The  free  convex  border  of  the  flap  is  then 
turned  over,  and  fitted  into  the  concavity  of  the 
wound . 

The  Flap  Method  is  that  chiefly  made  use  of 
at  the  present  day  in  amputating  through  the 
shafts  of  the  long  bones.  It  was  formerly  per- 
formed by  transfixion  in  order  to  save  time ; 
but  the  bulk  of  muscles  included  in  the  flap,  and 
the  fact  that  the  vessels  and  nerves  are  often 
sliced  longitudinally,  render  this  an  undesirable 
proceeding.  Hence  it  has  been  discarded,  and 
the  flaps  are  now  usually  marked  out  super- 
ficially, and  then  raised  by  dissection .  As  a  rule, 
they  consist  merely  of  skin,  subcutaneous  tissue 
and  deep  fascia,  a  little  muscle  being  perhaps 
included  towards  the  base. 

The  best  method  of  amputating  in  muscular 
parts,  such  as  the  thigh,  is  that  known  as  the 
Modified  Flap  and  Circular  (Fig.  412),  which  was 
originally  suggested  by  Lord  Lister.  In  this  two 
rectangular  flaps  with  the  corners  rounded  off 
are  raised  on  opposite  sides  of  the  limb,  the 
length  of  the  anterior  being  two-thirds  of  the 
diameter  of  the  limb  at  the  point  at  which  it  is 
proposed  to  divide  the  bone,  and  the  posterior 
flap  half  the  length  of  the  anterior.  These,  consisting  merely  of  skin  and  sub- 
cutaneous tissues,  are  dissected  up  ;  the  muscles  are  then  divided  circularly, 
being  retracted  for  another  half-diameter.  The  advantages  of  the  flap  and 
circular  methods  are  thus  combined.  In  cutting  the  flaps  it  is  most  essential 
that  they  should  not  taper,  but  should  remain  the  same  breadth  throughout, 
the  corners  being  merely  rounded  off. 

General  Remarks  on  Amputations. 

Certain  important  details  must  always  be  attended  to  by  the  operator  when 
selecting  an  amputation  suitable  for  any  particular  case. 


Fig.  412. — Lister's  Modi- 
fied Flap  and  Circular 
Amputation. 

The  continuous  dark  line  in- 
dicates the  outline  of  the 
anterior  flap  ;  the  dotted 
line,  the  lower  end  of  the 
posterior  flap  ;  the  line  of 
section  and  retraction  of 
the  muscles  is  represented 
as  an  interrupted  line. 


n68 


A  MANUAL  OF  SURGERY 


k 


1.  A  Sufficient  Covering  is  necessary,  in  order  to  protect  the  end  of  the 
bone  from  injurious  pressure.  Ii  the  skin  were  not  contractile,  and  if  the 
muscles  did  not  retract,  it  would  suffice  to  provide  two  flaps,  each  equal 
to  half  the  diameter  of  the  limb  at  the  point  of  section  of  the  bone  ;  but 
owing  to  the  contractility  and  retraction  of  living  tissues,  it  is  essential  to 
allow  at  least  a  diameter  and  a  half,  and  sometimes  two  diameters ;  in 
non-muscular  parts  the  former  may  suffice,  but  in  fleshy  parts,  especially 
when  amputating  low  down  in  the  thigh,  where  the  range  of  muscular 
contraction  is  much    greater,   the   latter.      It   is   usually   a   matter  of  some 

significance  whence  the  flaps  are  derived  ;  thus, 
a  single  flap,  e.g.,  a  long  anterior  or  posterior, 
is  not  to  be  recommended  owing  to  the  difficulty 
of  maintaining  its  nutrition.  Equal  flaps  are 
used  in  parts  like  the  arm,  where  the  end 
of  the  stump  will  not  be  exposed  to  pressure. 
Generally,  however,  the  anterior  flap  is  cut  longer 
than  the  posterior,  as  in  the  case  of  the  modified 
flap  and  circular,  or  sometimes  vice  versa;  in  the 
former,  owing  to  the  additional  retraction  of  the 
muscles,  a  covering  equal  to  two  diameters  of 
the  limb  is  provided,  leale's  amputation  (Fig.  413) 
consists  in  raising  a  long  square  anterior  flap, 
equal  in  breadth  and  length  to  half  the  circum- 
ference of  the  limb  at  the  point  of  section  of  the 
bone,  and  including  everything  down  to  the 
bone.  The  posterior  flap  is  similar  in  nature  to 
the  anterior,  but  only  a  quarter  of  its  length. 
The  free  end  of  the  anterior  flap  is  doubled 
over,  and  accurately  stitched  to  the  posterior. 
The  advantages  claimed  for  this  operation  are 
that  the  vessels  are  cut  long,  and  thus  the 
nutrition  of  the  flaps 
secured,  whilst  a 
covering  nearly  equal 
to  two  diameters  of 
the  limb  is  provided. 
The  great  objection 
to  the  method  con- 
sists in  the  amount 
of  the  limb  which 
has  to  be  sacrificed 
on  account  of  the 
length  of  the  anterior 
flap,  and  hence  it 
is  rarely  employed. 
Occasionally  the  covering  is  derived  from  the  sides  of  the  limb  (amputation 
by  lateral  flaps). 

2.  The  Cicatrix  should  be  situated  away  from  the  end  of  the  bone,  especially 
in  the  lower  extremity,  where  the  weight  of  the  body  has  to  rest  upon  the 
stump. 

3.  A  Dependent  Opening  is  desirable  for  purposes  of  drainage,  and  to 
ensure  this  the  anterior  flap  is  often  made  longer  than  the  posterior.  This, 
however,  is  not  such  an  important  matter  since  the  introduction  of  antiseptic 
methods. 

4.  All  these  objects  should  be  attained  with  as  little  sacrifice  of  the  limb  as 
possible,  since  the  higher  the  operation,  the  greater  the  shock  to  the  patient. 

As  to  the  operation  itself,  the  greatest  care  must  be  taken  to  maintain 
Asepsis,  since  muscular  and  fascial  planes  have  been  freely  opened,  and 
possibly  the  medullary  cavity  of  the  bone   exposed;  the   dangers  of  septic, 


Fig. 


413. — Teale's  Amputation.     (Treves' 
'  Operative  Surgery.') 


AMPUTATIONS  u$g 


absorption  under  such  circumstances  are  obvious.  Haemorrhage  is  prevented 
by  previous  exsanguination  of  the  limb  by  elevating  it  for  two  or  three  minutes, 
and  then  applying  an  elastic  tourniquet.  In  the  leg  a  piece  of  rubber  tubing 
may  be  employed,  Samway's  tourniquet  being  perhaps  the  best.  In  the  arm, 
however,  the  subcutaneous  position  qf  the  principal  nerves  leaves  them  much 
exposed,  and  paralytic  symptoms  have  followed  the  use  of  such  appliances, 
especially  when  made  of  solid  rubber  ;  a  fiat  elastic  bandage  carried  several 
times  around  the  limb,  and  secured  by  a  knot  or  with  a  safety  pin,  is  all  that  is 
needed.  Should  the  tourniquet  have  to  be  applied  close  to  the  area  of  opera- 
tion, it  must,  of  course,  be  soaked  in  carbolic  or  sublimate  lotion  ;  it  is  then 
advisable  to  protect  the  skin  over  which  it  is  placed  by  a  few  layers  of  gauze, 
so  as  to  prevent  blistering.  After  the  limb  has  been  removed,  the  main  vessels 
are  at  once  ligatured,  both  artery  and  vein  being  separately  tied.  It  is  well  to 
isolate  and  draw  them  down  for  a  little  distance,  so  as  to  make  sure  that  they 
have  not  been  buttonholed.  Any  other  vessels  which  can  be  seen  are  tied 
before  the  tourniquet  is  removed.  An  assistant  should  for  a  time  be  ready  to 
control  the  main  trunk  after  releasing  it  from  the  tourniquet.  In  some  cases 
it  may  be  impracticable  or  undesirable  to  apply  a  tourniquet,  and  then  the 
main  vessels  may  be  temporarily  controlled  by  digital  compression  at  some 
suitable  spot  whilst  the  amputation  is  completed.  Any  bleeding-points  are 
rapidly  secured  by  pressure  forceps,  and  subsequently  tied,  and  the  main 
trunks  isolated,  and  clamped  or  ligatured  before  division. 

For  special  methods  of  controlling  the  haemorrhage  in  amputation  through 
the  hip-joint,  see  p.  1181. 

We  have  already  drawn  attention  to  the  necessity  of  not  tapering  the  flaps, 
but  of  cutting  them  square,  the  corners  alone  being  rounded.  In  dissecting 
them  up,  the  deep  fascia  should  be  included  with  the  flap,  and  the  blade  of 
the  knife  always  turned  towards  the  part  which  is  to  be  removed,  so  that  the 
under  surface  of  the  flap,  and  with  it  the  nutrient  vessels,  shall  not  be  scored. 
Whilst  dividing  the  muscles  the  flaps  must  be  carefully  guarded  by  the  hands 
of  assistants.  Before  sawing  the  bone,  it  is  recommended  that  the  periosteum 
should  be  retracted  for  some  distance,  so  as  to  more  efficiently  provide  for  its 
nutrition ;  this  plan  should  certainly  be  adopted  for  the  humerus  and  femur. 
Any  irregular  bony  spicules  left  after  sawing  should  be  trimmed  off  with 
cutting  pliers.  Attention  must  next  be  directed  to  the  main  nerves  and  to 
any  tendons  which  lie  exposed  in  the  wound,  all  such  structures  being  cut  short, 
the  nerves  as  high  as  possible.  The  wound  is  usually  closed  by  a  continuous 
suture,  but  one  or  two  deep  stitches  should  also  be  inserted  to  draw  the 
muscles  together,  and  provision  made  for  drainage  from  one  of  the  angles  of 
the  incision.  The  dressing  is  applied  in  such  a  way  as  to  draw  the  flaps  down 
over  the  end  of  the  bone,  and  a  splint  is  often  necessary  in  order  to  control 
the  upper  ends  of  the  divided  muscles  and  to  keep  them  at  rest. 

The  chief  Complications  likely  to  arise  in  the  subsequent  course  of  the  case 
are  shock,  reactionary  haemorrhage,  and  those  which  result  from  sepsis;  these 
conditions  and  their  treatment  have  been  described  elsewhere. 

In  a  Healthy  Stump  the  end  of  the  bone  is  rounded,  and  the  medullary 
cavity  closed  by  a  layer  of  compact  tissue.  The  divided  muscles  and  tendons 
are  either  incorporated  in  the  cicatrix,  or  gain  fresh  adhesions  to  the  bones. 
The  vessels  are  obliterated  as  far  as  the  next  patent  branches,  whilst  the  nerve- 
ends  usually  become  bulbous  (Fig.  83,  p.  327),  but,  if  suitably  shortened,  do 
not  adhere  either  to  the  end  of  the  bone  or  to  the  cicatrix,  and  hence  give  rise 
to  no  trouble.  A  sufficient  covering  of  non-adherent  skin  and  subcutaneous 
tissue  should  form  a  pad  for  the  protection  of  the  bones. 

Affections  of  Stumps. — (a)  Necrosis  of  the  end  of  the  bone  is  sometimes  the 
result  of. carelessness  on  the  part  of  assistants,  who  can  readily. denude  it  of 
its  periosteum  by  rough  sponging,  etc.  ;  it  rarely  follows  if  the  periosteum  has 
been  first  retracted  before  the  bone  is  divided,  and  practically  never  apart  from 
sepsis.  A  small  annular  sequestrum  is  usually  all  that  separates,  but  should 
the  inflammation  spread  up  the  medullary  cavity  (septic  osteomyelitis),  a  more 

74 


1 170 


A  MANUAL  OF  SURGERY 


extensive  destruction  of  bone  tissue  follows  (for  symptoms  and  treatment  of 
which  see  p.  509).  (b)  Sloughing  of  the  ends  of  the  flaps  occurs  in  debilitated 
individuals,  especially  if  thin  skin  flaps  have  been  employed,  or  if  their  nutri- 
tion has  been  impaired  by  trauma,  or  if  unhealthy  tissue  has  been  incorporated 
in  their  substance  by  amputating  too  close  to  the  seat  of  disease  or  injury. 
The  process  is  usually  limited  in  extent,  and  rarely  calls  for  treatment  other 
than  keeping  the  part  dry  and  aseptic,  the  slough  being  then  slowly  absorbed  ; 
if  sepsis  is  present,  the  consequences  may  be  very  serious,  even  necessitating 
re-amputation  at  a  higher  level,  (c)  A  conical  stump  results  either  from  the 
flaps  being  cut  too  short,  or  from  the  parts  shrinking  as  a  result  of  septic  in- 
flammation ,  or  in  young  people  from  continued  growth  of  the  upper  epiphyseal 
cartilage  of  the  divided  bone.  In  bad  cases  the  bone  may  even  project 
through  the  integument,  and  necrose  ;  re-amputation  is  the  only  treatment. 
(d)  A  painful  stump  is  usually  due  to  the  adhesion  of  a  bulbous  nerve-end  to 
the  cicatrix  or  bone,  so  that  it  is  dragged  upon  at  each  movement  of  the  limb. 
The  pain  is  of  a  severe  neuralgic  nature,  and  is  treated  by  excising  the  bulb, 
or  re-amputation,  (e)  A  spasmodic  stump  sometimes  occurs,  being  due  either  to 
irritation  of  the  enlarged  nerve-ends,  or  to  some  central  cause.  In  the  former 
instance,  excision  of  the  bulbs  or  re-amputation  will  cure  the  case  ;  in  the 
latter,  the  trouble  will  persist  in  spite  of  treatment,  affecting  fresh  groups  of 
muscles  after  re-amputation. 

Special  Amputations. 

Amputation  of  the  Fingers  is  frequently  required  after  machine  accidents 
and  similar  injuries,  or  in  necrosis  following  a  whitlow  ;  in  these  cases  it  is 


Fig.  414. — Incisions  for  Amputa- 
tion of  Terminal  Phalanx  of 
Finger.     (Tillmanns.) 


Fig.  415. — Amputation  of  Finger  at 
metacarpophalangeal  articu- 
LATION, showing  Divided  Tendons 
and  Ligatured  Vessels.     (Till- 
manns.) 
often  impossible  to  follow  any  regular  routine,  the  flaps  being  obtained  from 
any  portion  of  sound  tissue  present.     The  following,  however,  are  the  chief 
plans  adopted  : 

Amputation  of  the  Terminal  Phalanx  is  usually  conducted  by  opening  the 
joint  on  the  dorsal  aspect,  and  cutting  a  palmar  flap  from  the  pulp  of  the  finger 
(Fig.  415). 

No  useful  result  follows  amputation  through  the  first  inter-phalangeal 
articulation,  since  the  portion  left  is  practically  fixed  and  useless,  no  tendons 
being  inserted  to  govern  it.  An  operation  which  is  sometimes  advantageous 
consists  in  amputating  through  the  middle  of  the  second  phalanx,  so  as  to  leave 
the  insertion  of  the  flexor  sublimis  tendon,  the  flaps  for  such  an  operation  being 
derived  from  am-  ^art  of  the  finger,  and  the  bone  divided  by  cutting  pliers. 


AMPUTATIONS 


1171 


Removal  of  a  finger  at  the  Metacarpophalangeal  Joint  (Fig.  415)  is  an 
operation  frequently  necessary.  It  is  best  conducted  by  means  of  a  racquet- 
shaped  incision  (Fig.  416,  A),  which  starts  over  the  knuckle,  extends  between 
it  and  the  next  finger,  curves  round  to  the  palmar  aspect  so  as  to  be  placed  a 
little  below  the  crease  in  the  skin  at  the  root  of  the  finger  (Fig.  417,  C),  and 
returns  in  the  same  way  to  the  back  of  the  knuckle.  This  incision  can  be  made 
with  one  sweep  of  the  knife,  but  there  is  no  real  advantage  in  such  a  pro- 
cedure. The  articulation  is  then  opened  from  behind,  and  is  found  further 
forwards  than  one  would  at  first  expect ;  the  structures  on  either  side  are  then 
successively  divided,  making  them  tense  by  rotation  of  the  finger,  and  the 
flexor  tendons  finally  cut  across.  Bleeding-points  (usually  one  on  each  side) 
are  secured,  and  the  wound  closed. 

The  question  of  removing  the  head  of  the  matacarpal  bone  is  one  which 

must  be  decided  by  the  occupation  of 
the  patient ;  if  he  is  a  working  man,  or 
needs  strength  of  hand,  it  should  be 
left,  as  its  removal  always  causes  weak- 
ness. In  ladies  and  those  where  small- 
ness  and  elegance  of  the  hand  are 
required  rather  than  strength,  it  can 
be  taken  away  by  slightly  prolonging 
the  incision  upwards,  clearing  the  bone 
on  either  side,  and  applying  cutting 
pliers.  The  gap  between  the  adjoining 
fingers  can  in  this  way  be  almost  ob- 
literated. It  is  especially  advisable  to 
do  this  in  the  case  of  the  index-finger, 
since  the  head  of  the  second  metacarpal 
bone  forms  an  unsightly  projection, 
and  is  very  exposed  to  injury.  For 
this  finger,  Faraboeuf's  method  (Fig. 
416,  B)  is  often  used  (p.  1174). 

Occasionally  the  four  fingers  and 
their  attached  metacarpal  bones  have 
to  be  removed  en  bloc.  Short  equal 
flaps  may  then  be  cut  from  the  front 
and  back  of  the  hand,  and  the  dis- 
articulation effected.  The  stump  that 
remains,  although  consisting  merely  of 
the  carpus  and  thumb,  is  very  service- 
able. 

Amputation  of  the  Thumb  should 
never  be  undertaken  unless  absolutely 
necessary,  since  its  removal  seriously  impairs  the  functional  utility  of  the 
hand;  as' large  a  portion  must  be  saved  as  practicable,  so  so  to  assist  the 
patient  in  grasping.  The  phalanges  may  be  removed  by  any  method  which 
enables  the  bone  to  be  covered  with  the  least  possible  sacrifice. 

When  it  is  also  necessary  to  take  away  the  metacarpal  bone,  one  of  the  two 
following  plans  should  be  adopted  :  . 

1  The  racquet  method  (Fig.  416,  C) .  In  this  an  incision  commences  in  the  inter- 
tendinous  hollow  known  as  the  tabatfere,  and  extends  along  the  dorsum  of  the 
thumb  to  the  head  of  the  metacarpal  bone,  the  oval  portion  sweeping  round  it 
at  the  level  of  the  web  when  the  thumb  is  abducted,  and  on  the  palmar  aspect 
corresponding  to  the  oblique  crease  at  its  root.  The  remainder  of  the  operation 
resembles  that  for  removal  of  a  finger.  Care  must  be  taken  not  to  wound  the 
trunk  of  the  radial  artery  as  it  passes  through  the  base  of  the  interosseous 
space  •  the  blade  of  the  knife  is  therefore  kept  closely  applied  to  the  bone. 

2  By  apahnarflap.  In  this  the  knife  is  first  carried  across  the  dorsal  aspect 
of  the  thumb  f-om  the  centre  of  the  web  between  it  and  the  index-finger,  to  a 


Fig.  416. — A,  incision  for  amputation 
of  finger  by  racquet  method ;  B,- 
Faraboeuf's  method  of  amputation, 
as  applied  for  index-finger;  C, 
racquet-shaped  incision  for  disarti- 
culation of  thumb  at  carpo-meta- 
carpal  joint. 


1 172 


A  MANUAL  OF  SURGERY 


point  on  the  palmar  surface  of  the  wrist  just  above  the  thenar  eminence.  The 
knife  is  then  rotated  so  that  its  cutting-edge  looks  outwards,  and  inserted 
deeply  through  the  ball  of  the  thumb,  transfixing  it,  so  as  to  emerge  at  the 
same  spot  in  the  centre  of  the  web  as  th.at  at  which  the  incision  commenced 
A  muscular  flap  with  a  well-rounded  border  is  readily  fashioned  by  cutting 
outwards.  The  remaining  soft  parts  are  then  divided,  and  disarticulation 
completed  by  opening  the  joint.  It  is  a  prettier  and  more  showy  operation 
than  the  former,  but  otherwise  has  no  advantages. 

Amputation  through  the  Wrist-Joint  is  seldom  performed  except  for  injuries, 
and  then  the  flaps  must  be  derived  as  best  they  can  from  healthy  tissues.  Three 
chief  methods  are,  however,  described  :  (a)  In  the  elliptical  (Fig.  417,  A),  the 
incision  takes  the  form  of  an  ellipse, 
the  highest  point  being  on  the  dorsum 
\  inch  below  the  level  of  the  wrist- 
joint,  and  the  lowest  in  the  centre  of  the 
palm  2  inches  below  the  former.  On 
the  ulnar  side,  the  incision  passes  be- 
tween the  pisiform  bone  and  the  base 
of  the  fifth  metacarpal,  whilst  on  the 
radial  side  it  crosses  the  carpo-meta- 
carpal  articulation.  After  dividing  the 
cellular  tissue,  and  dissecting  up  the 
palmar  flap,  the  joint  is  opened  from 
the  posterior  aspect,  and  the  disarticu- 
lation completed.  The  convex  end  of 
the  palmar  flap  is  fitted  into  the  con- 
cavity of  the  dorsum,  and  the  cicatrix 
thus  forms  a  curved  line  on  the  back 
of  the  stump,  (b)  A  long  palmar  flap 
(Fig.  417,  B)  is  sometimes  utilized,  ex- 
tending from  just  below  either  styloid 
process  down  to  about  the  middle  of 
the  metacarpal  bones,  the  sides  of  this 
flap  being  parallel  to  each  other.  The 
dorsal  incision  crosses  the  carpus  hori- 
zontally between  the  two  extremities 
of  the  former  wound.  Thepalmarflap  FlG-  4*7-— A  (thick  lines),  Amputa- 
is  then  dissected  up  so  as  to  include        tion     ^^g?1.    wrist    .by    elliptical 


method;  B  (thin  lines),  amputation 
through  wrist  by  single  palmar  flap 
— the  dotted  lines  in  each  represent 
the  dorsal  incisions  ;  C,  situation  of 
palmar  incision  (a  little  below  the 
web)  in  amputation  of  finger. 


only  skin  and  subcutaneous  tissue,  with 
perhaps  a  little  muscular  tissue  from 
the  thenar  and  hypothenar  eminences. 
The  wrist-joint  is  opened  from  the 
dorsum ,  and  the  amputation  completed 
by  the  division  of  the  flexor  tendons. 
(c)  In  a  few  cases,  amputation  by  an 
external  flap  (Fig.  418)  may  be  desirable  (Dubreuil's  method).  The  incision 
commences  at  the  junction  of  the  middle  and  outer  thirds  of  the  back  of  the 
wrist,  reaches  down  to  the  head  of  the  metacarpal  bone  of  the  thumb,  termi- 
nating at  a  point  in  the  palm  immediately  opposite  its  commencement.  This 
flap  is  dissected  up,  and  should  contain  a  certain  amount  of  muscular  substance 
from  the  thenar  eminence.  The  skin  and  subcutaneous  tissues  on  the  ulnar 
aspect  are  now  divided  by  a  circular  sweep  of  the  knife  around  the  inner  side 
of  the  limb.  Disarticulation  follows,  and  the  external  flap  is  carried  inwards, 
and  sutured  so  as  to  close  the  wound. 

Amputation  through  the  Forearm  is  usually  conducted  by  means  of  a  flap 
operation,  the  flaps  being  either  equal  in  length  or  one  a  little  longer  than  the 
other.  The  muscles  are  divided  circularly,  and  the  bones  should  be  thoroughly 
cleared  before  division. 

Disarticulation  at  the  Elbow-Joint  is  an  operation  very  rarely  seen,  and  is 
either  undertaken  by  the  elliptical  method  or  with  a  long  anterior  flap. 


AMPUTATIONS 


"73 


Amputation  through  the  Arm  may  be  carried  out  by  any  of  the  methods 
described,  e.g.,  the  flap,  circular,  or  modified  flap  and  circular,  the  choice  in 
any  particular  instance  being  determined  by  the  requirements  of  the  case. 

Disarticulation  at  the  Shoulder-Joint. — Three  chief  methods  are  practised 
for  the  performance  of  this  operation,  viz.,  Spence's  and  Larrey's,  or  that  by 
means  of  an  external  or  deltoid  flap.  In  all,  the  third  part  of  the  subclavian 
artery  may  be  controlled  by  digital  compression,  the  surgeon  endeavouring  to 
leave  the  division  of  the  main  vessels  until  the  last  stage  of  the  proceedings  ; 
but  it  is  perhaps  better  to  clamp  all  the  smaller  vessels  as  soon  as  they  are 
cut,  and  to  isolate  and  tie  the  main  trunks  before  their  division. 

(a)  Spence's  operation  (Fig.  419)- — A  preliminary  incision  similar  to  that  for 
excision  of  the  shoulder  is  first  made,  extending  downwards  and  outwards 
through  the  fibres  of  the  deltoid,  from  a  point  midway  between  the  coracoid 
and  acromion  processes.  This  passes  directly  down  to  the  bone,  and,  if  neces- 
sary, the  joint  is  at  once  opened  and  examined  prior  to  any  further  steps  being 
taken.     The  surgeon,  standing  on  the  outer  side  of  the  limb,  then  carries  his 


Fig.  418. — Amputation  through 
Wrist  by  Dubreuil's  Method.       „ 

(tlllmanns  >  ■+i9" s^ence  s  amputation  at  the 

''  Shoulder    by    Anterior    Racquet. 

(Treves'  'Operative  Surgery.') 

knife  from  the  lower  part  of  the  incision  downwards  and  inwards  across  the 
axillary  folds  around  the  limb  to  the  point  from  which  it  first  started,  thus 
making  the  incision  racquet-shaped.  The  skin  is  first  dissected  up  all  round 
for  an  inch  or  so,  and  then  the  muscles  on  the  inner  side,  the  deltoid  in  part, 
the  pectoralis  major,  the  coraco-brachialis  and  biceps,  are  divided  on  the 
slant,  thereby  exposing  the  main  vessels  and  nerves.  The  vessels  may  now 
be  secured  and  divided,  and  the  nerves  isolated,  pulled  down  and  cut  short, 
or  they  may  be  left  intact  for  a  time.  The  soft  structures  on  the  outer  side  of 
the  vertical  incision  are  next  separated  from  the  bone,  and  then  the  outer  half 
of  the  capsule,  together  with  the  muscles  inserted  into  the  greater  tuberosity 
of  the  humerus,  and  the  long  tendon  of  the  biceps,  are  divided.  The  inner 
half  of  the  capsule  and  the  subscapularis  are  then  divided  from  the  bone  so  as 
to  free  the  head.  By  retracting  the  external  flap  and  protruding  the  head 
of  the  bone  from  its  socket,  the  remainder  of  the  capsule  can  be  severed,  and 
then  the  knife,  travelling  downwards  between  the  humerus  and  the  axillary 
vessels,  is  made  to  cut  its  way  out,  thus  completing  the  disarticulation,  the 
vessels  and  nerves,  if  not  already  dealt  with,  being  divided  as  the  last  step  in 
the  proceeding.  If  the  knife  is  kept  close  to  the  bone,  the  trunk  of  the  posterior 
circumflex  artery  is  not  interfered  with. 

(b)  Larrey's  operation  (Fig.  420)  is  very  similar  to  the  above,  except  that  the 
vertical  incision  is  made  on  the  outer  aspect  of  the  joint,  reaching  downwards 
from  the  prominence  of  the  acromion  for  a  distance  of  about  6  inches,  the  oval 
portion  starting  from  its  centre,  and  being  directed  obliquely  downwards  and 


"74 


A   MANUAL  OF  SURGERY 


inwards.  The  tissues  are  reflected  on  either  side  of  the  humerus ;  the  joint 
is  opened  by  a  transverse  cut  over  the  great  tuberosity,  which  also  divides  the 
muscles  inserted  into  it.  The  knife  is  finally  carried  down  on  the  inner  side  oi 
the  humerus  so  as  to  sever  the  vessels  last,  if  considered  desirable. 

(c)  Amputation  by  the  external  or  deltoid  flap  is  but  little  practised  at  the 
present  time.  The  flap  is  either  cut  by  transfixion,  or  dissected  up.  It  is 
U-shaped,  its  base  extending  from  the  coracoid  process  in  front  to  the  root  of 
the  acromion  behind.  A  skin  incision  is  now  made  across  the  inner  aspect  of 
the  limb,  joining  the  ends  of  the  former  incision,  and  extending  about  2  inches 
below  the  axilla.  Disarticulation  is  then 
carried  out  in  the  same  way  as  in  the 
previous  methods. 

Occasionally  it  is  necessary  to  remove  the 
whole  of  the  upper  limb  together  with  the 
scapula  and  outer  third  of  the  clavicle,  for 
new  growths,  usually  of  a  sarcomatous  nature, 
or  for  injury.  This  so-called  Interscapulo- 
thoracic  Amputation  is  best  performed  ac- 
cording to  Berger's  method.  An  incision  is 
made  along  the  middle  third  of  the  clavicle, 
and  this  portion  of  bone  is  then  removed  so 
as  to  enable  the  surgeon  to  divide  between 
ligatures  the  subclavian  artery  and  vein  on 
a  level  with  the  lower  border  of  the  first 
rib.  The  anterior  flap  is  then  formed  by 
an  incision  reaching  from  the  centre  of  the 
former  and  extending  downwards  and  out- 
wards over  the  shoulder,  across  the  anterior 
fold  of  the  axilla,  and  as  far  as  the  lower 
angle  of  the  scapula.  The  pectorales  major 
and  minor  are  divided  along  this  line,  thereby 
exposing  the  brachial  plexus,  the  constituent 
nerves  of  which  are  severed  on  a  level  with 
the  section  of  the  vessels.  The  axillary 
space  can  now  be  opened  up  along  the  outer 

surface  of  the  serratus  magnus.  The  limb  is  then  rotated  inwards  and  adducted 
across  the  trunk,  and  the  patient  drawn  well  to  the  edge  of  the  table  so  as  to 
enable  the  posterior  incision,  which  unites  the  outer  ends  of  the  two  former, 
to  be  made.  The  flap  thus  marked  out  is  dissected  up,  and  the  different 
muscles  retaining  the  scapula  in  connection  with  the  body  are  divided  one 
after  the  other,  including  the  trapezius,  omo-hyoid,  levator  anguli  scapulae, 
rhomboids,  and  serratus  magnus.  These  may  be  incised  as  near  to  the  bone 
as  is  thought  compatible  with  the  total  removal  of  the  growth.  Any  remaining 
fibres  are  cut  across,  and  the  limb  is  thus  detached.  In  cases  of  new  growth 
there  may  be  a  large  number  of  vessels,  both  arteries  and  veins  requiring 
ligature  ;  but  in  a  healthy  limb  removed  for  injury,  none  but  the  posterior 
scapular  and  supra-scapular  will  give  any  trouble.  Naturally,  such  an  opera- 
tion is  accompanied  by  some  amount  of  shock,  but  the  results  hitherto 
obtained  have  been  very  gratifying. 

Amputations  of  the  Lower  Extremity. 

Amputation  of  the  Toes  at  the  metatarso-phalangeal  articulations  is  precisely 
similar  to  the  analogous  operation  on  the  fingers.  It  must  be  remembered 
that  the  joint  Jies  as  far  behind  the  web  as  the  apex  of  the  toe  is  in  front  of  it, 
and  hence  the  incision  must  start  farther  back  than  might  be  expected. 

For  the  removal  of  the  great  toe  from  the  metatarsal  bone,  Farabceufs  opera- 
tion is  the  best.  The  incision  (Fig.  421)  commences  over  the  head  of  the  latter 
bone,  and  well  to  the  inner  side  of  the  extensor  tendon  ;  it  extends  downwards 
nearly  as  far  as  the  interphalangeal  articulation,  and  then  crosses  the  plantar 


Fig.  420.  —  Larrey's  Ampu- 
tation THROUGH  THE 
Shoulder  Joint  by  Ex- 
ternal Racquet.  (Treves' 
'  Operative  Surgery.') 


AMPUTATIONS 


"75 


surface  of  the  toe  so  as  to  reach  the  centre  of  the  web  between  it  and  the 
second  toe  ;  thence  the  knife  is  carried  straight  back  to  the  commencement  of 
the  incision.  These  cuts  are  deepened,  the  tendons  divided,  the  joint  opened, 
and  the  toe  removed.  It  will  then  be  found  that  an  internal  flap  remains, 
which  can  be  brought  across  the  head  of  the  metatarsal  bone,  and  covers  it  in 
so  that  the  L-shaped  cicatrix  is  not  exposed  to  pressure. 

Amputation  of  the  great  toe  at  the  tarso-metatarsal  articulation  is  conducted 
either  by  a  racquet-shaped  incision,  or  by  dissecting  up  a  flap  from  the  inner 
side.  It  is  a  bad  operation,  leaving  a  terribly  mutilated  foot,  and  should,  if 
possible,  never  be  undertaken. 

Amputation  of  the  foot  at  the  Tarsometatarsal  Articulation  is  performed 
either  by  Lisfranc's  or  Hey  s  operation. 

Lisfranc's  amputation  (Fig.  422)  consists  really  of  a  disarticulation,  no  bone 


Fig.  421. — Farabceuf's  Ampu- 
tation of  the  Great  Toe. 
(Treves'  '  Operative  Sur- 
gery.') 


Fig.  422. — Incisions  for  Lisfranc's  Ampu- 
tation.    (Treves'  'Operative  Surgery.') 

being  sawn  across.  The  patient  lies  on  the  back  with  the  foot  elevated,  and 
extending  beyond  the  end  of  the  table.  On  the  right  foot  a  slightly  convex 
dorsal  incision  extending  down  to  the  bones  is  made  from  the  tip  of  the  fifth 
metatarsal  bone  on  the  outer  side  to  the  base  of  the  first  on  the  inner.  The 
plantar  flap  is  then  marked  out,  reaching  from  the  terminations  of  the  former 
incision  forwards  as  far  as  the  roots  of  the  toes,  and  being  necessarily  longer 
on  the  inner  than  the  outer  side.  On  the  left  foot  the  incisions  are  made  in 
the  opposite  direction.  This  latter  flap  is  dissected  up,  the  toes  being  fully 
extended  by  an  assistant ;  only  the  skin  and  subcutaneous  tissues  are  raised 
for  the  first  inch,  but  further  back  all  the  structures  in  the  sole  of  the  foot  are 
included.  The  appearance  of  the  peroneus  longus  tendon  will  indicate  that 
the  dissection  has  been  carried  back  far  enough.  Disarticulation  is  now  per- 
formed from  the  dorsal  aspect,  the  line  of  the  joints  (Fig.  423)  being  kept  in 
mind.  The  knife  is  entered  behind  the  spur  of  the  fifth  metatarsal  bone,  and  is 
at  first  directed  forwards  and  inwards  towards  the  head  of  the  first  metatarsal 
bone.     The  line  of  the  articulation  is  then  followed  as  far  as  the  base  of  the 


1 1 7^ 


A   MANUAL  OF  SURGERY 


X-CHOPART. 


LIS  F  RAK'G 


second  metatarsal,  which  projects  backwards  between  the  internal  and  ex- 
ternal cuneiform  bones.  The  joint  between  the  first  metatarsal  and  the  in- 
ternal cuneiform  is  now  opened  transversely  on  the  inner  side,  and  the  dorsal 
ligament  between  the  second  metatarsal  and  the  middle  cuneiform  divided. 
The  strong  interosseous  ligament  passing  between  the  internal  cuneiform  and 
the  base  of  the  second  metatarsal  is  next  severed  by  inserting  the  point  of  a 
knife  downwards  between  the   first  and   the  second  metatarsal  bones,  and 

cutting  backwards  towards  the  ankle,  ele- 
vating the  handle  of  the  knife  in  order  to 
do  so.  By  grasping  the  toes  in  the  left 
hand,  and  forcibly  depressing  them,  the 
remaining  ligaments  on  the  dorsal  aspect 
are  divided,  and  the  disarticulation  can 
then  be  completed. 

The  plantar  flap  is  sometimes  formed 
as  the  last  stage  of  the  operation,  having 
merely  been  mapped  out  in  the  first 
instance.  In  such  a  case  the  dorsal  in- 
cision is  first  made,  the  metatarsus  dis- 
articulated, and  the  plantar  flap  cut  from 
within  outwards. 

Hey's  operation  is  essentially  similar  to 
the  above,  with  the  exception  that  the 
projection  of  the  internal  cuneiform  is 
sawn  across  (Fig.  423),  leaving  a  more 
even  surface  of  bone.  It  is  certainly  to 
be  preferred  to  a  simple  disarticulation. 
Skey  advised  that  the  three  outer  joints 
should  be  opened  as  above,  and  that  then 
the  saw  should  be  applied  so  as  to  leave 
in  its  mortice  the  base  of  the  second  meta- 
tarsal, whilst  the  projection  of  the  internal 
cuneiform  is  removed. 

Amputation  at  the  Mid -tarsal  Joint 
(Choparf  s  amputation,  Fig.  423)  is  conducted 
in  a  very  similar  manner  to  Lisfranc's.  A 
plantar  flap  with  convex  end  is  marked 
out,  reaching  on  the  inner  side  of  the 
foot  from  a  point  immediately  behind  the 
tubercle  of  the  scaphoid  forwards  to  within  1  inch  of  the  root  of  the  toes,  and 
terminating  on  the  outer  side  on  a  level  with  the  calcaneo-cuboid  articulation, 
i.e.,  midway  between  an  external  malleolus  and  the  spur  of  the  fifth  metatarsal. 
It  should  be  1  inch  longer  on  the  inner  than  on  the  outer  side.  This  plantar 
flap  is  first  dissected  up,  including  everything  down  to  the  bones,  and  then  a 
dorsal  incision  is  made  with  a  slightly  convex  border.  The  joints  between  the 
astragalus  and  scaphoid  on  the  inner  side,  and  between  the  os  calcis  and 
cuboid  on  the  outer,  are  opened  from  above.  Disarticulation  is  completed  by 
a  few  touches  of  the  knife,  and  after  all  haemorrhage  has  been  arrested,  the 
plantar  flap  is  drawn  up,  and  united  by  sutures  to  the  dorsal.  Some  surgeons 
prefer  to  fashion  the  plantar  flap  after  opening  the  joints  from  the  dorsum. 

Chopart's  amputation  is  not,  on  the  whole,  a  very  satisfactory  proceeding, 
since  it  consists  in  the  removal  of  the  anterior  segment  of  the  arch  of  the  foot, 
the  posterior  half  being  left  without  support.  The  natural  result  of  this  is  that 
the  head  of  the  astragalus  travels  downwards,  and  presses  upon  the  anterior 
portion  of  the  stump,  causing  a  good  deal  of  pain  and  discomfort,  whilst  the 
os  calcis  is  drawn  upwards  by  the  traction  of  the  tendo  Achillis.  Formerly 
it  was  considered  that  the  resulting  deformity  was  purely  due  to  unbalanced 
muscular  traction,  and  hence  attempts  to  prevent  it  were  made  by  dividing 
the  tendo  Achillis,  or  by  stitching  the  extensor  tendons  to  the  under  surface 
cf  the  os  calcis.     Seeing,  however,  that  the  trouble  is  mainly  mechanical,  and 


Fig.  423. — Skeleton  and  Out- 
line of  Foot,  showing  Level 
of  Various  Amputations. 


AMPUTATIONS  1177 


hence  unavoidable,  it  would  perhaps  be  wiser  to  avoid  the  operation  entirely, 
substituting  for  it  a  subastragaloid  amputation,  or  modifying  it  by  removing 
the  astragalus  after  the  foot  has  been  taken  away.  Tripier's  amputation  has 
also  been  utilized  to  prevent  such  displacement ;  in  it  an  oblique  external 
racquet  is  made,  reaching  backwards  to  the  anterior  border  of  the  tendo 
Achillis  ;  disarticulation  follows  at  the  mid-tarsal  joint,  and  then  the  os  calcis 
is  sawn  across  horizontally  on  a  level  with  the  sustentaculum  tali,  so  as  to 
leave  a  broad  base  of  support,  which  is  not  so  likely  to  become  tilted  forwards. 
It  is  but  fair  to  say,  however,  that  in  not  a  few  cases  of  Chopart's  amputation 
an  excellent  stump  remains  without  any  of  these  inconveniences. 

Subastragaloid  Amputation  of  the  foot  is  occasionally  possible  in  cases  of 
injury,  where  the  astragalus  remains  uninjured.  The  best  plan  to  adopt  is 
that  known  as  Maurice  Perrin's  oval  operation.  A  racquet-shaped  incision  is 
made,  commencing  at  the  insertion  of  the  tendo  Achillis,  and  extending  along 
the  outer  border  of  the  foot  to  a  point  immediately  behind  the  spur  of  the 
fifth  metatarsal,  from  which  it  sweeps  over  the  dorsum,  along  the  instep,  and 
after  crossing  the  sole  returns  to  the  same  spot.  The  dorsal  part  of  the  flap 
is  then  dissected  up,  the  astragalo-scaphoid  joint  opened,  the  tendo  Achillis 

divided,  and  by  twisting  the  foot  in- 
wards the  joints  between  the  astragalus 
and  os  calcis  can  be  entered,  and  the  in- 
terosseous ligament  severed.  By  still 
further  inverting  the  foot  until  it  as- 
sumes a  position  of  extreme  varus,  the 
structures  on  the  inner  side  of  the  os 
calcis  can  be  detached,  and  by  con- 
tinuing the  same  torsion,  the  inner 
surface  of  the  bone  is  finally  cleared, 
the  dorsal  aspect  of  the  foot  looking 
downwards.  When  the  foot  has  been 
Fig.  424.— Incisions  in  Syme's  removed,  bleeding-points  are  secured, 
Amputation  of  Foot.  tendons  and  nerves  cut  short,  and  the 

wound,  which  now  lies  horizontally,  is 
secured  by  sutures.     A  very  firm  basis 
of  support  is  provided  by  this  operation,  and  the  stump  is  covered  by  the  skin 
of  the  heel,  which  is  accustomed  to  pressure. 

Amputation  of  the  Foot. — Syme's  amputation  consists  of  a  disarticulation  at 
the  ankle-joint,  together  with  removal  of  the  two  malleoli  and  the  articular 
surface  of  the  tibia.  The  patient  lies  on  the  back  with  the  leg  well  elevated 
and  projecting  over  the  end  of  the  table,  the  surgeon  standing  either  below 
or  a  little  to  the  right  of  the  patient.  Having  exsanguinated  the  limb,  the 
operation  is,  on  the  right  foot,  commenced  by  making  an  incision  from  the 
tip  of  the  external  malleolus  down  to  the  heel,  and  extending  up  to  a 
point  $  inch  below  and  behind  the  internal  malleolus  (Fig.  424).  On  the 
left  side  the  incision  is  made  in  the  opposite  direction.  For  this  purpose  a 
short-handled  strong-bladed  knife  should  be  employed  (an  ankle  knife).  The 
incision  is  directed  slightly  backwards,  otherwise  a  bucket-shaped  heel  flap 
is  formed,  in  which  discharges  may  collect.  The  knife  is  carried  down  to 
the  bone  at  the  first  cut,  and  the.  surgeon  then  proceeds  to  dissect  up  the  heel 
flap  thus  marked  out  by  inserting  his  thumb  into  the  wound,  and  partly 
peeling,  partly  cutting,  the  soft  tissues  from  the  back  of  the  os  calcis  (Fig.  425). 
This  is  sometimes  a  tedious  and  tiring  proceeding,  since  it  is  most  important 
to  keep  close  to  the  bone  for  fear  of  dividing  the  nutrient  vessels  of  the  flap 
(external  and  internal  calcanean).  The  dorsal  incision  is  then  made,  uniting 
the  ends  of  the  former  wound,  and  carried  slightly  forwards  so  that  a  short 
convex  flap  is  thereby  made.  This  is  dissected  up,  and  the  ankle-joint 
opened,  the  line  of  the  articulation  being  placed  £  inch  above  the  tip  of  the 
internal  malleolus.  By  division  of  the  lateral  and  posterior  ligaments,  of  the 
tendo  Achillis,  and  of  the  few  remaining  fibrous  connections  along  the  top  of 


1 1 78 


A  MANUAL  OF  SURGERY 


the  os  calcis,  the  foot  is  removed.  The  lower  ends  of  the  tibia  and  fibula  are 
then  cleared  and  sawn  off,  the  ends  of  the  dorsal  flap  being  meanwhile  held 
out  of  harm's  way  (Fig.  426).  The  main  vessels  are  tied,  as  also  any  other 
bleeding  points  ;  the  tendons  and  chief  nerves  are  drawn  down  and  cut  short, 
and  the  wound  closed  by  sutures,  provision  being  made  for  drainage  through 
one  of  the  angles. 

A  much  quicker  and  prettier  method  of  performing  this  operation  consists  in 
opening  the  joint,  and  disarticulating  immediately  after  the  incisions  have  been 
made,  whilst  the  os  calcis  is  subsequently  dissected  out  of  the  heel  flap  from 
above,  keeping  the  knife  close  to  the  bone. 

Syme's  amputation  gives  excellent  results  with  only  slight  shortening,  and 
the  patient  is  able  to  walk  on  skin  which  is  already  accustomed  to  pressure. 
It  is  specially  useful  where  amputation  is  required  for  tarsal  disease,  inas- 


Fig.  425. — Method  of  raising 
Heel  Flap  from  Os  Calcis. 


Fig.  426.—  Section  of  Tibia  and 
Fibula  in  Syme's  Amputation. 


much  as  it  is  then  rarely  safe  to  undertake  any  of  the  partial  or  more  con- 
servative methods  of  operating. 

Pirogojfs  operation  is  one  in  which  the  posterior  portion  of  the  os  calcis  is 
sawn  off,  and  applied  to  the  under  surface  of  the  previously  sawn  ends  of 
the  tibia  and  fibula.  The  operation  here  described  is  not  strictly  that  of 
Pirogoff,  but  rather  the  modification  suggested  by  Sedillot.  The  patient  and 
surgeon  being  relatively  placed  as  for  Syme's  operation,  an  incision  is  made 
extending  from  the  same  points,  viz.,  between  the  tip  of  the  external  malleolus 
and  a  point  f  inch  below  and  behind  the  inner  malleolus,  but  instead  of  passing 
directly  downwards  it  is  carried  obliquely  forwards.  Everything  is  divided  at 
once  down  to  the  bone,  and  the  dorsal  incision  is  then  made,  being  placed 
at  right  angles  to  the  plantar.  The  ankle-joint  is  opened  from  above,  and 
disarticulation  completed ;  the  structures  to  the  side  of  and  behind  the  joint 
are  then  divided,  so  that  a  saw  can  be  applied  to  the  exposed  surface  of  the 
os  calcis,  and  the  bone  cut  through  along  the  line  of  the  plantar  flap.  The 
lower  ends  of  the  tibia  and  fibula  are  now  cleared,  and  the  malleolus  and 
articular  surface  sawn  off  obliquely,  the  saw-cut  being  as  nearly  as  possible 
parallel  to  that  made  through  the  os  calcis.  The  object  of  this  obliquity  is 
to  enable  the  sawn  end  of  the  posterior  part  of  the  os  calcis  to  be  brought  into 
apposition  with  the  similarly  treated  ends  of  the  bones  of  the  leg,  and  wired  to 
them  without  any  traction  on  the  tendo  Achillis.     By  this  operation  a  some- 


AMPUTATIONS 


i '79 


what  longer  stump  is  obtained  than  in  Syme's,  and  the  patient  is  able  to  walk- 
on  the  posterior  part  of  the  os  calcis  instead  of  on  the  sawn  ends  of  the  tibia 
and  fibula.     The  operation  is  more  useful  in  cases  of  injury  than  for  disease. 

Amputations  of  the  Leg  maybe  undertaken  either  immediately  above  the 
malleoli   (supramalleolar)  or  in  the  middle  third,  or  a  hand's-breadth  below 
the  knee  (site  of  election).     In  the 
two    former  positions  almost  any 
operation  may  be  practised  accord-  - — .... 

ing  to  the  needs  of  the  case,  but  " '"- ■-- _,__ 

perhaps    the    most   satisfactory  is  "^, 

that  by  means  of  equal  lateral 
flaps,  each  of  which  is  equal  in 
length  to  one  diameter  of  the  limb, 
and  consists  below  of  skin,  fat  and 
deep  fascia,  but  for  the  upper  half 
the  muscles  are  also  included.  In 
dividing  the  bones,  care  must  be 
taken  not  to  leave  a  sharp  project- 
ing edge  on  the  front  of  the  tibia 
This  is  best  prevented  by  partially 
sawing  through  the  bone  in  an 
oblique  direction  from  above  down- 
wards, and  when  this  has  reached 
a  little  beyond  its  centre,  the  saw 
is  withdrawn,  and  a  horizontal  in- 
cision made,  cutting  across  the 
oblique  incision  in  such  a  way  as  to 
remove  a  wedge  of  bone  from  the 
front  of  the  tibia,  which  thus  be- 
comes suitably  bevelled  (Fig.  427). 
The  fibula  should  always  be  di- 
vided before  completing  the  sec- 
tion of  the  tibia. 

In  the  lower  third  of  the  leg, 
Teale's  amputation  (Fig.  413)  is 
sometimes  recommended,  and  gives 
good  results 

Amputation  of  (Toe  Leg  at  the 
Site  of  Election  may  be  performed  either  by  the  modified  flap  and  circular 
operation,  or  by  a  large  external  flap  (Favabceufs  operation).  In  the  latter, 
the  external  flap  (Fig.  427,  A  C),  which  is  U-shaped,  is  first  marked  out  with 
the  knife,  extending  ii  inches  higher  in  front  than  behind,  and  its  length 
being  equal  to  the  diameter  of  the  limb  at  the  point  at  which  the  bones  are  to 
be  divided.  The  incision  on  the  inner  side  is  then  made,  extending  directly 
across  the  limb  from  a  point  ih  inches  below  the  upper  end  of  the  anterior 
horn  of  the  former  incision  to  its  posterior  extremity  (Fig.  427,  B  C).  The 
external  flap  is  dissected  up,  commencing  anteriorly  ;  the  fingers  and  knife 
being  inserted  between  the  tibialis  anticus  and  the  tibia,  all  the  soft  parts 
down  to  the  bone  and  interosseous  membrane  are  divided  obliquely.  The 
anterior  tibial  artery  is  cut  long,  and  care  must  be  taken  not  to  free  the  flap 
from  the  interosseous  membrane  too  high,  for  fear  of  injuring  the  trunk  of  this 
vessel  as  it  passes  between  the  bones,  an  accident  which  would  seriously 
imperil  the  vitality  of  this  large  and  fleshy  mass.  The  tissues  on  the  inner 
side  of  the  limb  are  now  divided,  either  by  transfixion  or  circular  division. 
The  interosseous  membrane  and  bones  are  bared,  and  the  saw  applied 
according  to  the  method  already  described. 

Disarticulation  at  the  Knee-joint  is  a  very  useful  and  valuable  proceeding. 
The  methods  chiefly  employed  are  as  follows:  (i  )  Stephen  Smith's  operation, 
or  amputation  by  equal  lateral  flaps.      The  incisions  extend   from   a   point 


Fig.  427. — Farabckuf's  Amputation  at' 
the  Site  of  Election,  a  Hand's- 
Breadth  below  the  Knee. 

The  continuous  line,  A,  B,  C,  indicates 
the  shape  of  the  large  external  flap  ; 
the  dotted  line,  B,  C,  the  incision  on 
the  inner  side  of  the  limb.  The  direc- 
tion in  which  the  bones  are  sawn  is 
also  shown. 


nSo 


A   MANUAL  OF  SURGERY 


immediately   below   the   tuberosity   of    the   tibia  backwards  in  a  semilunar 

fashion,  to   terminate   in    the   middle   line  behind  on  a  level  with  the  joint 

(Fig.  428).     The  incision  on  the  inner  side  should  reach  a  little  lower  than 

that  on  the  outer,  in  order  to  ensure  sufficient  covering  for  the  inner  condyle, 

which  is  always  larger  than  the  outer.     The  flaps  are  dissected  up  all  round, 

including  the  subcutaneous  and  deep  fascia,  being  turned  back  in  front  like 

a  collar,  so  as  to  enable  the  surgeon  to  reach  and  divide  the  insertion  of  the 

ligamentum  patellae.     The  knife  is  now  carried  along  the  upper  margin  of  the 

tibia,   separating  the  attachments  of  the  semilunar  cartilages  to  the  bones 

by  dividing  the  coronary  ligaments.     The  surrounding  muscles  and  tendons 

are  cut  through  at  the  same  level,  together  with  the  crucial  ligaments,  and 

the  leg  is  finally  separated  by  boldly  sweeping  the  knife  through  the  soft  parts 

at  the  back  of  the  joint,  the  flaps  being 

well  retracted.     The  popliteal  vessels  are 

secured,  and   the   flaps   drawn    together 

in  the  median   line.      When  union   has 

occurred,  the  cicatrix  is  drawn  up  behind 

into  the  intercondyloid  notch  so  that  an 

excellent  hooded  covering  is  provided  for 

the  lower  end  of  the  femur.     The  chief 

objection   to   the   operation   is   that   the 

upper  part  of  the  synovial  membrane  of 

the  joint  remains  intact,  and  may  become 

distended  by  a  serous  effusion   through 

the  irritation   produced   by   wearing   an 

artificial  limb,     (ii.)  Amputation  can  be 

undertaken   by   a   long  anterior  flap,   the 

patella   being   left   in   situ    or    removed, 

according    to    circumstances.      A    short 

posterior  flap  is  also  formed  and  dissected 

up,    so   as   to   enable    the   muscles   and 

vessels  to  be  divided  transversely. 

Supracondyloid  Amputation  of  the 
Thigh  is  an  operation  often  requisite 
in  order  to  deal  with  disease  or  injury 
involving  the  knee-joint.  (a)  Carden's 
amputation  is  one  excellently  adapted  to 
this  purpose.  It  consists  in  the  forma- 
tion of  an  anterior  flap,  extending  from 
the  level  at  which  the  femur  is  to  be 
divided  to  a  point  midway  between  the  lower  border  of  the  patella  and  the 
tubercle  of  the  tibia ;  this  is  dissected  up  as  far  as  the  upper  border  of  the 
patella.  A  short  posterior  flap  is  then  cut  by  transfixion,  and  usually  there  is 
a  good  deal  of  retraction,  since  the  hamstring  muscles  are  included  in  it.  The 
soft  parts  are  now  divided  down  to  the  bone  all  round  just  above  the  patella 
by  cutting  from  without  inwards,  and  retracted  for  a  short  distance.  The 
condyles  thus  cleared  are  removed  by  the  saw  in  a  direction  parallel  to  the 
articular  surface.  The  chief  objection  to  this  operation  is  the  length  of  the 
anterior  flap,  which  is  badly  nourished,  and  sometimes  liable  to  slough. 
(b)  Lister's  modification  consists  in  making  a  transverse  incision  across  the 
front  of  the  limb  on  a  level  with  the  upper  border  of  the  tibia.  The  horns 
of  this  incision  are  joined  posteriorly  by  carrying  the  knife  downwards  at  an 
angle  of  forty-five  degrees  to  the  axis  of  the  leg.  This  flap  is  dissected  up, 
and  the  whole  of  the  integuments  and  subcutaneous  tissues  are  freed  and 
retracted  like  a  cuff,  so  as  to  enable  the  muscles  to  be  divided  circularly  just 
above  the  patella.  The  saw  is  then  applied,  and  the  bone  removed.  By  this 
means  the  covering  of  the  end  of  the  bone  is  taken  more  from  the  back  than 
from  the  front  of  the  limb,  (c)  Gritti's  operation  is  thus  performed :  A  large 
anterior  flap  similar  to  that  used  in  Carden's  operation  is  dissected  up,  includ- 


Fig.  428. — Stephen  Smith's  Am- 
putation  THROUGH   THE  KnEE- 

Joint  by  Lateral  Flaps. 


AMPUTATIONS 


ing  the  patella,  and  a  shorter  posterior  flap  is  then  fashioned.  The  soft  parts 
are  divided  by  a  circular  cut  of  the  knife,  and  the  femur  sawn  across  about  the 
level  of  the  adductor  tubercle.  The  cartilaginous  surface  of  the  patella  is  then 
removed  with  the  saw,  and  the  remaining  portion  of  the  bone  secured  by  a 
silver  wire  to  the  divided  end  of  the  femur.  Considerable  difficulty  may  be 
experienced  in  keeping  the  patella  in  accurate  apposition,  and  to  obviate  this 
Stokes  recommended  division  of  the  femur  at  a  slightly  higher  level  (above 
rather  than  through  the  condyles),  (d)  Amputation  by  a  long  posterior  -flap  is 
sometimes  required  in  cases  where  the  tissues  in  front  of  the  limb  have  become 
disorganized  from  disease  of  the  joint,  or  when  cicatrices  produced  by  a 
previous  excision  are  present.  The  posterior  flap  is  first  marked  out  and  dis- 
sected up,  including  merely  the  skin  and  subcutaneous  tissues.  A  transverse 
incision  is  made  across  the  limb  above  the  cicatrices  or  sinuses,  the  bone  sawn 
just  above  the  site  of  the  preceding  excision,  and  the  posterior  muscles  and 
vessels  divided  circularly.     A  very  good  stump  usually  results. 

Amputation  of  the  Thigh  may  be  conducted  by  any  of  the  general  methods 
already  described,  but  the  modified  flap  and  circular  (Lister's  operation, 
Fig.  412)  is  perhaps  the  best. 

Amputation  through  the  Hip-Joint.— Disarticulation  at  the  hip-joint  is 
always  an  operation  of  the  greatest  gravity,  and  every  precaution  should  be 
taken  to  minimize  the  immediate  risks  by  preventing  haemorrhage  and 
lessening  shock.  No  part  of  the  body  should  be  unnecessarily  exposed,  whilst 
the  head  is  kept  low,  and  although  the  operation  must  not  be  hurried  over,  no 
time  is  wasted. 

Perhaps  the  best  way  of  preventing  haemorrhage  is  to  secure  the  main 
vessels  before  dividing  them,  and  then  to  take  up  each  bleeding-point  as  it 
appears  ;  the  limb  can  thus  be  removed  with  the  loss  of  merely  a  few  ounces 
of  blood.  Other  plans  which  have  been  suggested  are :  (a)  Lister's  aortic 
tourniquet,  which,  however,  is  not  to  be  recommended,  partly  because  it  is 
difficult  to  apply  to  stout  or  muscular  individuals,  and  in  any  case  it  is  very 
liable  to  slip,  (b)  Davy's  rectal  lever  for  compression  of  the  common  iliac 
artery  consists  of  a  rod  of  ebony,  vulcanite,  or  metal,  which  is  inserted  into 
the  rectum,  and  directed  so  as  to  compress  the  artery  against  the  brim  of  the 
pelvis.  It  is  dangerous  in  application,  and  not  always  efficient,  (c)  An  elastic 
tourniquet  may  be  applied  either  around  the  upper  part  of  the  thigh  to  control 
the  lower  end  of  the  external  iliac,  or  around  the  body  in  such  a  way  as  to 
compress  the  abdominal  aorta.  For  the  latter  purpose  a  pin-cushion  or  pad 
is  placed  on  the  abdomen  over  the  aorta,  and  behind  the  back  a  board  pro- 
jecting a  few  inches  on  each  side  of  the  trunk,  and  with  two  notches  cut  at 
either  end.  The  elastic  rod  is  passed  over  the  cushion,  and  around  the  notches 
at  the  end  of  the  board  in  a  figure-of-8  fashion,  sufficient  tension  being  em- 
ployed to  force  the  cushion  down  on  the  aorta,  and  thus  control  the  circulation 
through  it.  This  method,  which  was  also  suggested  by  Lord  Lister,  is  cer- 
tainly efficient,  though  somewhat  cumbersome,  (d)  More  recently  Wyeth,  of 
New  York,  has  introduced  a  method  of  preventing  haemorrhage  by  applying  a 
rubber  tourniquet  close  to  the  pelvic  brim,  which  is  prevented  from  slipping 
by  inserting  long  needles  immediately  below  it.  The  limb  is  first  exsan- 
guinated by  elevation,  or  possibly  by  the  use  of  an  Esmarch's  bandage.  Two 
long  steel  needles,  10  inches  in  length  and  fa  inch  in  thickness,  are  then  in- 
serted, one  on  the  outer  side  of  the  thigh  and  one  on  the  inner.  The  former 
'is  introduced  J  inch  below  the  anterior  superior  spine  of  the  ilium,  and 
slightly  to  the  inner  side  of  this  prominence,  and  is  made  to  traverse  super- 
ficially for  about  3  inches  the  muscles  and  fascia  on  the  outer  side  of  the  hip, 
emerging  on  a  level  with  the  point  of  entrance.  The  point  of  the  second 
needle  is  thrust  through  the  skin  and  tendon  of  origin  of  the  adductor  longus 
muscle  h  inch  below  the  crutch,  the  point  emerging  1  inch  below  the  tuber 
ischii.  The  points  should  be  shielded  at  once  with  cork  to  prevent  injury  to 
the  hands  of  the  operator.  No  vessels  are  endangered  by  these  skewers.  A 
mat  or  compress  of  sterile  gauze  2  inches  thick  and  4  inches  square  is  laid  over 


Il82 


A   MANUAL  OF  SURGERY 


the  femoral  artery  and  vein  as  they  cross  the  brim  of  the  pelvis ;  over  this  a 
piece  of  strong  white  rubber  tubing,  ^  inch  in  diameter  when  unstretched,  and 
long  enough  when  in  position  to  go  five  or  six  times  round  the  thigh,  is  now 
wound  very  tightly  around  and  above  the  fixation  needles  and  tied.'*  By  this 
means  the  limb  can  be  removed  with  practically  no  loss  of  blood. 

Formerly  but  one  operation  was  utilized  for  the  removal  of  the  limb  at  the 
hip-joint,  viz.,  by  transfixion,  the  flaps  being  cut  antero-posteriorly.  The 
great  advantage  of  this  method  was  the  rapidity  with  which  it  was  executed  ; 
it  has,  however,  been  replaced  by  other  plans,  one  of  which  should  always  be 
adopted. 

Amputation  by  an  external  racquet  incision  (Fig.  429)  has  been  recommended 
by  many  surgeons,  especially  Furneaux  Jordan,  Esmarch,  and  Lister,  each  of 
whom  has  advocated  some  slight  modification.     The  surgeon  should  always 


Fig.  429. — Amputation  through  the  Hip-Joint. 

On  the  right  leg  Furneaux  Jordan's  method  is  indicated  ;  on  the  left  leg  the 
flaps  required  for  the  anterior  racquet  operation  are  shown. 

stand  to  the  outer  side  of  the  limb,  whilst  the  pelvis  of  the  patient  rests  at  the 
extreme  edge  of  the  table.  The  essential  features  of  this  operation  consist 
in  a  circular  division  of  the  structures  down  to  the  bone  below  the  lesser 
trochanter,  whilst  the  head  of  the  bone  is  disarticulated  and  removed  through 
the  external  vertical  portion  of  the  incision  extending  downwards  from  above 
the  great  trochanter ;  it  matters  little  whether  the  vertical  incision  is  made 
before  or  after  the  tissues  in  the  thigh  have  been  divided.  Perhaps  the 
simplest  plan  of  carrying  out  this  operation  is  as  follows  :  A  circular  incision 
is  made  through  the  skin  and  subcutaneous  tissues  5  or  6  inches  below  the 
great  trochanter.  These  are  dissected  up  for  a  few  inches,  and  the  muscles 
divided  circularly  down  to  the  bone,  which  is  at  once  sawn  through.  The 
external  incision,  6  or  8  inches  long,  is  then  made,  the  tissues  being  freed 
from  the  anterior  and  posterior  surfaces  of  the  femur,  and  the  rotator  muscles 
divided  along  the  borders  of  the  great  trochanter.  The  lower  end  of  the 
fragment  of  the  femur  is  then  grasped  by  lion  forceps,  and  after  forcibly  flexing 
and  rotating  the  bone  inwards,  the  capsule  of  the  joint  is  laid  open  on  its 
posterior  aspect.  By  everting  the  bone,  the  anterior  part  of  the  capsule  can 
be  reached  and  incised,  and  the  attachment  of  the  ilio-ps^oas  muscle  severed. 
The  ligamentum  teres  is  then  divided  by  inserting  the  point  of  the  knife  into 

*  Wyeth,  Annals  of  Surgery,  February,  1897. 


AMPUTATIONS  1183 


the  acetabulum,  and  the  head  of  the  bone  is  thus  set  free.  One  great  advan- 
tage of  this  operation  is  that  the  incisions  are  placed  as  far  as  possible  from 
the  risk  of  septic  contamination  from  the  genital  organs  and  perineum. 

To  our  minds,  the  best  method  of  amputating  at  the  hip-joint  is  by  means 
of  an  anterior  racquet  incision  (Fig.  429).  This  commences  over  the  centre  of 
Poupart's  ligament,  and  is  carried  down  along  the  course  of  the  main  vessels 
for  about  3  inches.  The  common  femoral  s"heath  is  exposed,  and  both  artery 
and  vein  are  secured  by  double  ligature  and  divided.  The  incision  is  then 
completed  ;  it  sweeps  over  the  inner  side  of  the  thigh  4  or  5  inches  below  the 
perineum  to  the  back,  and  is  brought  up  again  to  the  front  3  or  4  inches  below 
the  great  trochanter.  The  muscular  structures  in  the  outer  flap  are  then  cut 
through,  and  the  external  circumflex  artery  and  other  bleeding  vessels  secured 
by  pressure  forceps  en  route.  By  rotating  the  limb  inwards,  the  insertion  of 
the  gluteus  maximus  can  be  divided,  as  also  the  muscles  attached  to  the  great 
trochanter.  The  muscles  in  the  inner  flap  are  then  similarly  dealt  with  after 
rotating  the  limb  outwards,  the  internal  circumflex  artery,  etc.,  being  secured. 
The  capsular  ligament  is  next  divided  transversely,  and  the  head  of  the  bone 
disarticulated.  Finally,  the  limb  is  rotated  forcibly  outwards,  and  all  the  soft 
parts  at  the  back  of  the  limb,  including  the  sciatic  vessels  and  nerves,  are 
divided  from  within  outwards  with  one  sweep  of  the  knife.  The  wound  when 
sutured  lies  antero-posteriorly. 


CHAPTER   XLI. 
ANESTHESIA. 

The  practice  of  surgery  has  always  been  of  such  a  nature  as  to  render  some 
means  of  abolishing  the  pain  caused  thereby  a  desideratum  ;  but  although  in 
the  old  days  various  plans  were  adopted  to  attain  this  object,  yet  it  was  not 
until  the  end  of  the  last  century  that  any  real  advance  was  made  in  this 
direction.  In  1799  Sir  Humphrey  Davy  suggested  the  possibility  of  using 
nitrous  oxide  gas  as  a  means  of  rendering  patients  anaesthetic  during  surgical 
work;  but  as  then  employed,  it  was  so  uncertain  in  its  action  that  no  great 
benefit  was  derived  from  the  knowledge  thus  acquired,  and  many  years  elapsed 
before  it  came  into  extensive  use.  The  demonstration  of  the  properties  of 
ether  in  1846  by  Morton  in  Philadelphia,  and  of  chloroform  in  January,  1847, 
by  Sir  James  (then  Professor)  Simpson,  iieralded  in  a  new  era  of  surgery. 
Operations,  which  before  were  scanty  in  number,  became  greatly  multiplied, 
and  at  the  present  day,  with  our  advanced  knowledge  and  experience,  and  our 
constant  dependence  on  this  agent,  it  is  difficult  to  understand  how  surgical 
practice  could  have  been  conducted  without  it.  Anaesthetics  have  enabled  the 
surgeon  confidently  to  attack  almost  every  region  of  the  body,  and  instead  of 
operations  being  hurried  over,  in  order  to  minimize  the  patient's  sufferings, 
they  are  now  undertaken  with  much  more  deliberation,  accuracy  being  the 
great  requisite  at  the  present  day,  and  not,  as  formerly,  rapidity. 

Anaesthetics  may  be  divided  into  two  groups — the  local  and  the  general. 

Local  Anaesthesia  is  utilized  for  the  purpose  of  rendering  parts  insensitive  to 
pain,  where  slight  operations  of  short  duration  are  to  be  undertaken,  or, 
occasionally,  in  more  serious  cases,  where  the  patient  cannot  stand  a  general 
anaesthetic. 

1.  Cocaine  is  an  alkaloid  obtained  from  the  dried  leaves  of  the  Erythroxylon 
coca  (S.  America).  The  salt  most  commonly  used  is  the  hydrochlorate,  which 
exists  in  the  form  of  colourless  needles,  or  a  crystalline  powder  readily  soluble 
in  water.  Its  properties  as  a  local  anaesthetic  were  discovered  by  Koller  of 
Vienna,  and  it  was  at  the  Ophthalmic  Congress  at  Heidelberg  in  September, 
1884,  that  its  value  in  ophthalmic  and  surgical  work  was  first  publicly 
demonstrated. 

Mucous  membranes  are  readily  anaesthetized  by  applying  a  5  or  10  per 
cent,  solution  to  them  for  about  five  or  ten  minutes,  the  insensibility  lasting 
for  about  the  same  time.  In  dealing  with  the  skin  or  deeper  tissues, 
hypodermic  injections  of  the  drug  are  relied  on,  the  anaesthesia  following  the 
course  of  the  peripheral  nerves.  The  action  of  cocaine  is  supposed  to  depend 
partly  on  an  anaemic  condition  of  the  affected  tissues  induced  by  arterial  con- 
traction, partly  on  paralysis  of  the  terminations  of  the  sensory  nerves.  Much 
less  effect  is  produced  on  inflamed  tissues.  In  making  use  of  this  reagent,  it 
must  always  be  remembered  that  cocaine  has  a  distinctly  depressing  influence 
upon  the  heart,  and  hence  more  than  h  grain  should  never  be  employed.  When 
a  syringe  is  used  the  needle  should  be  inserted  in  the  line  of  incision,  and  the 


ANESTHESIA  1185 


injection  equally  diffused  along  it.  Should  any  toxic  effects  be  manifested  (as 
by  pallor  of  the  face,  a  cold  clammy  sweat,  giddiness,  weak  and  rapid  pulse \ 
the  patient  should  be  laid  with  the  head  low,  and  stimulants  administered. 
Some  recommend  that  a  little  nitro-glycerine  (1  drop  of  a  1  per  cent,  solution) 
should  always  be  injected  at  the  same  time  as  the  cocaine,  so  as  to  prevent 
contraction  of  the  peripheral  arterioles.  In  some  parts  of  the  body  it  may  be 
possible  to  control  the  circulation  so  as  to  hinder  the  general  absorption  of  the 
drug.  Thus,  for  circumcision  the  base  of  the  penis  may  be  constricted  by  an 
elastic  band,  whilst  a  similar  arrangement  may  be  applied  to  the  fingers  and 
toes  for  small  operations,  such  as  avulsion  of  a  toe-nail. 

2.  A  substitute  for  cocaine  has  recently  been  proposed  in  the  synthetic  com- 
pound known  as  Eucaine  Hydrochloride.  Its  toxic  properties  are  much  less 
marked  than  those  of  cocaine,  and  doses  of  even  5  or  10  grains  may  be 
employed  either  hypodermically  or  by  painting  over  a  mucous  membrane.  Its 
action  is  somewhat  slower  than  that  of  cocaine,  and  it  causes  a  little  congestion 
of  the  part,  whilst  cocaine  leads  to  anaemia ;  it  also  gives  rise  to  a  little 
tingling  pain  on  injection,  and  may  leave  a  certain  amount  of  oedematous 
thickening  for  a  time.  The  reports  hitherto  given  have  been  very  satisfactory, 
although,  on  account  of  the  irritation  produced,  it  does  not  seem  to  be  quite  so 
suitable  for  ophthalmic  work. 

3.  Local  anaesthesia  is  also  produced  by  freezing  the  part,  either  by  the 
application  of  ice  and  salt,  or  by  the  ether  spray,  or  with  ethyl  chloride. 
The  latter  reagent  is  now  put  up  conveniently  in  small  glass  or  thin  metal 
flasks  with  a  fine  capillary  outlet ;  on  holding  the  flask  in  the  hand  a  spray  is 
produced,  which  is  allowed  to  play  upon  the  part  to  be  operated  on.  The 
rapid  evaporation  from  the  surface  leads  to  the  freezing  of  the  skin,  which 
becomes  of  a  dead  white  colour.  The  anaesthesia  produced  is  of  a  very 
fugitive  nature,  and  a  certain  amount  of  pain  may  be  associated  with  the 
thawing  process,  but  less  than  that  caused  by  the  ether  spray. 

General  Anaesthesia. — 1.  Nitrous  Oxide  Gas  (N20)  is  most  commonly  used  in 
dental  work,  or  for  short  operations,  such  as  bending  a  stiff  joint  and  breaking 
down  adhesions,  the  avulsion  of  a  toe-nail,  or  the  opening  of  an  abscess.  It 
is  practically  safe  and  not  unpleasant,  either  in  its  use  or  in  its  subsequent 
effects.  It  is  also  employed  in  conjunction  with  ether,  the  patient  being  first 
anaesthetized  with  gas,  and  the  condition  maintained  by  ether.  Gas  has  also 
been  recommended  for  the  removal  of  adenoids ;  but  the  general  opinion 
now  obtaining  is  that,  to  perform  this  operation  satisfactorily,  a  more  lasting 
anaesthetic  is  required.  The  gas  is  stored  in  a  condensed  and  liquefied  form 
in  special  steel  cylinders,  closed  by  a  screw  which  can  be  readily  loosened,  so 
as  to  allow  the  gas  to  escape  through  a  tube  into  an  indiarubber  bag.  This  is 
attached  to  a  closely-fitting  face-piece,  with  a  suitable  arrangement  of  valves 
and  stop-cocks,  by  means  of  which  the  gas  is  allowed  to  reach  the  patient. 
A  valvular  exit  for  the  expired  air  is  also  present  (Fig.  430,  A,  B,  C  and  E, 
p.  1187).  In  its  usual  method  of  administration  the  bag  is  first  filled  with  gas,' 
and  then  air  is  completely  excluded  by  carefully  adjusting  the  padded  face- 
piece  to  the  irregularities  of  the  face.  Some  anaesthetists,  however,  by  means 
of  a  special  apparatus  devised  by  Dr.  Hewitt,  allow  the  administration  of  a 
minute  proportion  of  pure  oxygen  at  the  same  lime,  in  order  to  prevent  the 
lividity  of  the  face  and  the  twitching  of  the  limbs  often  present  when  anaes- 
thesia is  induced  in  the  ordinary  way.  These  symptoms  of  incipient  asphyxia 
may  also  be  avoided  by  allowing  the  last  few  inspirations  of  the  gas  to  be 
mixed  with  air.  This  may  be  done  by  raising  the  face-piece,  by  opening  the 
air-valve,  or,  as  suggested  by  Dr.  Flux,  by  using  an  open  inhaler  into  which 
the  gas  is  poured.  Of  course,  in  removing  teeth  the  mouth  is  firmly  gagged 
open  prior  to  the  commencement  of  the  administration. 

2.  Chloroform  is  perhaps  the  anaesthetic  most  generally  employed,  on  account 
of  the  ease  with  which  it  can  be  administered,  although  there  can  be  but  little 
doubt  that  its  use  is  attended  with  somewhat  more  risk  than  that  of  ether. 
Much  controversy  has  arisen  as  to  whether  the  heart  is  ever  directly  affected 

75 


1 1 86  A   MANUAL  OF  SURGERY 


Dy  the  drug,  or  whether  the  dangerous  symptoms  met  with  are  not  due  to 
primary  failure  of  the  respiration.  The  experimental  evidence  on  the  subject 
is  of  a  very  conflicting  nature ;  and  it  is  impossible  as  yet  to  consider  the 
question  solved.  The  Scotch  school  of  surgeons,  headed  by  Syme  and  Lister, 
has  always  maintained  that  the  breathing  alone  need  be  watched  during  the 
administration  of  chloroform,  failure  of  the  respiration  being  the  first  danger 
signal  ;  the  second  so-called  Hyderabad  Commission  has  sought  to  confirm 
this  view.  Many  practical  surgeons  and  anaesthetists  oppose  this  statement, 
holding  that,  although  the  respirations  may  fail  first  in  a  large  percentage,  and 
probably  a  majority,  of  fatal  cases,  yet  there  are  a  certain  number  in  which 
heart  failure  is  also  seen  as  a  result  of  the  direct  toxic  effect  of  the  chloroform 
upon  its  muscular  substance.  Certainly,  in  not  a  few  instances  of  death  during 
the  administration  of  chloroform  the  heart  stops  first,  but  a  great  distinction 
must  be  drawn  between  the  deaths  which  result  from  chloroform,  and  the  deaths 
that  occur  during  the  administration  of  chloroform.  An  overdose  of  chloroform, 
without  doubt,  leads  to  failure  of  the  respirations  ;  but  in  the  majority  of  such 
cases,  if  suitable  precautions  are  adopted  sufficiently  early,  a  fatal  result  may 
be  averted.  Cases  in  which  the  heart  stops  first  are  probably  due  to  syncope, 
and  are  not  entirely  dependent  on  the  nature  of  the  anaesthetic  administered. 

Chloroform  may  be  given  in  several  different  ways,  but  in  all  the  chief  points 
to  be  attended  to  are  regularity  of  dose,  and  full  admixture  with  air,  so  that 
not  more  than  4  per  cent,  of  the  vapour  is  inspired.  The  plan  so  often 
employed  of  pouring  an  unknown  quantity  of  chloroform  on  a  piece  of  lint, 
folded  in  two  or  three  layers  and  held  close  to  the  patient's  nose  and  mouth,  is 
most  unscientific  and  to  be  strongly  condemned.  The  Open  Method  is  that 
recommended  by  Lord  Lister.  A  mask  reaching  from  the  root  of  the  nose  to 
the  chin  is  made  from  the  side  of  a  towel,  and  fixed  with  a  safety-pin.  ,  This 
is  first  held  some  inches  above  the  patient's  nose,  and  moistened  from  the 
outside  with  chloroform  from  a  drop-bottle.  As  the  respiratory  passages 
become  tolerant  of  the  drug,  the  mask  is  gradually  lowered  to  touch  the  face, 
and  is  kept  continually  moistened.  At  the  end  of  two  or  three  minutes  the 
respirations  increase  in  frequency,  and  a  stage  of  excitement  may  be  reached, 
during  which  the  patient  may  sing,  shout,  or  struggle  violently  The  anaesthetic 
is  still  cautiously  pushed,  care  being  taken  that  during  the  deep  respirations 
which  follow  the  struggling  stage  an  overdose  is  not  administered.  Complete 
anaesthesia  is  indicated  by  relaxation  of  the  muscles,  loss  of  the  corneal  reflex, 
and  contraction  of  the  pupil,  and  it  is  usually  attained  in  about  five  minutes. 
As  long  as  the  operation  lasts,  the  anaesthetist  must  endeavour  to  maintain  this 
condition,  but  the  amount  needed  during  the  later  stages  is  much  less  than  at 
its  commencement. 

Junker's  inhaler  is  often  used  for  giving  chloroform,  especially  in  operations 
about  the  nose  and  face.  It  is  economical,  and  on  the  whole  satisfactory.  In 
this  apparatus  air  is  pumped  through  a  layer  of  chloroform  to  an  inhaler 
placed  over  the  patient's  mouth,  or  to  a  tube  passed  into  his  nose.  The  air 
laden  with  chloroform  is  inspired,  and  produces  the  usual  constitutional  effects  ; 
the  amount  administered  is,  to  a  certain  extent,  regulated  by  the  rapidity  with 
which  the  indiarubber  bulb  of  the  apparatus  is  squeezed  ;  after  a  time,  how- 
ever, the  lowered  temperature  induced  by  the  evaporation  leads  to  a  diminu- 
tion in  the  amount  of  chloroform  vapour  given  off.  Accidents  have  happened 
with  this  apparatus  from  filling  the  bottle  too  full,  or  from  having  the  india- 
rubber  tubes  fixed  to  the  wrong  nozzles  ;  in  either  instance  liquid  chloroform 
may  be  pumped  out  of  the  exit-tube. 

3.  Ether  is  generally  considered  to  be  a  safer  anaesthetic  than  chloroform,  in 
that  it  is  a  cardiac  stimulant.  It  is  usually  administered  by  Clover's  apparatus 
or  by  an  Ormsby's  mask. 

^Clover's  apparatus  (Fig.  430,  D  and  E)  consists  of  a  face-piece  similar  to  that 
utilized  for  giving  nitrous  oxide,  a  metal  receptacle  for  the  ether,  and  a  bag.  In 
this  apparatus  the  air  used  in  respiration  passes  over  the  surface  of  the  ether 
contained  in  the  receptacle,  the  proportion  of  ether  inspired  being  regulated, 


A  MYESTHESIA 


1 187 


so  that  at  first  a  considerable  admixture  of  air  is  permitted,  whilst  later  on  ether 
vapour  in  the  proportion  of  a  third,  a  half,  or  even  two-thirds,  is  inhaled. 
The  great  value  of  this  apparatus  is  the  ease  with  which  the  amount  of  ether 
administered  is  regulated;  but  a  distinct  disadvantage  exists  in  the  fact  that 


Tig.  4jo. — Apparatus   for   the   Administration   of  Nitrous   Oxide   and 
Ethet.  in  Combination. 

A,  steel  cylinders  containing  compressed  nitrous  oxide ;  B,  indiarubber  bag ; 
C,  three  way  stop  cock  with  valves;  D,  Clover's  ether  chamber;  E,  face- 
piece.  If  nitrous  oxide  alone  is  administered,  D  is  omitted.  When  ether 
alone  is  used,  A  and  C  are  omitted,  and  a  smaller  bag  substituted  for  B. 


the  patient  breathes  his  own  expired  air  again  and  again,  and  so,  unless  cam 
is  taken,  he  is  likely  to  become  cyanosed.  This  can,  however,  be  prevented 
by  removing  the  mask  occasionally,  and  giving  the  patient  a  few  breaths  of 
unmixed  air.     Another  objection  lies  in  the  amount  of  mucus  which  often 


1 1 88  A   MANUAL  OF  SURGF.UY 


collects  about  the  pharynx,  whilst  the  moisture  in  the  expired  air  condenses  in 
the  bag,  which  becomes  very  objectionable  unless  carefully  washed  out. 

In  Ormsby's  mash  the  ether  is  poured  over  a  sponge  which  is  contained  in  a 
wire  frame  prolonged  from  the  face-piece,  and  covered  over  by  a  bag  into 
which  the  patient  breathes.  It  is  an  unpleasant  means  of  inducing  anaesthesia, 
but  may  be  employed  for  maintaining  it  after  the  use  of  gas.  The  same 
objections  hold  good  as  in  Clover's  apparatus,  and  the  same  precautions  as  to 
letting  in  atmospheric  air  from  time  to  time  must  be  observed. 

In  the  administration  of  ether  it  is  now  usual  to  adopt  what  is  known  as  the 
'  gas  and  ether  method,'  by  which  is  meant  that  the  patient  is  first  anaesthetised 
with  nitrous  oxide,  and  the  anaesthesia  is  continued  and  maintained  by  means 
of  ether.  If  the  Clover's  inhaler  is  to  be  employed,  the  arrangement  shown  in 
Fig.  430  is  employed,  a  Clover's  ether-chamber  being  interposed  between  the 
face-piece  and  the  three-way  tube  of  a  nitrous  oxide  apparatus.  The  patient 
is  first  allowed  some  six  or  eight  full  inspirations  of  nitrous  oxide,  and  then  the 
ether-chamber  is  turned  to  permit  of  gradually  increasing  doses  of  ether  vapour. 
As  soon  as  symptoms  of  nitrous  oxide  narcosis  present  (twitching  of  muscles, 
irregular  stertor,  etc.),  the  gas-bag  is  detached  and  the  ordinary  ether-bag 
substituted. 

The  Ormsby's  mask  does  not  permit  of  this  gradual  addition  of  ether  vapour  ; 
full  nitrous  oxide  anaesthesia  must  be  induced  with  the  ordinary  apparatus, 
and  then  a  rapid  change  is  made  to  the  iully-charged  ether  inhaler.  The 
results  are  sufficiently  satisfactory,  but  much  more  experience  and  skill  are 
required  than  when  the  Clover  is  used. 

The  advantages  claimed  for  this  '  combined  method  '  are  that  anaesthesia  is 
induced  much  more  rapidly  (two  minutes),  and,  what  is  far  more  important, 
the  process  is  much  less  unpleasant  for  the  patient  than  when  ether  alone  is 
employed.  The  patient  is  apt,  especially  when  the  Ormsby's  mask  is  used,  to 
become  rather  livid  and  rigid,  but  these  conditions  pass  off  in  the  course  of  a 
minute  or  two. 

4.  To  obviate  the  depressing  effects  of  chloroform,  a  combination  known  as 
the  A.C.E.  Mixture  is  often  used,  consisting  of  alcohol,  chloroform,  and  ether, 
blended  in  the  proportion  of  one,  two  and  three  parts  respectively.  It  may  be 
given  either  from  a  Rendel's  mask,  or  by  the  open  method  as  for  chloroform, 
but  the  latter  plan  is  only  applicable  to  children  and  weakly  individuals,  who 
require  but  little  anaesthetic.  Renders  mask  consists  of  an  oval  box  open  at 
one  end  and  shaped  to  fit  the  nose  and  mouth,  and  the  fundus  perforated  with 
holes  to  permit  of  the  free  entrance  of  air  ;  it  may  be  made  of  leather,  or  pre- 
ferably of  celluloid  or  metal.  Two  or  three  sponges  are  placed  within  it,  and 
soaked  with  the  anassthetic,  the  patient  breathing  in  and  out  of  the  cone.  The 
inspired  air  is  thus  laden  with  the  vapour,  and  the  amount  admitted  is  regu- 
lated in  measure  by  covering  a  certain  proportion  of  the  inlet  holes  with  the 
hand.  The  objection  to  this  reagent  is  that  it  evaporates  somewhat  unequally, 
the  ether  coming  off  first,  and  leaving  an  excess  of  chloroform,  which  when 
administered  in  a  cone  may  be  dangerous ;  this  can,  however,  be  obviated  by 
remoistening  the  sponges  alternately  with  the  mixture  and  with  pure  ether. 

General  Remarks  as  to  the  Administration  of  Anaesthetics. 

The  medical  practitioner  must  never  lose  sight  of  the  fact  that  a  certain 
element  of  risk  is  necessarily  attached  to  the  artificial  induction  of  a  condition 
in  which  the  activity  of  the  nervous  system  is  entirely  suspended,  except 
for  the  maintenance  of  those  phenomena  which  are  actually  essential  for  life. 
Hence,  an  anassthetic  should  never  be  given,  unless  absolutely  necessary, 
without  careful  preparation  of  the  patient,  or  such  examination  as  shall  satisfy 
the  doctor  as  to  his  capability  of  safely  taking  it. 

The  Preparation  of  the  Patient  is  a  most  important  proceeding.  When 
practicable,  the  general  habits  of  the  individual  should  be  carefully  regulated 


ANESTHESIA 


for  a  few  days  prior  to  the  operation,  and  on  the  preceding  night  a  suitable 
purgative  is  administered,  castor-oil  being  perhaps  the  most  efficacious.  Any 
food  given  on  the  morning  of  the  operation  should  be  light  and  easily 
assimilable,  whilst  nothing  should  be  taken  for  at  least  three  hours  pre- 
viously, so  as  to  make  sure  that  the  stomach  is  empty.  In  casualty  cases,  it 
may  be  advisable  to  relieve  gastric  distension  with  an  emetic,  or  by  washing 
out  the  organ  before  commencing  the  administration.  The  anaesthetist  must 
ascertain  that  no  loose  artificial  teeth  are  present  in  the  mouth,  and  that  no 
tight  clothes  or  bands  encircle  the  neck  or  thorax.  In  very  nervous  cases,  or 
where  much  shock  is  anticipated,  a  preliminary  hypodermic  injection  of 
strychnine  or  a  nutrient  enema  may  be  administered. 

The  anaesthetic  should  never  be  pushed  in  the  early  stages,  but  is  given 
slowly  and  gradually,  especially  in  nervous  individuals.  When  there  is  any 
struggling,  the  movements  of  the  limbs  should  be  restrained  with  as  little  force 
as  possible,  and  care  must  be  taken  during  the  deep  respirations  which  follow 
such  struggling  not  to  administer  an  overdose.  The  condition  which  the 
administrator  should  aim  at  maintaining  is  one  characterized  by  total  muscular 
relaxation,  insensitiveness  of  the  cornea,  and  a  contracted  state  of  the  pupil, 
whilst  the  pulse  and  breathing  continue  regular.  If  the  pupil  commences  to 
dilate,  and  the  corneal  reflex  is  present,  the  patient  is  apt  to  move  when  the 
knife  is  used,  indicating  that  more  anaesthetic  is  required.  Dilatation  of  the 
pupil  with  an  insensitive  cornea  is  always  an  indication  for  suspending  the 
administration  for  a  time.  If  the  anaesthesia  is  not  sufficiently  deep,  vomiting 
is  likely  to  occur,  being  ushered  in  by  weakness  and  rapidity  of  the  pulse,  and 
pallor  of  the  face ;  this  may  often  be  averted  by  pushing  the  anaesthetic.  The 
anaesthetist's  chief  attention  must  be  directed  to  observing  the  state  of  the 
respiration  and  pupil ;  but  he  should  also  note  the  colour  of  the  lips,  cheeks, 
and  ears,  as  thereby  valuable  information  is  gained  as  to  the  condition  of  the 
circulation.  The  pulse  should  be  felt  occasionally,  but  it  is  less  important  to 
attend  to  this  than  to  the  other  points  noted  above.  After  the  deep  anaesthesia 
required  in  division  of  the  skin,  most  operative  proceedings  on  the  subcu- 
taneous tissues  are  comparatively  painless,  and  hence  the  anaesthetic  need  not 
be  pushed  quite  so  far.  Whilst  the  wound  is  being  closed,  the  patient  must 
be  again  somewhat  more  completely  under  control.  In  operations  upon  the 
mouth  associated  with  haemorrhage,  the  head  must  be  occasionally  turned  to 
one  side  to  allow  the  blood  to  gravitate  out  of  the  mouth,  and  the  pharynx 
well  sponged,  so  as  to  prevent  the  admission  of  clot  and  other  matters  into  the 
air-passages.  It  is  also  a  valuable  routine  plan  to  insist  upon  the  head  always 
being  turned  'on  one  side,  especially  when  ether  is  being  given,  since  mucus 
tends  to  collect  about  the  pharynx. 

The  After-Treatment  of  the  patient  is  always  a  matter  of  considerable  im- 
portance. He  is  carried  from  the  table  and  placed  on  his  back,  or  preferably, 
when  possible,  on  his  right  side,  in  bed  with  the  head  low.  Where  there  is 
any  tendency  to  shock,  hot-water  bottles,  well  wrapped  up,  should  be  applied 
to  the  feet  and  sides,  and  hot  blankets  over  all.  Absolute  quiet  must  be 
enjoined  for  some  hours,  and  the  room  darkened,  so  that,  if  possible,  the 
patient  may  fall  asleep.  No  food  is  administered  for  at  least  three  or  four 
hours,  and  then  only  very  cautiously,  a  little  weak  tea,  soda-water,  or  beef-tea 
being  given.  The  patient  is  likely  to  vomit  on  returning  from  unconsciousness, 
perhaps  bringing  up  a  little  bile-stained  mucus,  but  if  the  anaesthetic  has  been 
judiciously  given,  it  soon  ceases.  Occasionally,  however,  the  vomiting  persists 
for  some  time,  becoming  very  troublesome.  It  may  generally  be  checked  by 
a  hypodermic  injection  of  morphia,  and  by  washing  out  the  mouth  with  warm 
water ;  but  in  more  severe  cases,  lasting  for  some  days,  the  patient's  nutrition 
may  have  to  be  maintained  by  enemata,  and  the  stomach  kept  absolutely  at 
rest.  Benefit  may  sometimes  be  derived  by  giving  a  little  bismuth  and  hydro- 
cyanic acid  in  an  effervescing  mixture,  or  perhaps  champagne  ;  but,  as  a  ride, 
all  administration  of  food  by  the  mouth  should  be  stopped  until  the  vomiting 
has  ceased. 


moo  A   MANUAL  OF  SURGERY 

Three  chief  Dangers  are  encountered  during  the  administration  of  anaes- 
thetics : 

i.  Obstructed  Respiration  usually  results  from  falling  backwards  of  the  root 
of  the  tongue,  which  blocks  the  entrance  of  air  into  the  larynx.  The  respira- 
tions gradually  become  more  and  more  stertorous,  the  face  and  ears  become 
dusky,  and,  if  the  condition  is  not  relieved,  the  chest  continues  to  heave 
without  any  air  entering  or  leaving  it,  and  finally  ceases  when  the  patient  is 
completely  asphyxiated.  The  early  stages  of  this  condition  are  of  common 
occurrence,  whatever  the  anaesthetic,  and  the  administrator  must  always  be  on 
the  look-out  and  endeavour  to  prevent  it  by  turning  the  head  or  the  patient 
himself  so  that  the  tongue  falls  to  one  side.  If  it  occurs  in  spite  of  this 
position  being  adopted,  the  administration  is  at  once  suspended,  whilst  the 
tongue  must  at  all  hazards  be  drawn  forwards.  This  may  be  accomplished  in 
the  early  stages  by  pulling  on  the  beard  or  chin,  or  by  pressing  the  mandible 
forwards  by  the  fingers  placed  behind  the  angle  of  the  jaw.  In  the  later  stages 
the  mouth  should  be  forcibly  opened  by  a  gag,  and  the  tongue  grasped  by 
forceps  and  pulled  well  forwards,  or  a  finger  may  be  passed  back  into  the 
pharynx  to  draw  the  root  and  epiglottis  forwards,  and  at  the  same  time 
ascertain  that  the  entrance  to  the  glottis  is  free  from  obstruction.  Artificial 
respiration  should  be  undertaken  if  the  breathing  has  actually  stopped. 
Death  should  never  result  from  this  cause,  and  if  it  occurs,  it  can  only  be 
attributed  to  the  carelessness  of  the  anaesthetist. 

Obstruction  to  the  respiration  may  occasionally  arise  from  the  entrance  of 
vomited  material  into  the  air-passages  or  lungs,  the  patient  becoming  cyanosed 
during  an  attack  of  vomiting,  and  passing  rapidly  into  a  state  of  asphyxia. 
In  such  a  case  the  finger  must  be  swept  around  the  pharynx,  if  the  mouth 
can  be  opened,  to  see  that  the  glottis  is  clear,  whilst  tracheotomy  or  laryngo- 
tomy  may  be  necessary  should  the  teeth  be  firmly  clenched,  or  if  the  obstruc- 
tion is  below  the  entrance  to  the  glottis.  Fortunately,  this  accident  is  of  rare 
occurrence. 

2.  Complete  Cessation  of  Respiration  is  the  usual  primary  phenomenon  from 
an  overdose  of  chloroform ;  it  is  also  stated  to  happen  occasionally  during  ether 
narcosis.  The  pulse  continues  to  beat  distinctly  for  a  few  seconds,  although 
respiratory  movements  have  ceased.  Treatment  consists  in  at  once  stopping 
the  administration,  whilst  the  tongue  is  drawn  forwards,  and  the  fauces 
cleared  by  the  finger.  The  head  should  be  lowered  over  the  end  of  the  table, 
and  young  children  may  even  be  completely  inverted,  so  as  to  induce  a 
flow  of  blood  to  the  head.  Artificial  respiration  is  commenced  without  delay, 
whilst  the  thoracic  parietes  may  be  flicked  with  a  cold  wet  towel,  or  alternately 
douched  with  hot  and  cold  water.  Strychnine  or  ether  should  also  be  injected 
hypodermically,  and  if  the  condition  persists  and  the  heart's  action  ceases,  a 
Faradic  current  may  be  passed  from  the  second  or  third  intercostal  space  in 
front  to  an  electrode  placed  over  the  spine.  Attempts  at  resuscitation  should 
be  continued  for  half  to  three-quarters  of  an  hour.  At  the  same  time,  these 
measures  must  be  undertaken  with  discretion,  as  otherwise  it  is  quite  possible 
to  extinguish  the  feeble  spark  of  life  by  the  very  means  which,  used  wisely, 
would  have  restored  it. 

3.  Death  occasionally  results  from  primary  Cardiac  Failure,  which  may 
arise  (a)  from  fright  during  the  administration  of  the  anaesthetic  ;  (b)  from 
shock  with  cardiac  inhibition,  by  commencing  the  operation  before  com- 
plete anaesthesia  has  been  obtained  ;  and  (c)  from  an  overdose  of  chloroform 
or  ether  acting  directly  on  the  nerve  centres  or  on  the  muscular  substance 
of  the  heart.  On  post-mortem  examination  in  such  cases,  the  heart  muscle  is 
found  to  be  thin  and  flabby,  and  perhaps  infiltrated  with  fat;  the  ventricular 
walls  are  especially  affected.  Unfortunately,  this  condition  cannot  be  recognised 
with  certainty  by  the  stethoscope.  Patients  with  simple  valvular  lesions,  where 
the  defect  has  been  more  or  less  compensated,  do  not  generally  run  any  extra 
risk.  The  treatment  to  be  adopted  in  cases  of  cardiac  failure  during  anaesthesia 
is  the  same  as  for  stoppage  of  the  respiration. 


ANESTHESIA  1191 


The  Choice  of  an  Anaesthetic  in  any  particular  case  depends  mainly  on  the 
condition  of  the  circulatory  and  respiratory  apparatus  of  the  patient.  Ether  is 
perhaps,  on  the  whole,  the  safest  drug  to  employ,  especially  in  adults,  although 
it  is  less  pleasant  to  take  ;  it  may  cause  a  good  deal  of  bronchial  irritation  and 
congestion,  and  is  more  likely  to  give  rise  to  troublesome  after-vomiting, 
although  such  does  not  usually  last  long.  It  is  sometimes  followed  by  un- 
pleasant delirium.  Chloroform  is  easier  to  administer,  more  pleasant  to  take, 
and  less  likely  to  lead  to  objectionable  after-effects.  It  is  the  best  anaesthetic 
for  young  children  and  old  people,  though  its  action  upon  the  heart  contra- 
indicates  its  use  in  patients  whose  circulation  is  weak.  The  A.C.E.  mixture 
may  also  be  safely  employed,  if  the  precautions  already  indicated  on  an  earlier 
page  are  attended  to. 

Ether  is  certainly  contra-indicated  in  patients  suffering  from  any  bronchitic 
or  pulmonary  trouble,  and  its  administration  for  operations  about  the  face  or 
mouth  is,  of  course,  impracticable.  Chloroform  should  not  be  given  in  cases 
of  cardiac  weakness  or  advanced  renal  disease  ;  for  abdominal  work  it  is 
always  to  be  preferred  to  any  other  agent,  as  also  in  operations  on  the  brain. 


INDEX 


N.B.  —  The  more  important  references  are  always  placed  first,    the  less    important 
afte>~wanis. 


Abdominal  aorta,  ligature  of,  291,  279 

aneurism,  277 

operations,  general  remarks  on,  966 

surgery  (Chapter  XXXII.),  891-969 

walls,  injuries  of,  891 

wounds,  mortality  of,  203 
Abscess,  acute,  41-50 

alveolar,  735 

anal,  1029 

antrum,  740 

appendix,  948 

axillary,  49,  318 

cerebellar,  720,  821 

cerebral,  694,  718,  821,  818,  713,  761 

chronic  tuberculous,  50,  143,  655,  662 
diagnosis  of,  261,  659,  980,  990 

dorsal,  656,  662 

iliac,  660 

in  bone,  504,  505,  519 

in  hip-joint  disease,  615,  616 

in  kidney,  1058 

in  spinal  disease,  655 

intra-mammary,  868,  871,  49 

ischio-rectal,  1027,  49,  657 

lacunar,  119 

lumbar,  657,  662 

of  labium,  1140 

of  liver,  955 

of  spleen,  965 

of  tongue,  775 

palmar,  208,  49 

perineal,  11 32 

perinephritic,  1058,  660,  1052 

prostatic,  1108 

psoas,  657,  662 

pyremic,  104,  106 

residual,  52,  659 

retro-pharyngeal,  805,  656 

subcranial,  690,  677,  694,  720,  818 

sublingual,  783,  93 

submammary,  868,  872,  92 

subpericranial,  705 

subperiosteal,  503 

subphrenic,  900,  921,  948 

supramammary,  868 
Abscess,  chronic,  treatment  of,  662,  55 
of  breast,  871 


A.C.E.  mixture,  1188,  46S 
Accessory  thyroids,  837 
Acetabulum,  fractures  of,  566 
Achondroplasia,  528 
Acinous  cancer,  179 
Acne,  753 
Acro-arthritis,  605 
Acromegaly,  531 
Acromion,  dislocation  of,  550 

fracture  of,  449 
Actinomycosis,  148,  784,  22,  046 
Acupressure,  231 

Acupuncture  for  aneurism,  268,  270,  276 
278 

for  abscess  of  liver,  956,  957 

for  hydatid  of  liver,  959 
Adams   osteotomy,  610 
Adder's  bite,  205 
Adductor  longus,  injury  to,  366 
Adenoids,  766,  793 
Adenonn,  172 

of  adrenal  bodies,  1066 

of  breast,  875 

of  kidney,  1066 

of  palatal  glands,  798 

of  post-anal  gut,  649 

of  prostate,  11 11 

of  rectum,  1035 

of  testis,  1 152,  183 

of  thyroid,  830,  834 
Adeno-sarcoma  of  breast,  877 
Adhesions  in  hernial  sac,  972,  979,  994 

in  joints,  423,  573,  609 

intraperitoneal,  897,    8 
1010,  1015 
Adrenal  tumours,  1066 
Adventitious  bursre,  373 
Aerial  fistula,  828 
Aerobic  bacteria,  4 
Air  into  veins,  entrance  of. 
Air-passages,        surgery 

XXX.),  838-865 
Albuminuria,  1091 
Alexines,  13 
Alibert's  keloid,  214 
Alopecia  in  syphilis,  128 
Alveolar  processes,  affections  of,  735 


906,   947, 


See  Veins 
of      (Chapter 


1 194 


INDEX 


Alveolar  sarcoma,  158 

Ambulatory  treatment  of  fractures,  431 

Amoeba  coli,  955,  22 

Amputation  of  penis,  1140 

Amputations  (Chapter  XL. ),  1166-1183 

during  shock,  219,  200 

for  acute  arthritis,  581 

for  aneurism,  269,  277 

for  compound  fractures,  199,  435 

for  gangrene,  74,  76,  yj,  79,  80,  83, 
199,  269,  283,  434 

for  infantile  paralysis,  666 

for  lacerated  wounds,  198 

for  rupture  of  main  artery,  200,  248, 
424 

for  sa'coma  of  bone,  536 

for  secondary  haemorrhage,  241 

for  spreading  traumatic  gangrene,  83 

for  tuberculous  diseases  of  joints,  592, 
593.  594.  595.  618 
Amussat's  operation,  940 
Amyloid  degeneration,  53,  255,  580,  1092 
Anaerobic  bacteria,  4 
Anaesthesia  (Chapter  XLL),  1184-1191 

dolorosa,  658 
Anaesthetic,  choice  of,  1191 

leprosy,  147 
Anatomical  wart,  206 
Anel's  ligature  for  aneurism,  265 
Aneurism  (Chapter  X.),  256-280 

by  anastomosis,  170,  537,  706 

cirsoid,  170,  706 

diffuse  traumatic,  247 

of  bone  (osteo-aneurism),  537 

treatment  of,  263-269 

varicose   250,  705 
Aneurismal  varix,  249,  275,  305,  311,  683, 

705 
Aneurisms,  special,  270-280 
Angini  of  Ludwig,  93,  784 
Angioma,  169 
Angular  curvature  of  spine.     See  Pott's 

disease,  650 
Ankle,  acute  arthritis  of,  583 

amputation  at,  1177,  5l8 

ankylosis  of,  610 

effusion  into,  574 

excision  of,  626 

fracture-dislocations  of,  490,  569 

tuberculous  disease  of,  595 
Ankyloglossia,  773 
Ankylosis,   608,   78,   147,    332,   615.   665, 

7Si 
Anterior  crural  nerve,  affections  of,  350 
Anthrax,  113 
Antisepsis,  14 

Antiseptic  treatment  of  wounds,  14 
Antiseptics,   15 

Antistreptococcic  serum,  use  of: 
before  abdominal  section,  966 

operations  on  tongue  or  pharynx, 

783,  802,  804 
operations  on  joints,  569 
in  cellulitis,  92 
in  erysipelas,  99 


Antistreptococcic  serum  in  pyaemia,  107 

in  septicaemia,    102 
Antrum,  affections  of,  740 
Antyllus'  ligature  for  aneurism,  265 
Anus,  affections  of,  1026,  1029, 1032,  1034, 
1036,  1047 

artificial,  938,  922,924,  926,  927,  928, 
939,  999,   1004,   1007,   1014,   1016, 
1022,  1038 
Aorta,  abdominal,  aneurism  of,  277 

compression  of,  237,  278,  1181 

ligature  of,  291,  279 

thoracic,  aneurism  of,  270 
Aphasia,  700,  720 
Aplasia  cranii  congenita,  709 
Apncea,  863 
Appendicitis,  945,  1014 
Arachnoid  cyst,  683,  191,  186,  668 
Arm,  amputation  through,  1173 

deformities  of,  388 
Arterial  haemorrhage,  222,  235 
Arterial  suture,  249 

thrombosis,  246,  255,  76,  79 

varix,  706 
Arteries,  affections  of  (Chapter  X.),  246- 
280 

ligature  of,  280-297 
Arterio-venous  wounds,  249,  706 
Arteritis,  varieties  of,  250 
Arthrectomy   for   tuberculous   disease   of 

joints,  591,  593,  594 
Arthritis,  acute,  578,  540,  504,  750 

deformans.     See  Osteo-arihritis,  596 

following  nerve  lesions,  604 

tuberculous,  586 
Arthrodesis,  666 
Artificial  respiration,  865 
Ascarides,  1027,  1084 
Asepsis,  14,  1 168 
Asphyxia,  863 
Aspiration  for  hydronephrosis,  1055 

of  bladder,  1131 

of  chronic  abscess,  55 

of  empyema,  859 

of  hepatic  abscess  and  cyst,  957,  959 

of  pericardium,  863 
Asthenic  fever,  32,  220 
Astragalus,  dislocation  of,  570 

excision  of,  627,  407 

fracture  of,  493 

tuberculous  disease  of,  516 
Atheroma,  252,  256 
Atlas,  dislocation  of,  635,  658 
Atony  of  bladder,  1086,  1100,  11 12 
Atrophic  scirrhus,  884,  180 
Atrophy  of  bone,  529,  418,  470,  709 

of  muscles,  328,  642 

of  skull,  709 

of  testis,  1 161 
Auditory  nerve,  injury  of,  342 
Autoplasty,  709 
Axillary  abscess,  49,  318 

artery,  aneurism  of,  277 
ligature  of,  288 

cellulitis,  92 


INDEX 


i'95 


Bacilli,  2 

Bronchus.     See  Air-passages 

Bacillus  anthracis,  113 

Bruise,  190,  191 

coli  communis,  6,  44,  506,  661,  891, 

Bryant's  test-line,  474 

895.  899.  901.  922,  928,  946,  955, 

Bubo,  1138,  119 

961,  997,  1018,  1027,  1076,  1 120 

Bubonocele,  975,.  980 

leprae,  146 

Bulb,  haemorrhage  from  artery  of 

1 104 

mallei,  145 

Bullet  wounds.     See  Gunshot  wounds 

of  malignant  oedema,  82,  100 

Bullets,  kinds  of,  204 

tetani,  107 

Bunion,  414 

tuberculosis,  141 

Burns,  85 

typhosus,  3,  44,  5T0,  585 

Bursse,  diseases  of,  373 

Bacteria,  1-5 

Bursal  cysts  in  neck,  825 

Bacteriology  of  acute  abscess,  42 

Butcher's  wart,  206 

Baker's  cysts,  578,  369,  185 

Baker's  operation  for   fractured    patella, 

Caecjal  hernia,  973 

484 

Caecum,  cancer  of,  928 

operation  for  hernia,  987 

Calcium  chloride  in  blood,  298 

Balanitis,  1137,  119 

for  haemophilia,  245 

Ballooning  of  rectum,  1034 

Calculous  anuria,  T063 

Banks'   (Mitchell)   ODeration    for    hernia, 

Calculus,  biliary,  960,  1012 

987 

impacied  in  urethra,  1120 

Basal  meningitis,  692 

intestinal,  1013 

Base  of  skull,  fracture  of,  669 

prostatic,  1110 

Basilar  artery,  aneurism  of,  274 

renal,  ic6i 

Bassini's  operation  for  hernia,  984 

salivary,  786 

Beatson's  operation  (oophorectomy),  890 

vesical,  1094 

Bedsores,  80,  433,  633 

Callosity,  354 

Bell's  palsy,  341 

Callus,  425 

Bellocq's  sound,  770 

Canalization  of  veins,  242 

Benign  tumours,  151 

Cancellous  osteoma,  164 

Berger's  amputation  of  upper  extremity, 

Cancer  en  cuirasse,  883 

"74.  536 

Cancer,  general  facts  of,  172-181 

Biceps  cruris,  tenotomy  of,  372 

of  bladder,  1082 

cubiti,  injuries  of,  364,  365 

of  bone,  536 

Bilharzia  ha;matobia,  1090,  1027,  1055 

of  branchial  cleft,  823 

Biliary  fistula,  894,  960,  963 

of  breast,  880,  180 

passages,  affections  of,  959 

of  intestine,  927 

Bilocular  hydrocele,  1155 

of  jaw,  738,  742,  743,  749 

Biniodide  of  mercury,  15,  16,  18 

of  kidney,  1067 

Bites,  snake,  205 

of  larynx,  843 

Bladder,  affections  of  (Chapter  XXXVII.), 

°f  1>P.  733 

1072- 1 107 

of  liver,  959 

Bladder  in  hernia,  973 

of  nasal  fossa;,  765,  766 

Blastomycetes,  22 

of  oesophagus,  809 

Blood-clot,  organization  of,  2r3,  228,  512 

of  pancreas,  965 

Blood-cysts,  825,  186 

of  parotid,  788 

Bobbins,  decalcified  bone,  937 

of  penis,  1139 

Boil,  351,  814 

of  pharynx,  804 

Bone,  diseases  of  (Chapter  XVIII.),  495- 

of  prostate,  11 16 

538 

of  pylorus,  909 

Bone,  injuries  of  (Chapter  XVII.),  417-494 

of  rectum,  1036 

Boric  acid,  15 

of  scrotum  (chimney-sweep's) 

1 165 

Bottini's  operation,  1115 

of  spleen,  965 

Bougies,  urethral,  1124 

of  stomach,  907 

Brachial  artery,  compression  of,  237 

of  testis,  1154 

ligature  of,  289,  244 

of  thyroid,  836 

plexus,  affections  of,  343 

of  tongue,  778 

stretching  of,  344 

of  tonsil,  801 

Brain.     See  under  Cerebral,  Concussion, 

Cancrum  oris,  83,  751,  773 

and  Compression 

Capillary  hcemorrhage,  222,  24^ 

Branchial  cleft,  affections  of,  822 

naevus,  308 

Brasdor's  operation  for  aneurism,  266.  274 

Carbolic  acid,  15 

Breast,  diseases  of  (Chapter  XXXI),  866- 

Carboluria,  15,  1C92 

890 

Carbuncle,  352 

Bronchocele.     See  Goitre 

Carcinoma.     See  Cancer 

1 196 


INDEX 


Garden's  amputation,  1180 
Caries,  498,  496 
necrotica,  510 
of  spine,  650 
of  temporal  bone,  815 
syphilitic,  521 
tuberculous,  514,  650,  711 
Carotid  artery,  aneurism  of,  272 
compression  of,  236,  273 
ligature  of,  283,  271,  273,  274,  275 
Carr's  splint,  465 
Carrying  angle,  456 

Cartilage,  affections  of,  in  joint  disease, 
584,  580,  587,  596,  598,  606 
semilunar.     See  Semilunar 
Cartilages,  necrosis  of  laryngeal,  842,  843, 

844 
Cartilaginous  tumours.     See  Chondroma 
Caseation  in  tubercle,  143 
Castration,  1163,  1150 

for  enlarged  prostate,  1115 
Catarrhal  inflammation,  34 
Catgut  ligatures,  232,  18 
Catheter  fever,  11 13 

Catheterism,  asepsis  in,  634,  664,  1078, 
1113,  1124 
dangers  from,  1125 
difficulties  in,  1125 
for  enlarged  prostate,  11 13 
Catheters,  1124 
Cavernous  nrjevus,  308 
Cautery,  uses  of,  231,  358,  590,  639,  660, 

1046,  1049 
Cellulitis,  90 
of  axilla,  92 

of  ischio-rectal  fossa,  1028 
of  orbit,  93 
of  scalp,  93 
of  scrotum,  n 64 
pelvic,  93,  1074,  1104,  1083 
submammary,  92 
submaxillary,  93,  784 
Cellulo-cutaneous  erysipelas,  96 
Central  necrosis,  509 
Cephalhematoma,  667,  191 
Cephalhydrocele,  668 
Cephalotetanus,  no 
Cerebellar  abscess,  720 
Cerebral  abscess,  718,  692 
treatment  of,  721 
hremorrhage,  684,  695 
irritation,  686 
tumours,  714,  720 

operations  on,  716 
Cerumen  in  ear,  813 
Cervical  plexus,  injury  to,  343 

rib,  381,  276 
Chancre,  hard,  123 
of  anus,  1034 
of  lip,  731 
of  nipple,  867 
of  tongue,  777 
of  tonsil,  801 
of  urethra,  124,  1121 
Chancre,  soft  (chancroid),  1137 


Chapped  lips,  732 

Charcot's  disease,  602 

Chemiotaxis,  12,  24 

Chest.     See  Thorax 

Cheyne's,  Watson,  operation  for  femoral 

hernia,  991 
Cheyne-Stokes  respiration,  687,  719 
Chinosol,  16 

Chloroform,  administration  of,  1185 
Cholangitis,  suppurative,  955,  961 
Cholecystectomy,  964 
Cholecyst-enterostomy,  963,  960 
Cholecystitis,  961,911 
Cholecystotomy,  962,  955 
Cholelithiasis,  960 
Cholesteatoma,  816 
Cholesterine,  911,  52 
Chondro-arthritis,  596 
Chondroma,  163,  742,  747 
Chopart's  amputation,  1176 
Chordee,  119 

Chronic  abscesses,  treatment  of,  662 
Chronic  inflammation,  37-40 
Chylous  hydrocele,  1159,  315 
Chyluria,  1091 
Cicatrices.     See  Scar 
Circular  amputation,  n66 
Circumcision,  1135,  983 
Circumflex  nerve,  affections  of,  344 
Cirsoid  aneurism,  706,  170 
Clavicle,  dislocations  of,  549 

fractures  of,  446 
Claw  foot,  412 

hands  in  leprosy,  146 

of  ulnar  paralysis,  348 
Cleft  palate,  790 
Cline's  splint,  488,  492 
Cloacce,  501 
Clover's  inhaler,  1186 
Club-foot,  400 

hand,  389 
Coagulation  necrosis,  25,  44,  45 
Cocaine,  1185 
Cocci.     See  Micrococci 
Coccydynia,  470 
Coccyx,  excision  of,  469,  1026,  1039,  1164 

fracture  of,  469 
Cock's  operation  of  perineal  section,  1131 
Cold  in  treatment  of  inflammation,  36 
Coley's  fluid,  160,  181 
Colic,  appendicular,  949 

biliary,  961 

renal,  1063 
Collapse,  215,  896,  999,  1021,  1023 
Colles'  fascia,  1133 

fracture,  463 

law,  136 
Colliquative  necrosis,  25 
Colloid  cancer,  180,  909,  83i,  927 
Colopexy,  1049 

Colotomy,  939,   1018,    1026,    1034,    1035, 
1038,  1041,  1049 

methods  of,  compared,  944 

uses  of,  940 
Columnar  carcinoma,  178 


INDEX 


1197 


Columnar  carcinoma  of  bladder,  1033 
of  breast,  885 
of  intestine,  927 
of  rectum,  1036 
of  stomach,  908 
of  upper  jaw,  743 
Coma,  diabetic,  77 

diagnosis  of,  688 

in  cerebral  abscess,  719 

in  cerebral  tumour,  715 

in  head  injuries,  681,  683,  684,  G87, 
690,  691,  696,  703 

ura^mic,  1014 
Comminuted  fracture,  420 
Compound  fractures,  419,  434,  199 
Compression,  cerebral,  687 
Concussion,  cerebral,  684 

of  the  spine,  637,  640,  641 
Condylomata,  128 

of  anus,  1034,  1045 
Congenital  abnormalities  of  testis,  1142 

cysts,  182 

dislocation,  540 

fracture,  419 

hernia,  970,  976,  987,  991 

hydrocele,  1155 

induration  of  sterno-mastoid,  823,  366 

malformations  of  rectum,  1026 

syphilis,  136 
Congestive  stricture,  1120 
Conical  stump,  1170 
Conjunctivitis,  gonorrheal,  120 
Constipation,  995,  999,   ioeo,  1012,  T021, 

1024,  1033,  1037 
Contagion,  9 
Contraction,  Dupuytren's,  392 

of  scars,  214 
Contusions,  190 

of  abdominal  wills,  891 

of  bones,  417 

of  intestines,  921 

of  lung,  854 

of  kidney,  1002 

of  nerves,  326 

of  skull.  668 
Cooper  Rose's  inflating  bag,  771 
Corns,  354,  171 
Corradi's  method  of  treating  aneurysms, 

268 
Corrosive  sublimate,  15 
Costal  cartilage,  separation  of,  445 
Counter-irritation,  39 
Cowper's  glands,  inflammation  of,  119 
Coxa  vara,  393 
Coxalgia  and  coxitis.     See  Hip  disease, 

611 
Craniectomy,  linear,  710 
Cranio-cerebral  topography,  701 
Craniotabes,  524,  525.  700 
Cranium,  injuries  of,  668-680 

diseases  of,  707-713 
Crepitus,  421 

Croupous  inflammation,  34 
Crus  cerebri,  injuries  to,  700 
Crutch  palsy,  433,  345 


Cryptoscope,  201 
Cubitus  valgus,  456 

varus,  456,  459 
Curvature  of  spine,  angular,  650 

lateral,  38 r 
Cut  throat,  825 
Cylindroma,  159 

Cystic  hygroma,  31  \,  650,  823,  824 
Cystine,  1095 
Cystitis,  1076,  1100,  1112 

in   spinal    affections,  634,   640,    643, 
659,  1076 
Cysto-adenoma,  831,  878,  172 
Cystoscope,  1075 
Cystotomy,  perineal,  1079 
Cystotomy,  suprapubic,  1105,  1080,  1084 
Cysts,  181-189 

blood,  186,  825 

branchial,  822 

degeneration,  189 

dental,  737 

dentigerous,  747,  171 

dermoid,  182,  649,  707,  784,  S23,  874, 
1067 

foreign  bodies,  186 

hydatid,  187,  537,  715,  825,  861,  874, 
958,  1067 

implantation,  186 

in  floor  of  mouth,  784 

involution,  870,  873 

Morrant  Baker's,  578,  185 

mucous,  732 

of  breast,  872 

of  jaw,  737,  747,  171,  183 

of  kidney,  1067 

of  labia,  1141 

of  neck,  823 

of  ovary,  183,  184,  185 

of  pancreas,  964 

of  round  ligament,  1159,  185 

of  spermatic  cord,  1158,  185 

of  thyroid,  831,  83^,  825 

of  thyro-glossal  duct,  823,  778,  784, 

183 

of  Wolffian  body,  1158,  183 
sebaceous,  361,  707,  825 
serous,  185,  825,  873,  1067 
Czerny-Lembert  suture,  930 

Dactylitis,  tuberculous,  514 
Davy's  lever,  1181 
Decalcified  bone,  use  of,  517 
Deformities  (Chapter  XVI.),  378-416 

in  rickets,  525 
Degeneration,  cysts  of,  189 

in  arteries,  254 

in  nerves,  328 
Delirium  tremens,  221,  422 
Dental  cysts,  737 
Dentigerous  cysts,  747,  171 
Depressed  fractures,  674 
Dermatitis  maligna,  867 
Dermoid  cysts.     See  Cysts 
Diabetes,  1093 
Diabetic  gangrene,  77,  1094 


INDEX 


Diaphragmatic  hernia,  994 

Diaphysitis,  acute,  502 

Diffuse  traumatic  aneurism,  247 

Digital  compression  of  arteries,  229,  236, 

264 
Dilatation  of  cardiac  orifice,  807,  8io,  912 

of  oesophagus,  810 

of  pylorus,  911 

of  rectum,  1034 

of  urethra,  n 27 
Diphtheria,  34,  758,  841,  847,  852 
Diplococci,  2 

Diplococcus  urea:  liquefaciens,  1076 
Direct  inguinal  hernia,  977 
Dislocations  (Chapter  XIX.),  539-572 

of  spine,  634 
Dissecting  aneurism,  259,  253 
Dissection  wounds,  206 
Distal   ligature    for   aneurism,   266,   271, 

274,  277 
Distension     of    bladder    with    overflow, 

1085,  1087 
Disunited  fracture,  438 
Diverticula  of  oesophagus,  805 
Diverticulum  of  Meckel,  921,  ion 
Dorsal  dislocation  of  hip,  562 
Dorsalis  pedis  artery,  ligature  of,  297 
Drainage  in  abdominal  operations,  968 

in  treatment  of  wounds,  195,  19 
Dressings  for  operations,  19 
Drowning,  865 
Dry  gangrene,  68 
Duct  cancer,  884,  879 

papilloma,  879 
Duodenum,  perforating  ulcer  of,  921,  901, 

87 
Dupuytren's  contraction,  392 

enterotome,  1008 

fracture,  490 

splint,  492 
Dura  mater,  injuries  of,  677,  690 
sarcoma  of,  712 

thickening  of,  causing  epilepsy,  703 
Durham's  tracheotomy  tube,  849 
Dyspeptic  ulcer,  777 
Dysphagia,  811 
Dyspnoea.     See  Asphyxia 

Ear,    affections    of   (Chapter    XXVIII.), 

813-821 
Ecchondroses,  164 
Echinococcus  tasnia,  187,  301,  958 
Ecthyma,  130 
Ectopia  testis,  1143 

vesica;,  1072,  894 
Ectrodactylism,  390 
Eczema  of  external  auditory  meatus,  814 

of  nipple  (Paget's),  867 

of  scrotum,  1165 

varico-e,  306,  62 
Eczematous  ulcer,  63 
Eggshell    crackling,  534,    537,    712,   713, 

74°-  747 
Elbow-joint,  acute  arthritis  of,  582 
amputation  through,  1172 


Elbow-joint,  ankylosis  of,  609 

dislocations  of,  556 

effusion  into,  574 

excision  of,  622,  610 

tuberculous  disease  of,  593 
Electrolysis  for  aneurism,  268,  270,  275, 
278 

for  cirsoid  aneurism,  706 

for  hydatid  cysts,  959 

for  intra-orbital  aneurism,  275 

for  na;vi,  309,  732 
Elephantiasis  Arabum,  315 

Graecorum,  146 
Elliptical  (oval)  method    of  amputating, 

1167 
Emboli,  301,  72,  103,  254,  261,  262,  423, 

302 
Embolic  gangrene,  72 
Embryonic  tissue,  25,  45 
Emphysema,  surgical,  439,  713,  827,  855, 

923 
Emprosthotonos,  109 
Empyema,  858,  855,  656,  901,  906,  956 
of  antrum,  740 
of  frontal  sinuses,  713 
pulsating,  858 
Encephalitis,  691,  692 
Encephalocele,  707,  708 
Encephaloid  cancer,  i3o,  884 
Encysted  hernia,  977 

hydrocele  of  cord,  1158,  185,  980 
of  epididymis,  1157,  184 
of  round  ligament,  1159,  185 
End-to-end  anastomosis  of  gut,  933 
Endarteritis,  251,  39,  76,  142,  131,  132 
Endocarditis,  infective,  103 
Endosteal  sarcoma,  533,  712,  748 
Endothelioma,  159,  788 
Enterectomy,   93  r,    893,    924,    927,    928, 

1003,  1004,  1008,  1016 
Enteritis,  acute,  922,  1005 
Enterocele,  973 
Enteroliths,  1073 
Enteroplasty,  931,  927 
Enteroptosis,  105 1,  984 
Enterorrhaphy,  932,  928 
Enterostomy,  931,  1015 
Enterotome,  Dupuytren's,  1008 
Enterotomy,  931 
Epididymectomy,  1149 
Epididymitis,  1147,  1126,  1148,  119 
Epilepsy,  traumatic,  703 
Epiphysis,  separation  of,  420 
Epiphysitis,  499,  507,  518,  523 
Epiplocele,  973 
Epispadias,  1117 
Epistaxis,  769.439,  671,  222 
Epithelioma,  175 

after  lupus,  357,  359 

branchial,  823 

of  anus,  1036 

of  bladder,  1082 

of  glands  in  neck,  825 

of  gum,  738 

of  jaw,  lower,  749 


INDEX 


1 199 


Epithelioma  of  jaw,  upper, 

742,  743 

External  carotid,  aneurysm  of,  274 

of  larynx,  843 

ligature  of,  285,  243,  789, 

802, 

of  lip,  733 

804,  827 

of  nipple,  867 

External  iliac,  ligature  of,  293,  278,  280 

of  nose,  765 

External  popliteal  nerve,  affections  of,  350 

of  oesophagus,  809 

Extirpation  of  aneurism,  267 

of  palate,  798 

Extracapsular  fracture  of  femur,  471 

of  penis,  1139 

of  humerus,  451 

of  pharynx,  804 

Extradural     abscess.       See     Subcranial 

of  scalp,  707 

abscess 

of  scar,  215 

Extragenital  chancres,  124 

of  scrotum,  1165 

Extra-medullary  haemorrhage,  spina 

1,638 

of  stomal  h,  908 

Extravasation  of  blood,  222 

of  tongue,  778 

of    urine,    1133,     1074,    1083, 

1087, 

of  tonsil,  801 

1105,  1118 

Epi'vphlitis,  945 

Extroversion    of    bladder.      See    Ectopia 

Epulis,  737,  162 

vesicae,  1072 

Krethitic  shock,  217 

Exudation  cysts,  185 

Ergot,  gangrene  from,  78 

Erysipelas,  94,  799,  1165 

Facial  artery,  compression  of,  237 

curative  action  of,  98, 

[Co 

ligature  of,  286 

Erythema  nodosum,  97 

Facial  cleft,  oblique,  730 

Esmarch's  operation  for  cl 

osurc  of  lower 

nerve,  affections  of,  340 

jaw,  751 

operation  on,  342 

Estlander's  operation,  860 

paralysis,  340,  671,  788,  815 

Ether,  administration  of,  1186 

tic,  342 

Ethmoid,  diseases  of  the,  7 

61 

Facies  Hippocratica,  896,  999,  ioio 

Eucaine,  1185 

Ftecal  fistula.     See  Fistula 

Excision  of  joints,  620-627 

Faeces,  impaction  of,  1016,  1017 

for  acute  arthritis, 

581 

False  joints,  436,  546 

for  ankylosis,  610 

passages,  it 25 

for  dislocations,  5 

17 

Farabceuf's  amputations,  1171,  1174, 

1179 

for  fractures,  423, 

460 

Farcy.     See  Glanders 

for  tuberculous  di: 

ease,  591 

Fat  embolism,  423 

of  breast,  888 

Fatty  hernia,  162,  993 

of  condyle  of  jaw,  752 

tumour.     See  Lipoma 

of  Gasserian  ganglion 

339 

Femoral  artery,  aneurism  of,  279 

of  hydrocele  sac,  1157 

compression  of,  237 

of  larynx,  845 

ligature  of,  294,  279,  280 

of  mandible,  749 

hernia,  989 

of  maxilla,  744,  765,  766 

strangulated,  1006 

of  noevi,  309 

Femur,  fractures  of,  470 

of  parotid  gland,  789 

separation  of  lower  epiphysis  of. 

482 

of  pylorus,  917,  911,  9 

12 

upper  epiphysis  of,  478 

of  rectum,  1038 

Fever,  31,  219 

of  rib  for  empyema,  860 

Fibrin  ferment,  32,  219,  245,  422 

of  rib  for  hepatic  abscess,  957 

Fibroblasts,  25,  209,  227 

of  rib  for  sub-phrenic  abscess,  902 

Fibro-adenoma  of  breast,  875 

of  stomach,  916,  911 

thyroid,  830 

of  stricture  of  urethra, 

1130 

Fibro  cystic  disease  of  jaw,  748,  171 

of  thyroid,  833,  836 

of  testis,  1152,  183 

of  varicocele,  1160 

Fibroid,  recurrent,  157,  880 

Exclusion  of  intestine,  928 

Fibroid  thickening,  28 

Exomphalos,  991 

Fibroma,   162,   166,   167,   665,   707, 

732. 

Exophthalmic  goitre,  835 

742,  747,  764,  875 

Exophthalmos  (proptosia), 

275.  334,  672, 

Fibro-myoma,  166,  189,  1111 

683,  740,  835 

Fibro-sarcoma,  157,  166,  885 

Exostoses,  164,  712 

Fibrous  polypus,  764 

Exostosis  bursata,  165 

Fibrous  union  of  fracture,  436 

of  ear,  814 

Fibula,  fractures  of,  488 

of  first  rib,  275 

Fifth  nerve,  affections  of,  335 

subungual,  165 

Filaria  sanguinis  hominis,  315,  316, 

1091 

Expansion  of  bone,  515,  533,  537 

Fingers,  amputations  of,  1171 

Extension  of  leg,  476 

chancre  of,  124 

in  hip-joint  disease,  617 

deformities  of,  389,  391 

INDEX 


Finsen  light  cure  for  lupus,  358 

Fission,  3 

Fissure  of  anus,  1032 

of  lip,  congenital,  723-730 
Fissure  of  Rolando,  701 

Sylvius,  702 
Fissures  of  nipples,  866 
Fistula,  56 

aerial,  828 

biliary,  894,  960,  963 

bimucosa,  899,  925 

branchial,  822 

cervical,  824 

fsecal,  894,  899,  921,  948,  953,  1004, 
1006,  1008 

gastric,  906 

-in-ano,  1029 

median  cervical.  824 

oesophageal,  826 

penile,  119 

perineal,  1108,  1116,1122,1132,  1133 

pharyngeal,  828 

recto- vesical,  1083,  1104 

salivary,  789 

scrotal,  1165 

umbilical,  894 

urinary,  894,   1073,   1108  11 16,  1132, 
1134,  119 
Flap  amputation,  1167 
Flat  foot,  409 
Floating  kidney,  1050 

spleen,  965 
Fluctuation,  46,  48 
Foetal  residues,  151 
Foot,  amputation  of,  1175,  1177 

contusions  of,  199 

deformities  of,  403 
Forcible  straightening  of  spine,  662 
Forcipressure,  231 
Forearm,  amputation  through,  1172 
Foreign  bodies  in  air-passages,  757,  838 
in  appendix,  946 
in  bladder,  1075 
in  ear,  814 
in  hernial  sac,  974 
in  intestine,  1012 
in  nose,  757 
in  oesophagus,  806 
in  stomach,  903 
in  urethra,  n  18 
Fourth  nerve,  paralysis  of,  335 
Fractures  (Chapter  XVII.),  417-494 
Fractures,  early  operation  upon,  432 
Fragilitas  ossium,  418 
Frank's  operation  of  gastrostomy,  914 
Freezing  for  anaesthesia,  1158 
Frontal  lobes,  injuries  of,  686,  695,  699 

sinuses,  affections  of,  713,  761 
Frost-bite,  85 
Fungi,  21 

Fungus  haematodes,  66 
Furuncle.     See  Boil,  350,  814 
Fusiform  aneurism,  257 

Galactocele,  872 


Gallbladder,  affections  of,  959 
Gall-stones,  960,  1012 
Ganglion,  363 
Gangrene  (Chapter  V.),  67-89 

acute  emphysematous,  81 

after  aneurism,  247,  261,  263,  267 

during  treatment  of  fractures,  433 

from  diabetes,  T],  1094 

from  ligature  of  main  artery,  78,  282 

from  rupture  of  artery,  247 

from  splint  pressure,  80 

of  intestine,  997,    1003,    1004,   1016, 
1019 

of  lung,  861 

senile,  74,  255,  256 
Gant's  osteotomy  of  femur,  610 
Gartner's  duct,  cyst  of,  184 
Gasserian  ganglion,  removal  of,  339 
Gastrectomy,  916,  911 
Gastric  ulcer,  903 
Gastrocnemius,  rupture  of,  366 
Gastroenterostomy,  918,  905,  907,  911 
Gastrostomy,  914,  810,  911,  907 
Gastrotomy,  912,  807 
Gelenkmaus,  606 
Genu  recurvatum,  398 

valgum,  394,  526 

varum,  398,  526 
Giant  cells,  142,  158,  227,  357,  498 
Glanders,  145 

Glands,  affections  of  lymphatic,  317-325 
Glandular  cancer,  179 
Glass  wounds   201,  249 
Gleet,  116,  118 
Glenard's  disease,  105 1 
Glioma,  156,  714 
Glossitis,  774 

Glossopharyngeal  nerve,  affections  of,  342 
Gluteal  artery,  aneurism  of,  279 
bursa,  377 

haemorrhage  from,  244 
ligature  of,  292 
Goitre,  828 

Golding-Bird's  sling  for  flat-foot,  411 
Gonococcus,  115,  44,  585,  579,  895 
Gonorrhoea,  115 
Gonorrhoea]  arthritis,  585,  665 
Gottstein's  curette,  769 
Gout,  1088,  584,  600 
Granulation  tissue,  45,  61,  211 
Granulomata,  infective,  121 
Gravel,  1087,  1096 
Graves'  disease,  835 
Gravitation  paraplegia,  638 
Great  sciatic  nerve,  affections  of,  348 

stretching  of,  349 
Greenstick  fracture,  419 
Gritti's  amputation,  1180 
Growth  of  bone,  496 
Gubernaculum  testis,  1142 
Gumma,  131,  531,  715.  -jjj 
Gums,  affections  of,  735-738 
Gun-shot  wounds,  202-205 
of  abdomen,  203 
of  lung,  856 


INDEX 


Gun-shot  wounds,  of  skull,  676,  698,  203, 
205 

Hematemesis,  909,  223 
Hematocele  of  cord,  1145,  981 

of  tunica  vaginalis,  1144,  186 
Hematoma,  191 

of  abdominal  walls,  891 

of  ear,  813 

of  vulva,  1 141 
Hematuria,  1090,  1096,  1052,  223,  1109 
Hemoglobinuria,  1090,  78 
Haemophilia,  245,   1090 

joints  in,  605 
Hemoptysis,  223,  854 
Hemorrhage  (Chapter  IX.),  222  245 

during  amputations,  1169 
at  hip-joint,  1181 

from  catheterism,  1125 

from  gastric  ulcer,  905 

reactionary,  238 

secondary,  239 

special  sources  of,  243 

treatment  of,  229 
Hemorrhoids,  1044 
Hemostatics,  230 
Hemothorax,  854 
Hahn's  tracheotomy-tube,  850,  781 
Hallux  rigidis  (H.  flexus).  413 
Hallux  valgus,  413 
Halsted's  operation  for  hernia,  988 
for  scirrhus  mammas,  887 

suture,  930 
Hammer-toe,  414 

Hammond's  splint  for  fracture  of  man- 
dible, 442 
Hand,  amputations  of,  1172 

deformities  of,  389 
Hare-lip,  723 

Head  injuries  (Chapter  XX 111.),  667-704 
Healing  of  wounds,  208 

by  granulation,  211 

by  organization  of  blood-clot,  213 

by  primary  union,  211 

under  a  scab,  213 
Heart,  wounds  of,  862 
Heat  in  treatment  of  inflammation,  36 
Heat-stroke,  689 

Hectic  fever,  6,  52,  580,  589,  617,  659 
Hernia  (Chapter  XXXIII.),  970- 1008 

cerebri,  702,  677 

en-bissac,  979,  1002 

en-rnasse,  1002 

fatty,  993,  162,  981 

femoral,  989 

inguinal,  974 

internal,  ion,  1001 

interstitial,  979,  1002 

of  lung,  857 

strangulated,  996 

testis,  1151 

umbilical,  991 

ventral,  993,  893,  953 
Herpes  labialis,  732 

in  neuralgia,  332 


Herpes,  preputialis,  1139 

zoster,  348 
Hesselbach's  triangle,  978 
Heteroplasty,  710 
Hey's  amputation,  1176 

saw,  678 
Hilton's  method  of  opening  abscess,  49 
Hip-joint,  acute  arthritis  of,  579,  582,  507 

amputation  through,  1181,  618 

ankylosis,  609,  610 

congenital  dislocation  of,  540 

dislocations  of,  560 

effusion  into,  574 

excision  of,  624,  618 

osteo-arthritis  of,  601 

tuberculous  disease  of,  611 
Hodgen's  splint,  476 
Hodgkin's  disease,  324 
Hoffa's  operation,  543 
Horn,  sebaceous,  361,  n 39 
Hospital  gangrene,  83 
Hourglass  contraction  of  stomach,  907 
Housemaid's  knee,  376 
Howship's  lacune,  498 
Humerus,  fractures  of,  450 

separation  of  lower  epiphysis,  458 
upper  epiphysis,  452 
Hunterian  chancre,  123 

ligature  for  aneurism,  265 
Hunter's  canal,  ligature  of  femoral  artery 

in,  294 
Hydatid  cysts,  187 

of  bone,  537 

of  brain,  715 

of  breast,  874 

of  kidney,  1067 

of  liver,  958 

of  lung,  861 

of  Morgagni,  184,  1158 

of  neck,  825 

of  spine,  665 

of  spleen,  965 
Hydrarthrosis,  577 
Hydrencephalocele,  707 
Hydrocele,  bilocular,  1155 

congenital,  1155 

chylous,  1 159,  315 

of  breast,  873 

of  cord,  1158,  185 

of  hernial  sac,  972 

of  neck,  825 

of  round  ligament,  1159,  185 

of  tunica  vaginalis,  1154,  185 
Hydrocephalus,  710 
Hydrogen,  peroxide  of,  179 
Hydronephrosis,    1053,    94,    1055,    1062, 

1112,  1123 
Hydrophobia,  112 
Hydrops  antri,  741 

articuli,  577 

of  frontal  sinuses,  713 
Hygroma,  314,  824,  650 
Hyoid,  fracture  of,  443 
Hyperemia,  24 
Hyperostoses,  166 

76 


INDEX 


Hypertrophy  of  bone,  530 

of  breast,  876 

of  gums,  735 

of  prostate,  1110 

of  skull,  711 

of  tonsils,  800 
Hypoglossal,  injury  to,  343 
Hypospadias,  11 19 
Hypostatic  pneumonia,  433,  471 
Hysteria  in  spinal  injuries,  640 
Hysterical  joints,  608,  399 

Ichthyosis  linguae,  775 
Ileo-colostomy,  927,  928 
Iliac  abscess,  660 

aneurism,  278 

colotomy,  942 

vessels,  ligature  of,  291,  293,  279,  213 
Immunity,  10 
Impacted  calculus  in  urethra,  1120 

faeces,  1017 

fracture,  420 

gall-stones,  962,  963 
Impassable  stricture,  treatment  of,  ir3o 
Imperforate  anus,  1026 
Impermeable  stricture  of  urethra,  1121 
Implantation  cysts,  186 
Incised  wounds,  192 
Incontinence  of  urine,  1084,  643,  658 
Infantile  hernia,  977 

hydrocele,  1155 

paralysis,  666 
Infarct,  301,  104  ;  and  see  Emboli 
Infection,  8 
Infective  diseases  (Chapter  VI.),  90-149 

gangrene,  72,  81 

granulomata,  121 

processes,  10 
Inferior  dental  nerve,  operations  on,  338 

maxilla,  fracture  of,  440 
Inflamed  aneurism,  263,  269 

hernia,  995 
Inflammation  (Chapter  II.),  23-40 
Inflammatory  fever,  87 
Infra-orbital   nerve,    operations  on,  337, 

338 
Infusion  of  salt  solution,  224 

for  abdominal  injuries,  892,  924 

for  haemorrhage,  224 

for  sepsis,  8,  102 

for  shock,  219 
Ingrowing  toenail,  360 
Inguinal  aneurism,  278 

colotomy,  942 

hernia,  974 

strangulated,  1006 
Inhalers,  anaesthetic,  1186,  1188 
Injections  in  gonorrhoea,  117 

in  hydrocele,  11 57 
Innominate  artery,  aneurism  of,  271 

ligature  of,  283,  276 
Inoperable  malignant  disease,  160,  181 
Insanity,  traumatic,  704 
Intercostal     artery,    haemorrhage    from, 
244,  857 


Intercostal  neuralgia,  348 
Interma.xilla  in  hare-lip,  726 
Intermediate  haemorrhage,  238 
Internal  carotid,  aneurism  of,  274 

ligature  of,  285 

wounds  of,  682 
Internal  derangement  of  knee-joint,  567 

iliac  artery,  ligature  of,  291,  n  16 

mammary  artery,  haemorrhage,  243 
ligature  of,  287 

popliteal  nerve,  affections  of,  350 
Interscapulo-thoracic  amputation,  1174 
Interstitial  emphysema,  855 

hernia,  979 

inflammation,  35 

keratitis,  139 

mastitis,  869 
Intestinal  anastomosis,  932-938 

obstruction  (Chapter  XXXIV. ),  1009- 
1024 
Intestines,  affections  of,  921 

injuries,  921 

operations  on,  929 
Intracapsular  fracture  of  humerus,  450 

of  femur,  470 
Intracranial  aneurism,  274 

inflammation,  690,  718,  719,  818 
Intramammary  abscess,  868,  871,  49 
Intramedullary  haemorrhage  of  spine,  638 
Intrameningeal  haemorrhage,  683 
Intra-orbital  aneurism,  275 
Intra-uterine  fractures,  419 
Intubation  of  larynx,  853 
Intussusception,  1018 
Inunction,  mercurial,  134,  139 
Inversion  of  testis,  1143 
Involucrum,  501 
Involution  cysts,  870,  873 
Iodoform,  15,  590,  663,  55 
Iritis,  syphilitic,  128 
Irreducible  hernia,  994,  972 
Irrigation  of  abdomen,  892,  897,  900,  903 
of  chronic  abscess,  55 
of  pleural  cavity,  860 
Irritability  of  bladder,  1085 
Irritable  ulcer,  63,  777 
Ischaeinic  contraction  of  muscles,  433 
Ischio-rectal  abscess,  1027 
Ivory  exostosis.     See  Osteoma 

Jaundice,  954,  956,  960,  962,  963 
Jawbone.     See  Maxilla  or  Mandible 
Jaws,  affections  of,  739-752 
Joints,   diseases  of  (Chapter  XX.),   573- 
627 
injuries  of  (Chapter  XIX.),  539-572 
Jordans,   Furneaux-,   amputation  at  hip- 
joint,  1182 
Jugular  vein,  ligature  of,  821,  243 
Junker's  inhaler,  1186 

Keloid,  214,  162 
Keratitis,  interstitial,  139 
Kidney,  affections  of  (Chapter  XXXVI.), 
1050-1071 


INDEX 


1203 


Kidney,  amyloid  disease  of,  54 

Lateral  implantation,  928 

Kingsley's  splint,  414 

lithotomy,  1100 

Kinking  of  gut,  899,  1013,  1016 

sinus,  thrombosis  of,  720,  820,  103, 

of  ureter,  1051,  1053 

106 

Knee-joint,  acute  arthritis  of,  583 

Lavage,  912 

amputation  through,  1179 

'  Leather-bottle  stomach,'  908,  910 

ankylosis  of,  610 

Leg,  amputation  of,  1179 

contractions  of,  399 

Leiomyoma,  166 

dislocations  of,  567 

Lembert's  suture,  929 

effusion  into,  594 

Leontiasis  ossea,  742 

excision  of,  626 

Leprosy,  146 

subluxation  of,  567 

Leucocytes,  migration  of,  24,  227 

tuberculous  disease  of,  594,  399 

phagocytic  action  of,  12 

Knock-knee,  394,  396 

Leucocytosis,  47 

Kobelt's  tubes,  cysts  in  connection 

vith, 

Leucoplakia,  775 

1158,  183,  184 

Leukaemia,  323 

Kocher's  method  of  reducing  disloca 

ions 

Ligature  of  vessels,  280  297 

of  humerus,  555 

causing  gangrene,  78 

of  thyroidectomy,  833 

for  hemorrhage,  232-235 

operation  on  the  tongue,  782 

Ligatures,  234 

Kraske's  operation,  1039,  1026 

Lingual  artery,  ligature  of,  780,  285,  286 

Kyphosis,  386 

nerve,  operations  on,  338 
Lip,  affections  of,  723-735 

Labia,  affections  of,  1140 

Lipoma,  160,  650,  665,  990,  981 

Lacerated  wounds,  197-200 

arborescens,  162,  576 

Laceration  of  brain,  694 

diffuse,  161 

Lachrymal  bone,  fracture  of,  439 

fibrolipoma,  161 

Lacunar  abscess,  119 

ncevolipoma,  162 

Laminectomy,  644 

nasi,  754 

in  Pott's  disease,  664 

of  femoral  canal,  990 

Langenbeck's  operation   for  excision    of 

parosteal,  161 

rectum,  1039 

pericranial,  161 

on  nasal  cavity,  766 

sarcolipoma.  162 

Laparotomy  for  abdominal  contusion 

,  892 

subserous,  162 

for  cancer  of  intestine,  928 

Lisfranc's  amputation,  1175 

of  stomach,  910 

Lister's   amputation,    modified   flap   and 

for  injury  of  intestine,  922 

circular,  1167 

for  intestinal  obstruction,  1014,  1C17 

supracondyloid,  1180 

for  intussusception,  1022 

antiseptic  treatment  of  wounds.  14 

for  perforation  of  appendix,  951, 

952 

dressings,  19,  20 

of  intestine  in  typhoid  fever 

925 

strong  mixture,  193 

of  stomach,  906,  899 

Liston's  long  splint,  475,  617 

for  peritonitic  adhesions,  906 

Lithiasis,  1088,  1061 

for  peritonitis,  898 

Litholapaxy,  1098 

tuberculous,  899 

Lithotomy,  lateral,  1100,  1105,  1107 

for  rupture  of  gall-bladder,  960 

suprapubic,  1105,  1107 

of  intestine,  923  et  seq. 

Lithotrity,  1098 

of  liver,  954 

Littr^'s  hernia,  996,  1010 

of  stomach,  902 

operation,  942 

for  ulcer  of  stomach,  905,  906,  907 

Liver,  affections  of,  953-959 

Lardaceous  disease,  53,  1092 

amyloid  disease  of,  54 

Larrey's  operation,  1173 

Local  anaesthesia,  1184 

Laryngeal  paralysis,  843,  270,  27r, 

273. 

Localization  of  cerebral  injuries,  699 

809,  864,  853,  830 

Loose  bodies  in  joints,  605 

stenosis,  842,  828,  852 

Lordosis,  388,  614 

Laryngectomy,  845 

Loreta's  operation,  911 

Laryngitis,  oedematous,  842,  93,  96, 

444. 

Lorenz's  bloodless  operation,  543 

775,  784,  805,  806,  827 

Lowenberg's  forceps,  769 

Laryngoscope,  841 

Lower  jaw.     See  Mandible 

Laryngotomy,  847,  838,  839 

Ludwig's  angina,  93.  784 

Larynx,  diseases  of,  841 

Lumbar  abscess,  657,  662 

foreign  bodies  in,  838 

colotomy,  941 

injuries  of,  826,  840 

hernia,  994 

Lateral  anastomosis,  938,  928,  964,  1008 

operations  on  kidneys,  1068-1071 

curvature  of  spine.  See  Scoliosis 

38i 

puncture,  692 

76 2 


1204 


INDEX 


Lungs,  affections  of,  854-862 

Melanosis,  159 

Lupus,  action  of  erysipelas  on,  98 

Melanotic  sarcoma,  158 

erythematosus,  358 

Melon-seed  bodies,  369,  375,  605 

vulgaris,  356,  777,  797 

Meningeal  haemorrhage,  cerebral,  680 

Luschka's  tonsil,  803 

spinal,  638 

Luxatio  erecta,  553 

Meningitis,  691,  693,  720,  820 

Lymphadenitis,  acute,  317 

spinal,  638,  659 

chronic,  319 

Meningocele,  647,  707 

Lymphadenoma,  323,  171 

Meningoencephalitis,  692 

Lymphangiectasis,  315,  731,  774 

Meningo-encephalocele,  708 

Lymphangioma,  314,  171 

Meningo-myelocele,  647 

Lymphangitis,  312,  313 

Mercurialism,  134,  739,  774 

Lymphatic  glands,  affections  of,  317-325 

Metacarpals,  dislocation  of,  559 

vessels,  affections  of,  312-317 

fracture  of,  467 

Lymphorrhcea,  315,  314 

Metastasis,  35,  785,  1146 

Lympho-sarcoma,  324,  156 

Metatarsalgia  (Morton's  disease),  416 

of  testis,  1153 

Microcephaly,  710 

of  tonsil,  801 

Micrococci,  1 

Lysol,  16 

Microstoma,  730 

Middle  turbinated  bone,  disease  of,  761 

McBurney's  spot,  947 

Miliary  tuberculosis,  659 

MacEwen's  operation  for  hernia,  987 

Mirault's  operation  for  hare-lip,  728 

osteotomy,  398 

Moist  gangrene,  68 

MacEwen's  treatment  of  aneurism,  268, 

Mollities  ossium.     See  Osteomalacia 

270,  276,  278 

Molluscum  contagiosum,  362 

Macrocheilia,  731,  315 

fibrosum,  163,  169 

Macrodactyly,  390 

Moore's  method  of  treating  aneurysms,  268 

Macroglossia,  774,  315 

Morgagni,   hydatid  of,   cysts  from,   184, 

Macrostoma,  730 

1158 

Malar,  fracture  of,  440 

Morris's  bitrochanteric  test,  474 

Malarial  spleen,  965 

Morton's  disease,  416 

Malignancy,  characteristics  of,  151 

Motor  area,  topography  of,  701 

Malignant  cysts  of  neck,  825 

wounds  of,  699 

endocarditis,  103 

Mouth,  affections  of,  772,  783 

cedema,  82 

Moveable  kidney,  1050 

pustule,  114 

Mucous  cysts,  714,  732,  782 

tumours,  151 

membranes,  tuberculous  disease  of, 

ulcers,  66 

359 

Mallet  finger,  391 

polypus,  762 

Malpositions  of  testis,  1143 

tubercles,  128,  135,  137,  172,  1034 

Mamma.     See  Breast 

Mulberry  calculus,  1045 

Mandible,  diseases  of,  739.  747 

Mumps,  785 

excision  of,  749 

Murexide  test,  1087 

injuries  of,  440,  548 

Murphy's  button,  935,  918,  920,  938 

tumours  of,  747 

Muscles,  affections  of,  363-367 

Mandibular  cleft,  730 

Musculo  spiral  nerve,  affections  of,  344 

Massage,  40 

Myelitis,  spinal,  639 

Massage  in  treatment  of  fractures,   431, 

Myelocele,  646 

4SL  459.  460,  465.  484.  489.  493 

Myeloid  sarcoma,  157,  534,  712,  738,  748 

Mastitis,  acute,  867 

Myeloma,  158 

chronic,  869 

Myeloplaxes,  158 

Mastoid  disease,  815 

Myoma,  166 

Maunsell's  operation,  933,  1022 

Myo-sarcoma,  157,  1066 

Maxilla,  affections  of,  739-744 

Myositis,  366 

excision  of,  744 

Myositis  ossificans,  367,  608,  751 

injuries  of,  440 

Myxcedema,  834,  532 

Meckel's  diverticulum,  921,  ion 

Myxo-lipoma,  162 

Median  hare-lip,  730 

Myxoma,  153 

nerve,  affections  of,  346 

Median  cervical  fistula,  824 

Naevo-lipoma,  310,  162 

Medulla  oblongata,  injuries  to,  701 

Nsevus,  307,  169 

of     bone,     inflammation     of.       See 

lymphatic,  314 

Osteomyelitis 

of  lip,  732 

Medullary  cancer,  180 

of  scalp,  706 

Meltena,  223,  1045 

of  tongue,  778 

INDEX 


1205 


Naevus,  unius  lateris,  308 
Nails.     See  Onychia 
Nasal  bone,  fracture  of,  439 

polypi,  762 

septum,  fracture  of,  439 
Naso-pharynx,  diseases  of,  722 
Neck,    affections    of    (Chapter   XXIX.), 
822-837 

tuberculous  glands,  319,  321 
Necrosis,  acute,  502 

of  bone,  496,  497,  500,  502,  509,  522, 
1 169,  434,  43s,  83 

of  jaw,  739 

of  ossicles,  815 

of  palate,  789 

of  temporal  bone,  8r5 

quiet,  497,  606 
Needles,  201 
Nelaton's  line,  473 

operation  on  the  naso- pharynx,  766 
Nephrectomy,    1069,    1052,    1055,    1058, 

1060,  1064,  1066,  1067 
Nephrorrhaphy,  1071 
Nephrotomy,  1069 
Nephrolithotomy,  1055,  1058 
Nerve  extraction,  333 

grafting,  331 

stretching,  333 

suture,  330 
Nerves,  affections  of  special,  334-350 

bulbous     ends     of,    328,    169,    215, 
1 170 

injuries  of,  326,  673,  424 

tumours  of,.  167 
Neuralgia,  332,  261 

of  joints,  608 

of  testis,  1161 

trigeminal,  335 
Neurasthenia,  traumatic,  640 
Neurectomy,  333 
Neuritis,  331 
Neuroma,  167-169,  328 
Neuropathic  arthritis,  603 
Neurotomy,  333 
Nipple,  affections  of,  866 
Nitrous  oxide  gas,  1185 
Nodes,  511,  513,  520,  711,  61 
Noma.     See  Cancrum  oris 
Nose,    affections   of    (Chapter    XXVI. ), 
753-771 

Oblique  inguinal  hernia,  975 
Obstructed  hernia,  995 
Obstruction,      intestinal       (Chapter 

XXXIV.),  1009-1024 
Obturator  hernia,  994 
Obturators  for  palate,  797 
Occipital  artery,  compression  of,  237 
ligature  of,  286 
lobe,  injuries  of,  700 
Odontomata,  170,  747,  748 
O'Dwyer's  tube,  853 
CEdema,  lymphatic,  315 
malignant,  82 
of  brain,  695 


CEdema     of    glottis.       See     Larynguis, 
cedematous 

of  scrotum,  1164 
CEsophagostomy,  810 
CEsophagotomy,  807,  810 
CEsophagus,  affections  of,  805 
Ogston's  operation  for  tiu-foot,  412 

for  genu  valgum,  397 
Olecranon,  fracture  of,  460 
Olfactory  nerve,  affections  of,  334 
Omental  adhesions,  1010 

hernia,  973,  984 

tumour,  898,  899 
Onychia,  360 
Oophorectomy,  for  osteo-malacia,  530 

in  cancer  of  breast,  890 
Operation  for  cerebral  tumours,  716 
Operations,    general  antiseptic   methods 
for,  16-19 

general  remarks  on  abdominal,  966 
Ophthalmoplegia  externa,  335 
Opisthotonos,  109 
Optic  nerve,  affections  of,  334 

neuritis,  93,  334,  715,  720,  818,  820 
Orbital  cellulitis,  93 
Orchitis,  1146 
Ormsby's  mask,  1188 
Os  cilcis,  fracture  of,  493 

tuberculous  disease  of,  516 

incisivum,  724,  726,  728 

magnum,  dislocation  of,  559 
Ossicles,  necrosis  of,  815 
Osteitis,  497,  499 

deformans,  520 

tuberculous,  514 
Osteo-aneurism,  537 
Osteo-arthritis,  596,  577 

of  hip,  601 

of  spine,  665 

of  temporo-maxillary  joint,  750,  602 
Osteo  -  arthropathy,     hypertrophic     pul- 
monary, 532 
Osteoblasts,  434,  496 
Osteo-chondritis,  syphilitic,  523 
Osteoclasia,  439 
Osteoclasts,  498 
Osteoma,  164 

of  antrum,  742 

of  lower  jaw,  747 

of  skull,  712 

of  spine,  665 

of  upper  jaw,  742 
Osteomalacia,  529 
Osteomyelitis,  502,  509,  434,  497,  499 

gummatous,  523 

of  cranium,  711,  714 

of  spine,  650 
Osteo-periostitis,  chronic,  511 
Osteophytes,  581,  587,  598,  603,  609,  613, 

665 
Osteoplastic  section  of  upper  jaw,  766 
Osteoporosis,  496,  498 
Osteo-psathyrosis,  418 
Osteo-sarcoma.     See   Sarcoma   of  bone, 
533 


[206 


INDEX 


Osteosclerosis,  496 
Osteotomy,  394,  397,  399 

for  ankylosis,  399,  610 

for  genu  valgum,  397 
Otorrhcea,  chronic,  surgical  complications 

of,  814 
Ovarian  cysts,  184,  185 

dermoids,  183 
Oxalates,  1088,  1094 
Oxyuris  vermicularis,  1027 
Oztena,  759 

Pachydermatocele,  163,  707 
Pachymeningitis,  639,  690 
Paget's  eczema  of  nipple,  867,  880 
Pain  in  burns,  86 

in  gangrene,  67,  71,  75 

in  inflammation,  30 

in  Pott's  disease,  653 
Painful  scar,  215,  169 

stump,  1170 

subcutaneous  nodule,  168 
Palate,  cleft,  790 

diseases  of,  797 
Palmar  abscess,  208 

arch,  hremorrhage  from,  244 

fascia,  contraction  of,  392 

ganglion,  compound,  369 
Pancreas,  affections  of,  964 
Panophthalmitis,    following    cellulitis    of 

orbit,  93 
Panostitis,  502 
Papilloma,  171 

of  bladder,  ic8i 

of  breast,  879 

of  kidney,  1066 

of  larynx,  843 

of  nipple,  867 

of  rectum,  1036 

of  scalp,  706 
Paracentesis  abdominis,  900 
Paralysis,  infantile,  666,  379,  399,  401,  405 
Paralysis   of  gut,    897,  961,    1001,  1005, 
1010,  1013 

of  larynx.     See  Laryngeal  paralysis 
Paraphimosis,  11 36 
Paraplegia,  641,  643 

bedsores  in,  80 

gravitation,  638 

in  Pott's  disease,  657,  664 
Parasitic  cysts,  187 
Parenchymatous  glossitis,  acute,  774 

goitre,  830 

inflammation,  35 
Parker's  tracheotomy  tube,  850 
Paronychia,  207 

Parotid  gland,  affections  of,  785 
Parovarian  cysts,  184 
Parrot's  nodes,  523 

Pasteur's  treatment  of  hydrophobia,  113 
Patella,  dislocation  of,  566 

fractures  of,  482 
Pathogenic  bacteria,  5,  6,  8 
Paul's  tube,  931,  942,  943,  1015,  1017 
Peau  if  orange  in  cancer  of  breast,  £83 


Pelvic  cellulitis,  93,  1074,  1083    1104 
Pelvis,  fractures  of,  467 
Penis,  affections  of,  1135 
Perforating  ulcer  of  duodenum,  921,  87, 
901 
of  foot,  355 
Perforation  of  appendix,  947,  948 

of  gastric  ulcer,  905 

of  intestine,  925 

of  palate,  797 
Periarteritis,  250 
Pericardial  effusion,  863 
Pericranial  lipoma,  161 
Perigastritis,  906 
Perineal  abscess,  1132 

cystotomy,  1079,  1075,  1085,  IT14 

fistula,  1108,  1116,  1122,  1132,  1134 

section,  1131 
Perinephritic  abscess,   1058,    1052,    1055, 

1059,  1062 
Perinephritis,  1058 
Perineuritis,  331 
Periosteal  sarcoma,  535 
Periostitis,  acute,  499,  500,  502,  711 

albuminosa,  505 

chronic,  511,  520,  711 

tuberculous,  513 
Peripheral  neuritis,  1093 
Periproctitis,  1027 
Peritonism,  897,  969 

Peritonitis,    893,    895,    947,    949,    1005, 
1006,  1014 

tuberculous,  899 
Perityphlitis,  945 
Permanganate  of  potash,  16 
Peroneal  artery,  ligature  of,  297 
Peronei,  tenotomy  of,  371 
Peroneus  longus,  dislocation  of  tendon  of, 

364 
Peroxide  of  hydrogen,  16 

Pes  cavus,  412 

Petechise,  222,  7,  101,  104 

Phagedena,  125,  83,  66 

Phagocytosis,  12 

Phalanges,  amputation  of,  1170 

dislocation  of,  559 

excision  of  head  of,  415 

fractures  of,  467 
Phantom  tumour,  894 
l'haryngotomy,  subhyoid,  844 

transhyoid,  844,  804 
Pharynx,  affections  of,  802 
Phelp's  box,  65i 

operation  (talipes),  408 
Phimosis,  1135,  971,  983,  1084 
Phlebitis,  302,  103 
Phleboliths,  300,  306 
Phlegmonous  inflammation,  35,  90 
Phosphates  in  urine,  1089,  1095,  529 
Phosphatic  calculi,  1095 
Phosphorus  necrosis  of  jaw,  739 
Phrenic  nerve,  injury  to,  343 
Picric  acid  in  treatment  of  burns,  88 
Pigeon  breast,  525 
Piles,  1044 


INDEX 


1207 


Pirogoff's  amputation,  1178 

Pistol  splint,  465 

Plantar  arch,  hemorrhage  from,  244 

Pleurosthotonos,  109 

Plexiform  angioma,  170,  706 

neuroma,  169 
Pneumatocele  capitis,  713 
Pneumectomy,  862 
Pneumocele,  857 
Pneumococcal  arthritis,  585 
Pneumococcus,  44,  506,  585,  639,  859 
Pneumogastric  nerve,  affections  of,  342 
Pneumothorax,  854,  856,  901 
Pneumotomy,  861 
Poisoned  wounds,  205 
Polydactylism,  389 
Polyorchism,  1142 
Polypus  of  antrum,  740 

of  ear,  815 

of  nose,  762 

of  rectum,  1035,  1032,  1045 

of  umblicus,  894 

of  urethra,  11  n,  1120 
Pons  Varolii,  injuries  to,  700 
Popliteal  aneurism,  280 

artery,  ligature  of,  295 

bursas,  376 
Post-mortem  wounds,  206 
Pott's  disease,  650 

fracture,  489 

puffy  tumour,  690 
Priapism,  637,  640,  644,  n  13 
Primary  arterial  hemorrhage,  235 

calcareous  degeneration    ol    arteries, 

255 

union  of  wounds,  211 
Proctectomy,  1038 
Proctitis,  1027,  120 
Prolapse  of  anus,  1047,  1045 

of  intestine,  893,  944 

of  lung,  858 

of  rectum,  1047 
Proptosis,  8315 
Prostate,  affections  of,  1107- n  16 

senile  enlargement  of,  11 10 
Prostatectomy,  n  15 
Prostatotomy,  11 14 
Protective  albumens,  13 
Protozoa,  22 
Proud  flesh,  64 
Pseud-arthrosis,  436,  546 
Pseud-elephantiasis,  315,  61 
Pseudo-neuroma,  167 
Pseudo-paralysis,  syphilitic,  524 
Psoas  abscess,  657,  662,  51,  990 
Psoriasis  linguag,  776, 

syphilitic,  129 
Psorosperms,  22,  174 
Ptomaines,  4 
Ptosis,  334 

Pubic  dislocation  of  hip,  565 
Pudic  artery,  haemorrhage  from,  244,  1104 

ligature  of,  292 
Pulled  elbow,  558 
Pulmonary  haemorrhage,  854,  857 


Pulpy  disease  of  synovial  membrane,  586 
Pulsating  empyema,  858 

exophthalmos,  275 
tumours  of  bone,  537 
of  scalp,  705,  706 
Punctured  fracture  of  skull,  674 
wounds,  200 

of  chest,  855 
of  heart,  862 
of  intestine,  924 
Pus  in  acute  abscess,  47 
in  chronic  abscess,  51 
in  hepatic  abscess,  956 
Pustule.     See  Malignant  pustule 
Pyaemia,  103-107,  100,  301,  304,  434,  506, 
509,  548,  580,  694,  711,  785,  820,  955, 
1044 
Pyasmic  joints,  585 
Pyelitis,  1055 

Pyelonephritis,  1056,  1078,  n  12,  1123 
Pylephlebitis,  104,  300,  949,  955,  1044 
Pylorectomy,  917,  911,  912 
Pyloroplasty,  917,  912 
Pylorus,  affections  of,  911,  907 
Pyogenic  organisms,  43 
Pyonephrosis,  1057,  11 12 
Pyorrhoea  alve  ilaris,  736 
Pyrexia.     See  Fever 
Pyuria,  1091,  1109 

Quiet  necrosis.     See  Necrosis 
Quilled  suture,  194 
Quincke's  lumbar  puncture,  692 
Quinsy,  799 

Rabies,  112 

Racquet  method  of  amputation,  1167 

Radial  artery,  compression  of,  237 

ligature  of,  290 
Radical  cure  of  hernia,  983,  991,  993,  1005 

of  hydrocele,  1157,  1158 
Radius,  congenital  absence  of,  389 

dislocations  of,  557 

fracture  of,  462 

separation  of  lower  epiphysis,  465 
Railway  spine,  640 
Ranula,  784 

Rarefaction  of  bone,  496,  498 
Rashes  of  syphilis,  127 
Ray  fungus,  148 
Raynaud's  disease,  77,  1091 
Reaction,  216,  685 

of  degeneration,  329 
Reactionary  haemorrhage,  238 
Recklinghausen's  disease,  168 
Recto-vaginal  septum,  wound  of,  1141 

vesical  fistula,  103  7,  1083,  1104,  1164 
Rectum,  affections  of  (Chapter  XXXV.), 

1025- 1049 
Rectus  abdominis,  injuries  of,  893,  894 
Recurrent  dislocations,  396,  544,  548 

fibroid,  157,  880 

haemorrhage,  238 
Redness  in  inflammation,  29 
Regeneration  of  nerves,  329 


1208 


INDEX 


Reid's  lines,  702 
Rendel's  mask,  1188 

Repair  of  bone  after  caries,  498,  652,  654 
after  fractures,  425,  434 
after  necrosis,  498-502,  508 

of  muscle,  364 

of  tendon,  364 

of  wounds,  208 
Resection.     See  Excision 
Residual  abscess,  52,  659 

urine,  1085 
Resolution  in  inflammation,  28 
Respiration,  artificial,  864 
Retained  testis,  1142,  980 
Retention  cysts,  186,  872 

of  urine,  1086,  643,  1112,  1130 
Retro-peritoneal  abscess,  901,  948 

pharyngeal  abscess,  805,  656 
Rhabdomyoma,  167 
Rhagades,  137 
Rheumatic  arthritis,  583 
Rheumatic  gout.    See  Osteo-arthritis,  596 

spondylitis,  664 

synovitis,  583 
Rheumatoid  arthritis.   See  Osteo-arthritis, 

596 
Rhinitis,  757,  120,  138 
Rhinophyma,  754 
Rhinoplasty,  755 
Rhinoscopy,  756 
Ribs,  fracture  of,  444 
Richter's  hernia,  996,  999 
Rickets,  524,  382,  386,  393,  394,  400 
Riggs's  disease,  736 
Rigor,  46 

Robson's  (Mayo)  bobbin,  937,  938 
Rodent  ulcer,  177 
Rontgen  X  rays,  201,  178,  422,  457,  512, 

1063 
Rouge's  operation,  766 
Round-celled  sarcoma,  155 
Rupia,  130 

Rupture.     See  Hernia 
Rupture  of  aneurism,  262 

of  arteries,  256 

of  bladder,  1073 

of  gall-bladder,  957 

of  kidney,  1051 

of  intestine,  922 

of  liver,  953 

of  main  artery,  246 

of  muscles,  364 

of  nerves,  326 

of  rectus  abdominis,  894 

of  spleen,  965 

of  stomach,  902 

of  tendons,  364 

of  ureter,  1052 

of  urethra,  1118,  1133 

of  vas  deferens,  1145 

Sacculated  aneurism,  259 
Sacral  tumour,  congenital,  649 
Sacro-iliac  disease,  619 
Sacrum,  fractures  of,  469 


Salivary  fistula,  789 

calculus,  786 

glands,  affections  of,  785-790 
Salivation  in  mercuriilism,  135 
Sanitas,  16 

Saphena,  varix  of,  305,  990 
Saprcemia,  6,  too 
Saprophytes,  5 
Sarcinse,  2 
Sarcoma,  154-160 

after  fractures,  428 

curative  action  of  erysipelas  on,  98, 160 

of  bladder,  1082 

of  bone,  533 

of  brain,  715 

of  breast,  879 

of  cranium,  712 

of  dura  mater,  712 

of  jaws,  738,  742,  743,  748,  749 

of  kidney,  1066 

of  lymphatic  glands,  324,  156 

of  muscle,  367 

of  naso-pharynx,  764 

of  nose,  765 

of  palate.  798 

of  parotid,  788 

of  rectum,  1036 

of  scalp,  707 

of  skull,  712 

of  spine,  665 

of  spleen,  965 

of  testis,  1 183 

of  thyroid,  836 

of  tonsil,  801 
Sayre's  apparatus  for  talipes,  407 

plaster  jacket,  661 

treatment  of  fractured  clavicle,  448 
Scalds,  85 
Scalp,  affections  of,  705 

injuries  of,  667 
Scapula,  fractures  of,  449 

winged,  343,  551 
Scar,  affections  of,  214 
Schede's  operation,  861 
Schizomycetes,  1 
Schwartze's  operation,  816 
Sciatica,  348,  619 
Sciatic  artery,  aneurism  of,  279 
haemorrhage  from,  244 
ligature  of,  292 

dislocation  of  hip,  563 

nerve,  stretching  of,  349 
Scirrhous  ulcer,  882 
Scirrhus,  180 

of  breast,  881,  871,  873 

of  pancreas,  965 

of  prostate,  11 16 

of  pylorus,  908 
Sclerosis  of  bone,  497,  498,  512,  522 
Sclerotitis,  gonorrhoea!,  121 
Scoliosis,  381 
Scrotal  fistulas,  1165 

tumours,  1162 
Scrotum,  affections  of,  1164 
Scurvy  rickets,  528 


INDEX 


1209 


Sebaceous  cysts,  361 
of  neck, 825 
of  nipple,  867 
of  scalp,  707 
Sebaceous  glands,  cancer  of.    See  Rodent 
ulcer 

horn,  361,  1 139 
Secondary  hcemorrhage,  239 
Semilunar  cartilage,  dislocation  of,  567, 607 
Semimembranosus  bursa,  enlargement  of, 

376 
Semimembranosus,  tenotomy  of,  372 
Senile  atrophy  of  bone,  470,  529,  709 

gangrene,  74 

hypertrophy  of  prostate,  11 10 

tuberculosis,  140 
Sepsis,  5 

in  treatment  of  chronic  abscess,  52 

secondary  haemorrhage  with,  239 
Septic  arthritis,  578 

intoxication,  6 

meningitis.     See  Meningitis 

osteomyelitis.     See  Osteomyelitis 

peritonitis.     See  Peritonitis 
Septic  pneumonia.  84,  441,  781,  809,  827, 
840,  852,  855 

traumatic  fever,  6,  827 
Septic  wounds,  196 
Septicemia,  100 
Septum  nasi,  fracture  of,  439 

lateral  deviation  of,  759 
Sequestra,  497,  498,  514,  515,  1169 
Sequestration  dermoids,  182 
Sequestrotomy,  509 
Serotherapy,  14 
Serous  cysts,  185,  825,  873,  1067 

synovitis,  chronic,  576,  577 
Seventh  nerve.     See  Facial  nerve 
Shell  wounds,  204 
Shock,  215-219 

anaesthesia  during,  219 

from  amputations,  1168 

from  catheterism,  1125 

in  abdominal  surgery,  892,  893,  902, 
905,  922,  926,  954,  960,  965,  966 

in  burns,  87,  89 

in  intestinal  obstruction,  999,  1010 

use  of  saline  injections  in,  219 
Shoulder-joint,  acute  arthritis  of,  581 

amputation  through,  1173 

ankylosis  of,  609 

dislocation  of,  551 

effusion  into,  574 

excision  of,  621 

tuberculous  disease  of,  593 
Sinus,  56 

Sixth  nerve,  affections  of,  340 
Skin  grafting,  64,  707,  754,  890 

purification  of,  18 

surgical  diseases  of  (Chapter  XIV. ), 
35!-362 
Skull,  affections  of,  707 

injuries  to,  668 
Sloughing  of  flaps,  1170 
Smith's  (Stephen)  amputation,  1179 


Snake-bites,  205 

Snap-finger,  391 

Socin's  operation,  834 

Soft  chancre,  1137 

Softening,  yellow,  of  brain,  696 

Sounding  bladder,  1097 

Spasm  of  oesophagus,  808 

Spasmodic  stricture  of  urethra,  1120 

Spasmodic  stump,  1170 

Spence's  operation,  1173 

Spermatic  cord,  hajmatocle  of,  1145 

hydrocele  of,  1158,  185 

torsion  of,  1143 
Spermatocele,  1158 
Spina  bifida,  646,  401 

occulta,  649 
ventosa.     See  Tuberculous  dactylitis, 

Spinal  accessory  nerve,  aft  ctions  of,  343 

stretching  of,  343,  381 
Spinal  cord,  diseases  of,  665,  666 

haemorrhage,  637 

injuries  of,  637 

pressure   on,    in    Pott's   disease, 
657,  664 

total  transverse  lesion  of,  642 
Spine,  deformities  of,  381 

diseases  of  (Chapter  XXII.),  646-666 
injuries  to  (ChapterXXI. ),  628  645 
Spirilla,  2 

Splay-foot.     See  Flat-foot 
Spleen,  affections  of,  965,  54 
Splenectomy,  965 
Splenopexy,  965 

Splint  pressure  causing  gangrene,  80,  433 
Splints,  uses  of,  429 
Spondylitis,  rheumatic,  664 
Spondylolisthesis,  388 
Sponges,  method  of  purifying,  17 
Spongy  gums,  725,  135 
Spontaneous  fracture,  418,  261,  529,  533 

gangrene,  77 
Spore  formation  in  bacteria,  4 
Sprains,  363,  539,  628 
Spreading  gangrene,  acute,  81,  433 
Spreading  oedema,  695 
Sprengel's  shoulder,  388 
Spring-finger,  391 
Stabs,  200 

Stacke's  operation,  818 
Staphylococci,  1,  6,  43,  90,  103,  351,  352, 

S05.  509 
Staphylorraphy,  796 
Starch  bandage,  430 
Stercoral  ulcers,  997,  1034,  1038 
Sterno-mastoid,  action  of, in  torticollis,  378 

congenital  induration  of,  823,  379 

tenotomy  of,  380 
Sternum,  fractures  of,  445 
Stewart's    treatment   of   aneurisms,    268, 

272,  276 
Sthenic  fever,  32 
Stings,  205 
Stomach,  affections  of,  902 

operations  on,  912 


INDEX 


Stomatiiis,  772 

mercurial,  135 
Stone.     See  Calculus 
Strain,  246,  257,  326,  363,  539,  628 
Strangulated  hernia,  996,  1008 
Strangulation,  internal,  1010,  ion 
Strangury,  1063,  1077 
Streptococci,  2,  6,  83.  43,  90,  94,  100,  103, 

160,  505,  578,  895,  946 
Stricture  of  appendix,  947,  949 

of  bile  duct,  963 

of  intestine,  926,  1016,  1021 

of  oesophagus,  808 

of  pylorus,  911 

of  rectum,  1033 

of  urethra,  11 20 
Stumps  (amputation),  affections  of,  1169 
Styptics,  230 
Subaponeurotic  abscess,  705 

hrematoma,  668 
Subastragaloid  amputation,  1177 

dislocation,  571 
Subclavian  artery,  aneurism  of,  275 

compression  of,  237 

ligature  of,  287,  271,  272,  276,  277 
Subclavicular  dislocation  of  the  shoulder, 

554 
Subcoracoid  dislocation  of  the  shoulder, 

553 
Subcranial    abscess,   690,   677,   694,   720, 
818 

inflammation,  690 
Subdeltoid  bursa,  affections  of,  377,  574 
Subglenoid   dislocation   of  the  shoulder, 

552 
Sublingual  abscess,  783,  93 
Subluxation  of  head  of  radius,  558 

of  knee,  567 
Submammary  abscess,  868,  872 
Submaxillary  cellulitis,  93 
Subphrenic  abscess,  900,  948 

pyopneumothorax,  901 
Subserous  lipoma,  162,  993 
Subspinous  dislocation  of  the  shoulder, 

554 
Subungual  exostosis,  165 
Sulphur  in  chronic  abscess,  56 
Superior  maxilla,  affections  of,  739,  704 

excision  of,  744 

fracture  of,  440 
Suppression  of  urine,  1057,  1126 
Suppuration  (Chapter  III.),  41-57 
Supracondyloid  amputation  of  thigh,  1180 

fracture  of  femur,  481 
of  humerus,  456 
Supracoracoid  dislocation  of  the  shoulder, 

554 

Supra-orbital  nerve,  operations  on.  336 

Suprapubic  aspiration,  1131 

cystotomy,  1105,  1075,  1080,  1084 
puncture  for  enlarged  prostate,  11 16 

Supratrochlear     nerve,     operations     on, 

337 
Sutures,  193 

intestinal,  929 


Sylvester's  method  of  artificial  respiration, 

865 
Syme's  amputation,  J177,  518 
horseshoe  splint,  492 
operation  for  restoration  of  lip,  734 

of  urethrotomy,  n  29 
treatment  of  chronic  ulcers,  63 
Symonds'  tube,  810,  811 
Sympathetic    nerves,    affections   of,    350, 
168,  271,  835 

in   shock,    action   of,    217,    891, 
1023 
Symptomatic  gangrene,  72 
Syncope,  216 
Syndactylism,  390 
Synostosis,  608 

Synovial  membrane,  pulpy  disease  of,  586 
Synovitis,  acute,  573 
chronic,  576 
gonorrhoeal,  121,  585 
syphilitic,  595 
Syphilis,  121 
Syphilitic  affections  of  anus,  1034 

of  arteries,  254,  256,  131 

of  bone,  520 

of  breast,  867,  872 

of  bursas,  375 

of  cranium,  522,  712 

of  epididymis,  1150 

of  intestine,  926,  1034 

of  joints,  595 

of  larynx,  842 

of  lip,  731 

of  lymphatic  glands,  125,  128,  319 

of  meninges,  693,  703,  715 

of  muscles,  367 

of  nerves,  326,  331 

of  nipple,  867 

of  nose,  753,  761 

of  palate,  797 

of  pharynx,  803 

of  rectum,  1034 

of  spine,  639,  664,  665 

of  testis,  1 150 

of  tongue,  775,  777 

of  tonsil,  801 
Syphilitic  ulcers,  66,  131,  132 
Syringo-myelia,  joint  lesions  in,  604 
Syringo-myelocele,  646 

Taenia  echinococcus,  157,  958,  301 
Tagliacozzian  operation,  755 
Talipes,  400,  666,  647 
Tarsectomy,  408 
Tarsus,  amputation  through,  1176 

tubercle  of,  515 
Taxis,  1000 

Teale's  amputation,  1168,  1179 
Teeth  in  congenital  syphilis,  139 

in  rickets,  525 

tumours   in    connection   with.      See 
Odontomata 
Temporal  artery,  compression  of,  237 

ligature  of,  286 
Temporo-maxillary  joint,  diseases  of,  750 


INDEX 


Temporo-maxillary  joint,  injuries  of,  548 

Tracheotomy,  847,  839 

osteoarthritis  of,  652 

Tracheotomy,     preliminary,     744,      780, 

Tendo  Achillis,  rupture  of,  366 

804 

tenotomy  of,  371 

Traumatic  aneurism,  247,  249 

Tendon  sheaths,  diseases  of,  368 

delirium,  220,  422 

Tendons,  displacement  of,  363 

epilepsy,  703 

operations  on,  365,  370,  372,  373 

fever,  6,  219,  220,  422 

Tenoplasty,  373 

gangrene,  72,  78,  80,  81.     See  Gan- 

Teno-synovitis, 368 

grene 

Tenotomy,  370,  666 

insanity,  704 

of  sterno-mastoid,  380 

neuroma,  169,  328 

Testicle,  affections  of  (Chapter  XXXIX. ), 

Transfusion,  224 

1142-1165 

Transhyoid  pharyngotomy,  804 

Tetanus,  107- 112 

Transillumination  of  antrum,  741 

neonatorum,  894 

Trendelenburg's  position,  1105 

Tetany,  834 

trachea  tampon,  781,  808 

Thecal  whitlow,  208 

Trephining,  678,  679,  682,  683,  690,  697, 

Thiersch's  method  of  skin-grafting,  65 

704,  713,  716,  721,  820,  821 

of  nerve  extraction,  333 

Trigeminal  neuralgia,  335 

Thigh,  amputation  of,  1181 

Trismus,  109,  149,  751 

Third  nerve,  affections  of,  334 

Trochanter,  fracture  of,  478 

Thomas's  hip-splint,  617,  475,  662 

Tropical  abscess  of  liver,  955 

knee-splint,  594 

Trusses,  981,  991 

wrench,  412 

Tuberculous  abscess,  50,  143,  662 

Thoracic  duct,  wound  of,  313 

disease  of  bladder,  1080 

Thorax,  deformities  of,  in  adenoids,  768 

of  arteries,  254 

in  rickets,  525 

of  bone,  513 

punctured  wounds  of,  855 

of  brain,  715 

Thrombosis,  arterial,  75,  76,  79,  246,  255 

of  breast,  871,  872 

of  cerebral   sinuses,   680,    694,    761, 

of  burste,  375 

820 

of  cranium,  711 

of  lateral  sinus,  694,  820 

of  epididymis,  1148 

venous,  298 

of  hip-joint,  611 

Thrush,  772 

of  intestine,  925,  926 

Thumb,  amputation  of,  1171 

of  joints,  586 

dislocation  of,  559 

of  kidney,  1059 

Thyroid  body,  diseases  of,  828 

of  larynx,  842 

Tlyroid  cancer  of  bone,  537 

of  liver,  959 

Thyroidectomy,  partial,  833 

of  lymphatic  glands,  319 

Thyroid  dislocation  of  hip,  564 

of  mastoid,  876 

Thyroid  vessels,  ligature  of,  288,  836 

of  mucous  membrane,  359 

Thyro-glossal  duct.     See  Cyst  of,  823 

of  peritoneum,  899,  895 

Thyrotomy,  845 

of  prostate,  1109 

Tibia,  fracture  of,  487 

of  sacro-iliac  joint,  619 

rachitic,  400 

of  skin,  356 

syphilitic,  400,  520,  524 

of  spine,  650 

Tibial  arteries,  compression  of,  237 

of  tarsus,  515 

ligature  of,  296,  297 

of  temporo-maxillary  joint,  751 

nerves,  affections  of,  350 

of  testis,  1 148 

Tic  douloureux,  or  epileptiform  tic,  335 

of  tongue,  777 

Tic,  facial,  342 

of  vesiculas  seminales,  1164 

Toenail,  ingrowing,  360 

dactylitis,  514 

Toes,  amputation  of,  1174 

empyema,  859 

Toes,  deformities  of,  413-416 

endarteritis,  142,  254 

Tongue,  affections  of,  773-783 

ischio-rectal  abscess,  1028 

Tonsil,  affections  of,  798 

lupus,  356 

Topography,  cerebral,  701 

teno-synovitis,  368 

Torsion,  231 

ulcers,  359,  66 

Torsion  of  testicle,  1143,  1006 

Tuberculated  leprosy,  146 

Torticollis,  378,  823 

Tuberculosis,  140 

Tourniquets,  237,  1169,  1181 

acute  miliary,  659 

Toxins,  4 

Tubulo-dermoids,  183 

Trachea,  foreign  bodies  in,  839 

Tumour,  congenital  sacral,  649 

wounds  of,  826 

Pott's  puffy,  690 

Tracheal  tug,  270,  273 

Tumours  (Chapter  VII.),  150-181 

INDEX 


Tumours  of  adrenals,  1066 

of  antrum,  742 

of  bladder,  108 1 

of  bone,  533 

of  brain,  714,  720 

of  breast,  874 

of  cranium,  712 

of  frontal  sinuses,  714 

of  gum,  737 

of  intestine,  927 

of  kidney,  1065 

of  larynx,  843 

of  lip,  732 

of  liver,  959 

of  lymphatic  glands,  322 

of  mandible,  747 

of  maxilla,  742 

of  muscle,  367 

of  nipple,  867 

of  nose,  754,  764,  765 

of  oesophagus,  808 

of  palate,  798 

of  pancreas,  965 

of  parotid,  787 

of  penis,  1139 

of  pharynx,  804 

of  prostate,  1110,  1116 

of  pylorus,  910 

of  rectum,  1035,  1104 

of  scalp,  705 

of  scrotum,  1162 

of  spine,  665,  659 

of  spleen,  965 

of  stomach,  907 

of  sub-maxillary  gland,  789 

of  testis,  1152 

of  thyroid  gland,  828 

of  tongue,  778 

of  tonsil,  801 

of  urethra,  1120 
Typhlitis.     See  Appendicitis 
Typhoid  disease  of  joints,  585 

osteitis,  510 

state,  33 

ulcer,  perforation  of,  925 

Ulceration  (Chapter  IV.),  58-66 
Ulcer  of  anus,  1032,  1036 

of  bladder,  1080 

of  duodenum,  921,  87 

of    intestine,     901,    926,    927,    997, 
1001 

of  palate,  797 

of  scars,  215 

of  stomach,  903 

of  tongue,  777 
Ulcers,    perforating,    of    duodenum,    87, 
921,  901 

of  foot,  355 

phagedenic,  125 

scirrhous,  882 

tuberculous,  66,  359,  777,  843 
Ullman's  operation,  934 
Ulna,  dislocation  of,  557,  559 

fracture  of,  460 


Ulnar  artery,  compression  of,  237 
ligature  of,  290 
nerve,  affections  of,  347 
Umbilical  hernia,  991 
Umbilicus,  affections  of,  894 
Unna's  treatment  of  ulcers,  62 
Ununited  fracture,  436 
Uranoplasty,  794 
Ureter,  rupture  of,  1052 
Urethra,  affections  of,  n  17 
Urethral  fever,  1114,  1126 
Urethritis,  116,  1126 
Urethrotomy,  1128,  1129 
Uric  acid  and  urates,  1087,  1094 
Urinary  deposits,  1087 
Urine,  abnormalities  of,  1087 
Uvula,  elongation  of,  798 
Urinary  fever,  1077,  1100 

Vaginal  hydrocele,  1155 
Varicocele,  981,  1159,  1067 
Varicose  aneurism,  250 

eczema,  62,  306 

ulcers,  61,  306 

veins,  304,  300,  808,  1044,  1122,  1159 
Varix,  304 
Vasectomy,   1116 
Veins,  affections  of  (Chapter  XL),  298- 

311 
entrance  of  air  into,   242,  680,  826, 

851 
Venesection,  310 
Venous  haemorrhage,  222,  241 

sinuses,  thrombosis  of.     See  Throm- 
bosis of 
wounds  of,  680 
Ventral  hernia,  993,  953,  893 
Vermiform  appendix.     See  Appendicitis 
Verruca  necrogenica,  206,  356 
Vertebral  artery,  haemorrhage  from,  243 

ligature  of,  287 
Vesical  calculus.     See  Calculus 

fistula.     See  Fistula 
Vesiculas  seminales,  affections  of,  11 64 
Vicious  union  of  fractures,  438 
Villous  tumour  of  bladder,  1081 

of  rectum,  1036 

of  pelvis  of  kidney,  1066 
Vocal  cords,  paralysis  of.    See  Laryngeal 

paralysis 
Volvulus,   1011 
Vomiting  after  concussion,  685 

after  shock,  217 

anaesthetic,  1189 

cerebral,  715,  719 

faecal,  999,  1010,  1023 

in  intestinal  obstruction,  1010,  1023 

in  peritonitis,  896 

in    strangulated   hernia,    999,    1005, 
1010 

persistent,  after  taxis,  1001,  1023 

with  moveable  kidney,  1051 
Von    Hacker's    method   of   gastroenter- 
ostomy, 919 
Vulva,  affections  of,  1140 


INDEX 


1213 


Wagstaffe's  fracture,  487 

Wardrop's  operation    for  aneurism,  266, 

272 
Warts.     See  Papilloma,  171,  355 

anatomical,  or  butchers',  206,  356 

malignant,  175 

on  lip,  733 

venereal,  1139 
Wax  in  ear,  813 
Weak  ulcer,  64 
Webbed  fingers,  390 
Wheelhouse's  operation,  1130 
Whitehead's  operation  on  haemorrhoids, 
1047 
on  tongue,  780 
White  swelling,  586 
Whitlow,  207 

Witzel's  method  of  gastrostomy,  916 
Wolffian  body,  cysts  of,  184,  1158 
Wolfler  suture,  931 
Wolfler's  operation  of  gastroenterostomy, 

918,  920 
Wool-sorter's  disease,  115 
Wool  truss,  982 
Wound  phagedena,  83 
Wounds  (Chapter  VI 1 1.),  190-221 

of  abdominal  walls,  891 

of  air  passages,  826 

of  arteries,  246 

of  bladder,  1073 

of  brain,  694 

of  gall  bladder,  959 

of  heart,  862 

of  intestine,  921  et  seq. 

of  joints,  539 

of  kidney,  1051 

of  larynx,  826,  840 


Wounds  of  liver,  953 

of  lung,  854 

of  muscles,  363,  364 

of  nerves,  326,  327 

of  pancreas,  964 

of  recto-vaginal  septum,  1141 

of  scalp,  667 

of  scrotum,  1164 

of  spine,  630 

of  spleen,  965 

of  stomach,  902 

of  testis,  1144 

of  throat,  825 

of  tongue,  774 

of  trachea,  826 

of  ureter,  1052 

of  urethra,  1118 

of  veins,  241,  249,  680 

of  vulva,  1141 
Wrist-drop,  345 
Wrist-joint,  acute  arthritis  of,  582 

amputation  at,  1172 

ankylosis  of,  609 

dislocation  at,  559 

effusion  into,  574 

excision  of,  623 

tuberculous  disease  of,  593 
Wry-neck.     See  Torticollis 
Wyeth's  method  of  preventing   hnemor 
rhage,  n8i 

Xanthine,  1095 

Yeasts,  22 

Zooglcea,  2 

Zygoma,  fracture  of,  440 


THE    END 


Bailliere,  Tinda/l  and  Cox,  8,  Henrietta  Street,  C event  Garden. 


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Manual  of  surgery  for  students  and  jjract 

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